Objective: To systematically evaluate the application effect of endoscopic papillary balloon dilatation (EPBD) with different balloon dilatation duration for biliary duct calculi, and find the most appropriate dilatation duration for EPBD using a network meta-analysis. Materials and Methods: PubMed, Embase and Cochrane Library databases were searched for relevant randomised controlled trials (RCTs) published up to August 2020. Node split, consistency and inconsistency models analysis were all conducted in network meta-analysis. Results: Eighteen RCTs with 2256 participants were finally analysed. EPBD was divided into four categories based on balloon dilatation duration, including EPBD (P0.5), EPBD (>0.5, ≤1), EPBD (1, ≤2) and EPBD (>2, ≤5). Compared with EPBD (>0.5, ≤1), EPBD (>2, ≤5) had a lower risk of early complications (odds ratio [OR] = 0.23, 95% credible interval [CI] = 0.05–0.96) and post-endoscopic procedure pancreatitis (PEP) (OR = 0.17, 95% CI = 0.03–0.72). Endoscopic sphincterotomy (EST) tended to have less need for mechanical lithotripsy (OR = 0.37, 95% CI = 0.16–0.88) and PEP (OR = 0.26, 95% CI = 0.08–0.71) than EPBD (>0.5, ≤1). EPBD (>2, ≤5) was the safest endoscopic procedure with respect to early complications (surface area under cumulative ranking curves [SUCRA] = 79.0) and PEP (SUCRA = 85.3). In addition, EPBD (>2, ≤5) and EST had the highest probability of being the best (SUCRA = 82.6) and the worst (SUCRA = 10.8), respectively, regarding late complications. Conclusion: EPBD and EST are two methods used to treat uncomplicated choledocholithiasis (stone diameter <10 mm and stone number <3). The extension of balloon dilatation duration has no significant influence on successful stone removal in the first endoscopic session or preventing the need for mechanical lithotripsy. However, it can reduce the risk of early complications, especially PEP. What's more, EPBD seems to have less late complications compared with EST, and the effect of prolonged balloon dilatation duration on late complications still needs to be further explored. Therefore, 2–5 min is the recommended dilatation duration range for EPBD using balloon with ≤10 mm diameter. Further research based on a specific population and with a longer follow-up time are needed.

Background and Aim: In the era of minimally invasive procedures and as a way to decrease the incidence of post-operative pancreatic fistula (POPF), the use of staplers for distal pancreatectomy (DP) has increased dramatically. Our aim was to investigate whether reinforced staplers decrease the incidence of clinically relevant PF after DP compared with staplers without reinforcement. Methods: PubMed, Scopus, Web of Science and Cochrane Library were searched for eligible studies from inception to 1 November 2021, and a systematic review and a meta-analysis were done to detect the outcomes after using reinforced staplers versus standard stapler for DP. Results: Seven studies with a total of 681 patients were included. The overall incidence of POPF and the incidence of Grade A POPF after DP are similar for the two groups (overall POPF, risk ratio [RR] = 0.85, 95% confidence interval [CI] = 0.71–1.01, P = 0.06; I² = 38% and Grade A POPF, RR = 1.15, 95% CI = 0.78–1.69, P = 0.47; I² = 49%). However, the incidence of clinically significant POPF (Grades B and C) is significantly lower in DP with reinforced staplers than DP with bare staplers (Grades B and C, RR = 0.45, 95% CI = 0.29–0.71, P = 0.0005; I² = 17%). Nevertheless, the time of the operation, the blood loss during surgical procedure, the hospital stay after the surgery and the thickness of the pancreas are similar for both techniques. Conclusion: Although staple line reinforcement after DP failed to prevent biochemical PF, it significantly reduced the rate of clinically relevant POPF in comparison to standard stapling.

Objective: To compare gasless laparoscopy with conventional laparoscopy for the surgical management of postmenopausal patients. Methods: The medical records of 80 postmenopausal patients who underwent laparoscopic surgeries between February 2016 and February 2020 were reviewed. Forty patients underwent gasless laparoscopy and 40 patients underwent conventional single-port access (SPA) laparoscopy. The two groups were compared in terms of surgical outcomes. Results: Of 80 patients, 42 underwent adnexal surgeries and 38 underwent uterine surgeries such as total hysterectomy or myomectomy. Between the gasless SPA and conventional SPA laparoscopic groups, no significant differences were observed in terms of age, body mass index, parity or history of previous abdominal surgery. The mean retraction setup time from skin incision was 6.8 ± 1.2 min with gasless laparoscopic surgery. There was no significant difference in mean total operation times for the gasless (71.3 ± 31.4 min) and conventional (82.5 ± 36.4 min) groups. There was also no significant difference between the groups in terms of operation type, laparotomy conversion rate or duration of hospitalisation. There were no major complications in either group. Conclusions: Gasless laparoscopy is a safe and feasible alternative to conventional laparoscopy for postmenopausal women.

Background: The present study aims to report the outcomes of a multidisciplinary, minimally invasive approach to treating patients with delayed presentation of oesophageal perforation. Patients and Methods: The present study is a retrospective analysis of prospectively maintained data at a tertiary care centre. All patients with oesophageal perforation presenting over 48 h after the onset of symptoms and without oesophageal obstruction were included in the study. Self-expanding Metallic Stent (SEMS) or endoscopic clip placement was performed in all the patients, followed by video-assisted thoracoscopic surgery (VATS) debridement and decortication of pleural cavity collection. 'Success' was defined as, discharge without the need of oesophageal diversion and complete healing of leak site at 8 weeks with successful removal of the stent. Results: Between March 2012 and December 2019, 12 patients (10 males, median age of 55 years– range of 39–71 years) with oesophageal perforation and delayed presentation underwent treatment with this approach. Ten patients had spontaneous perforation (83.3%) and one patient each had upper gastrointestinal endoscopy-induced and post-traumatic perforation. The median duration of symptoms was 8 days (range 3–31 days). SEMS was placed in ten patients and, in two patients, an over-the-scope clip was used. VATS decortication was done in ten patients (83.3%) and the remaining two (16.7%) underwent VATS debridement. One patient required oesophageal diversion and another patient expired due to sepsis. The overall success with this approach was 83.3%. Conclusion: This multidisciplinary, minimally invasive approach is feasible in patients with thoracic oesophageal perforation and delayed presentation, with a high success rate.

Background: Surgery continues to be the mainstay of treatment of hydatid cysts of the liver. Laparoscopy provides a lesser invasive tool for achieving results same as with the established open surgical techniques. The purpose of the study was to evaluate the feasibility and safety of laparoscopic management of hepatic hydatid disease in children. Patients and Methods: It was a prospective randomised study conducted over a period of 7 years. Children with Gharbi Type I, II, III cysts, ≤3 cysts and superficial accessible cysts were treated laparoscopically and their outcomes were compared with matched controls treated by open approach. Results: Sixty patients were included in the study with thirty patients in each matched group. Thirty paediatric patients (male 12:female 18) with 35 liver hydatid cysts underwent laparoscopic surgery. The mean cyst size was 8.8 ± 2.39 cm. Two patients needed conversion to open. No significant spillage of cyst contents was observed in any of the patients. Duration of hospital stay, time to removal of drains, duration of parenteral analgesia, severity of pain in postoperative period, time to ambulation and time to return to full orals were significantly lower in laparoscopic group compared to open group. Complication rates in both the groups were similar. Conclusion: With proper patient selection, laparoscopic management of hydatid cysts of the liver in children is feasible and safe option with low morbidity, low rates of conversion and minimal complications.

Background: This study describes the surgical technique of thoracoscopic resection of posterior mediastinal neurogenic tumours and reporting the surgical outcomes. Methods: This is a retrospective analysis of 21 patients operated over 7 years in a dedicated thoracic surgery centre. The demographic and post-operative parameters along with complications were recorded and analysed. Results: Twelve patients had right-sided tumours, while 9 had left-sided lesions, and 9 were on the left side. The most common diagnosis was schwannoma (n = 15, 71.42%), followed by neurofibroma (n = 4, 19.04%). The average surgery duration was 104 min (85–135 min), and the mean blood loss was 120 ml (25 ml–250 ml). The average lesion size was 4.8 cm (2 cm–7 cm). Conversion to open procedure was required in one patient. Two patients (14.2%) developed complications. One patient developed Horner's Syndrome and the other developed post-operative lung atelectasis. The median follow-up was 36 months (6–90 months). No recurrence was observed during the follow-up period. Conclusions: Thoracoscopic approach to posterior mediastinal neurogenic tumours is feasible and allows for low morbidity, short hospital stay and superior cosmesis.

Background: Laparoscopic definitive surgery for choledochal cyst (CC) in infants requires advanced skills because of their small size. If patients with a prenatal diagnosis of CC have any biliary symptoms, they need semi-emergency definitive surgery. This study aimed to estimate whether laparoscopic definitive surgery for CC can be performed safely and effectively in infants, especially when emergency surgery is required. Patients and Methods: From January 2006 to December 2019, 21 patients under 1 year of age underwent laparoscopically or open definitive surgery, and 16 patients aged 3–5 years underwent laparoscopic surgery for CC at our institution. In cases of prenatal diagnosis, elective surgery (EL) was performed at about 6 months of age for patients with no biliary symptoms; the semi-emergency surgery (EM) was performed when patients had any biliary symptoms. Surgical outcomes were retrospectively compared between the Lap <1 y and Op <1 y groups and between the Lap <1 y and Lap 3–5 y groups. In addition, the surgical outcomes of those who underwent EM were also evaluated. Results: Operative time was significantly longer, and blood loss was significantly lower in the Lap <1 y group than in the Op <1 y group. All surgical outcomes were similar between the Lap <1 y and Lap 3–5 y groups and between the EM and EL groups. Conclusion: Laparoscopic definitive surgery for CC in infants under 1 year of age is safe and feasible. Even semi-emergency laparoscopic surgery can be performed safely and effectively in small infants.

Background: Repeat laparoscopic liver resection has been used safely and effectively on hepatocellular carcinoma (HCC). However, few studies have been performed on repeat HCC surgery by a da Vinci robot. This study aims to evaluate the outcomes of the patients with repeat HCC treated using a da Vinci robot or laparoscopic system at a single centre. Methods: All of the patients with repeat HCC treated using a da Vinci robotic or laparoscopic system between April 2017 and April 2020 were included in this retrospective study. Results: There were 24 patients with a mean age of 56 years who underwent da Vinci robotic or laparoscopic surgery for treatment of repeat HCC who were included in this study. The operations lasted 152 ± 25 min and 142 ± 34 min. The average intraoperative blood loss was 284 ± 89 ml and 251 ± 92 ml. The average hospitalisation stay lasted 9 ± 2 days and 9 ± 3 days. The rates at which surgeons switched to open surgery were 9% and 23%. No serious perioperative or post-operative complications were encountered. Conclusion: Da Vinci robots can provide a precise dissection of the tissue under a perfect view. It is a technically feasible procedure for less rates at which surgeons switched to open surgery on repeat HCC.

Background: Although recent studies have reported potential benefits of laparoscopic approach in distal pancreatectomy, reports of conversion during minimally invasive distal pancreatectomy (MIDP) were limited. Methods: This was a retrospective study using data from Sir Run Run Shaw Hospital around May 2013 to December 2018. Outcomes of patients who had conversions during MIDP were compared with patients with successful MIDP and with patients undergoing open distal pancreatectomy (ODP). Results: Two-hundred and eighty-three cases were included in this study: 225 (79.5%) had MIDP, 30 (10.6%) had conversions and 28 (9.9%) had outpatient department. The risk factors for conversion included large lesion size (heart rates [HR]: 5.632, 95% confidencevinterval [CI]: 1.036–1.450, P = 0.018) and pancreatic cancer (HR: 6.957, 95% CI: 1.359–8.022, P = 0.009). Compared with MIDP, those who required conversion were associated with longer operations (P = 0.003), higher blood loss (P < 0.001) and more severe of the complications (P < 0.001). However, no statistically significant differences were found between the conversion group and ODP. Conclusions: Large lesion size and pancreatic cancer were reported to be independent risk factors for conversion during MIDP. As for post-operative outcomes, the outcomes of successfully MIDP were better than those for conversion. However, conversion did not lead to worsening outcomes when compared with ODP.

Background: Complete mesocolic excision with central vascular ligation for colonic cancers improves overall survival. To achieve better short term and oncological results, different laparoscopic techniques have been described for right-sided colonic cancers. Laparoscopic right hemicolectomy by the Initial Retrocolic Endoscopic Tunnel Approach (IRETA) is proposed to be easy and offer desired oncological resection; we present our results with IRETA. Patients and Methods: The data of all patients who underwent right hemicolectomy by IRETA for colonic cancer between January 2019 and March 2020 were retrospectively analysed for demographics, clinical features, oncological completeness of resected specimen, complications, hospital stay, morbidity and mortality. Results: A total of eight patients (05 males and 03 females) were identified. The mean operating time was 190 ± 32.40 minutes. Margins of all resected specimens were free of tumour except for one in which retro-peritoneal circumferential resection margin was positive. On average 13.75 ± 2.63 lymph nodes were retrieved. Except for wound infection in one patient, no other morbidity was seen. Conclusion: Laparoscopic radical right hemicolectomy by IRETA is safe and gives desired oncological results.

Background: Bariatric metabolic surgery is evolving as an option for the treatment of type 2 diabetes mellitus (T2DM) in patients with obesity and T2DM, warranting more studies on the efficacy of bariatric metabolic surgery on T2DM. Objective: To determine T2DM remission in patients with obesity and T2DM with up to two years follow-up after bariatric metabolic surgery. Materials and Methods: A retrospective review of prospectively maintained data was undertaken to identify patients who had T2DM and underwent bariatric surgery at a single centre in 2016. Data collected included age, gender, body mass index (BMI), fasting plasma glucose, haemoglobin A1c, hypertension, (HTN), Obstructive sleep apnea (OSA), initial weight and the weight at intervals of 6, 12, and 24 months. Data on the treatment of T2DM before the surgery was also collected. The criteria of the American Diabetes Association were used for the definition of T2DM remission. Only the data on patients in this study who had more than 12 months' follow-up information was analysed. Results: Two hundred and eighty patients with T2DM were identified. 191 patients had more than 12 months' follow-up information. Mean age and BMI were 49.58 ± 10.64 years and 44.03 ± 7.86 kg/m² respectively. There were 29 patients on insulin, 21 (10.9%) on insulin only and 8 (4.2%) on insulin and oral hypoglycaemic agents (OHA). One hundred and forty-six patients (76.4%) were on OHA, 134 on a single OHA and 12 on more than one OHA. Twenty-six patients (13.6%) were newly diagnosed with T2DM when they came in for bariatric metabolic surgery. One hundred and fifty-six patients (81.7%) achieved complete remission. 14 (7.3%) of these patients used to be on insulin with or without OHA and 142 (74.3%) were patients either on OHA or no OHA. There were 12 (6.4%) patients in partial remission. There was improvement in 23 (12.04%). Eight patients were on insulin but at lower doses and 15 were on a single OHA. The average percentage of total weight loss at 6, 12 and 24 months was 29.7%, 33.9% and 35.6% respectively. Patients with shorter duration of T2DM had higher remission rates as compared to patients with longer duration (r = −0.874, P = 0.001). There was also a significant resolution of HTN (81.8%) and OSA (82.3%) after bariatric metabolic surgery. Conclusion: This study collaborates reports that there is significant remission of T2DM after bariatric metabolic surgery in patients with obesity and T2DM. There is a need for prospective, multi-centre, and long-term studies on bariatric metabolic surgery to treat patients with obesity and T2DM.

Background: Thoracoscopic enucleation of oesophageal leiomyomas has been adopted by many centres. The procedure when performed in prone position gives good results. The long-term outcome has not been reported earlier. This single-centre study establishes the role of this particular technique. Methods: A retrospective analysis of a prospectively maintained hospital database was performed and after following the study criteria eleven cases of oesophageal submucosal tumours were included in the study. All patients underwent thoracoscopic enucleation in the prone position by a single surgeon. Peri-operative data were recorded and patients followed up for a mean period of 78 months (range = 24–120 months). Results: Thoracoscopic enucleation in prone position was done for all patients with no conversions to an open procedure. Two patients had a mucosal rent during dissection that was repaired. There was no post-operative morbidity greater than Clavien-Dindo Grade 2. Long-term follow-up is available for eight patients (73%) with no recurrence of disease or symptoms. Conclusion: Oesophageal submucosal tumours (predominantly leiomyomas) are benign neoplasms with an indolent biological behaviour and deserve a procedure that would serve the purpose of minimal post-operative morbidity coupled with excellent outcome. Thoracoscopic enucleation in the prone position provides a physiological benefit that translates into better peri-operative outcomes without compromising the long-term outcome and should be the preferred form of treatment for oesophageal submucosal tumours.

Aims: The three main types of anastomotic configurations following colorectal resection are Side-to-Side Anastomosis (S-S), End-to-Side Anastomosis (E-S) and End-to-End Anastomosis (E-E). This study aims to present results from a local cohort supplemented by a systematic review with meta-analysis of existing literature to compare the post-operative outcomes between E-S and S-S. Methods: A cohort study of patients who underwent right colectomy with E-S or S-S anastomosis, was conducted at the National University Hospital Singapore. Electronic databases Embase and Medline were systematically searched from inception to 21 August 2020, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Studies were included if they compared post-operative outcomes between E-S and S-S. Results: In the cohort study, 40 underwent E-S and 154 underwent S-S. Both post-operative ileus (12.5% vs. 29.2%, P = 0.041) and length of hospital stay (9.35 days vs. 14.04 days, P = 0.024) favoured E-S, but anastomotic bleed favoured S-S (15.0% vs. 3.2%, P = 0.004). Five studies were included in the meta-analysis with 860 E-S and 1126 S-S patients. Similarly, post-operative ileus (odds ratio [OR] =0.302; 95% confidence interval [CI]: 0.122–0.747; P = 0.010) and length of hospital stay (mean differences = ‒1.54 days; CI: ‒3.00 to ‒0.076 days; P = 0.039) favoured E-S. Additional sensitivity analysis including only stapled anastomosis showed a lower rate of anastomotic leak in E-S patients (OR = 0.185; 95% CI: 0.054–0.627; P = 0.007). Conclusions: This is the first systematic review to show that the E-S technique produces superior post-operative outcomes after right colectomy compared to S-S. However, the choice of anastomosis was largely surgeon dependent, but surgeon factors were not reported.

Objectives: For patients with lung cancer, surgical resection remains the best curative option and is associated with the longest disease-free survival. We present our institutional outcomes treating pulmonary malignancy with robotic lobectomy over the course of 1 year. Methods: A retrospective review was conducted on patients who underwent robotic pulmonary lobectomy for malignancy at a single institution in 2018. Results: Over the course of 1 year, 166 patients underwent robotic lobectomy for pulmonary neoplasm. The mean age of the patients was 75 years; 73% were current or prior smokers and 52% of the patients were male. The mean body mass index was 28 kg/m². Conversion to open thoracotomy occurred in 7% of patients. The mean total hospital length of stay (LOS) was 3 days. Histopathological examination revealed a mean tumour size of 2.7 cm with 11 lymph nodes harvested. Left-sided tumours had a significantly higher number of lymph nodes harvested when compared to right-sided tumours (11.6 vs. 9.8, P = 0.01), despite sampling the recommended minimum of three N2 stations. The most common pathology was adenocarcinoma (65%), followed by squamous cell carcinoma (17%) The 30-day operative mortality was 0.6%. Conclusions: Robotic video-assisted thoracoscopic surgery is a safe, feasible and oncologically adequate procedure for lung malignancies. Comparison of our outcomes to previously reported national averages suggests a similar hospital LOS, lymph node harvest, conversion rate to open thoracotomy and 30-day mortality rate. We acknowledge the limitations of this non-randomised, retrospective study. Future research on robotic lobectomies is encouraged.

Background: Minimally invasive pancreatic pancreatoduodenectomy (MIPD) is increasingly adopted worldwide and its potential advantages include reduced hospital stay and decrease pain. However, evidence supporting the role of MIPD for tumours requiring vascular reconstruction remains limited and requires further evaluation. This study aims to investigate the safety and efficacy of MIPD with vascular resection (MIPDV) by performing a 1:1 propensity-score matched (PSM) comparison with open pancreatoduodenectomy with vascular resection (OPDV) based on a single surgeon's experience. Methods: This is a retrospective review of 41 patients who underwent PDV between 2011 and 2020 by a single surgeon. After PSM, the comparison was made between 13 MIPDV and 13 OPDV. Results: Thirty-six patients underwent venous reconstruction (VR) only and 5 underwent arterial reconstruction of which 4 had concomitant VR. The types of VR included 22 wedge resections with primary repair, 8 segmental resections with primary anastomosis and 11 requiring interposition grafts. Post-operative pancreatic fistula (POPF) occurred in 3 (7.3%) patients. Major complications (>Grade 2) occurred in 16 (39%) patients, of which 7 were due to delayed gastric emptying requiring nasojejunal tube placement. There was 1 (2.4%) 30-day mortality (OPDV). Of the 13 MIPDV, there were 3 (23.1%) open conversions. PSM comparison demonstrated that MIPDV was associated with longer median operative time (720 min vs. 485 min (P = 0.018). There was no statistically significant difference in other key perioperative outcomes such as intra-operative blood loss, overall morbidity, major morbidity rate, POPF and length of stay. Conclusion: Our initial experience with the adoption MIPDV has demonstrated it to be safe with comparable outcomes to OPDV despite the longer operation time.

Purpose: Rectal prolapse is known to be a rare condition in males compared to females. This study aimed to analyse the frequency of male rectal prolapse and compare the results of different surgical approaches performed at a single centre. Patients and Methods: The authors included patients who underwent surgical treatment for rectal prolapse from March 2016 to February 2021. The proportion of males, mean age and recurrence rates were calculated. Patients were divided into two groups, transanal approach and laparoscopic abdominal approach group, to identify the para-operative parameters including functional tests. Results: A total of 56 males, comprising 23.7% (56/236) of all patients. The mean age was 60.8 years, with a recurrence rate of 7 cases (12.5%) during 7.2 months of follow-up. Forty patients underwent transanal procedures, and fifteen underwent laparoscopic abdominal procedures. The mean operative time was longer in the laparoscopic group (transanal vs. abdominal, 57.5 vs. 70.6 min, P < 0.003), and intra-operative bleeding was greater in the transanal group (12.4 vs. 3.4 ml, P < 0.001). Full-layer prolapse (36.8 vs. 81.2% P = 0.003) and longer length (5.6 vs. 7.8 cm, P = 0.048) were more common in laparoscopic group. Time to feeding resumption was shorter after the transanal group (1.2 vs. 1.7 days, P = 0.028). There was no difference between the groups in terms of post-operative complications and recurrence rates. Both Wexner's constipation and incontinence scores showed significant improvement postoperatively. Conclusion: The frequency of male rectal prolapse was 23.7%, and perioperative factors differed between transanal and abdominal approaches, but recurrence rates and functional test results did not differ significantly.

Aim: In this study, we aimed to investigate the effect of magnetic resonance imaging (MRI) in detecting diaphragmatic injury by comparing preoperative computed tomography (CT) and MRI imaging results with diagnostic laparoscopy/thoracoscopy results in patients with left thoracoabdominal penetrating injury. We investigated whether MRI reduces the rate of unnecessary surgery by examining its sensitivity and specificity. Materials and Methods: Patients with left thoracoabdominal penetrating injuries who applied to the Emergency Surgery Unit of Istanbul University Istanbul Faculty of Medicine between November 2017 and December 2020 were evaluated. Patients who underwent emergency surgery, who could not undergo MRI or CT for any reason or who could not be operated on were excluded from the study. Preoperative MRI and CT images of patients who underwent diagnostic laparoscopy/thoracoscopy due to left thoracoabdominal injury in our clinic were evaluated retrospectively by a radiologist who did not know the surgical results. MRI results of the cases were compared with surgical findings and CT images. Results: A total of 43 (41 males, mean age: 31, range: 15–57) patients were included in the study. The most common physical examination finding was lateral injury. The diaphragmatic injury was detected in 13 (30%) cases during surgical interventions. Laparoscopic repair was performed in 11 (84%) cases and thoracoscopic repair was performed in 2 (15%) cases with diaphragmatic injuries. MRI images of 14 (32%) cases were found to be compatible with diaphragmatic injury, in 1 of them no injury was observed during surgical intervention. According to these data, the sensitivity of MRI was calculated as 100%, specificity 94%, positive predictive value 86%, and negative predictive value 100%. The mean hospital stay was 6 days (1–30) in all cases. Conclusion: In our study, MRI was found to have high specificity and sensitivity in detecting diaphragmatic injuries. The number of negative laparoscopy/thoracoscopy can be reduced by performing surgical intervention only in cases with positive or suspected diaphragmatic injury on MRI. Results should be supported by conducting new studies with larger case series with normal MRI findings and long follow-ups.

Background: The treatment of patients with cholelithiasis with common bile duct (CBD) stones is CBD clearance with cholecystectomy. While traditional teachings advocate waiting for 4–6-week post-endoscopic retrograde cholangiography (ERCP) with CBD clearance, recent studies favour an early laparoscopic cholecystectomy (LC). Hence, this study was conducted to evaluate the optimal timing of LC post-ERCP. Methods: We conducted a prospective observational study between March 2017 and October 2018. Patients diagnosed with cholelithiasis and CBS stones on ultrasonography or computed tomography were included. They were assigned to one of two groups (<2 weeks and >2 weeks) based on the time interval between ERCP and subsequent LC. Chi-square test was used to analyse the intraoperative and post-operative outcomes between the two study groups, Results: One hundred and forty patients were included in the study of which 69 underwent an early LC (<2 weeks). There was a significant decrease in the blood loss and incidence of bowel injury in the early group. Calots triangle was better defined and critical view of safety was achieved more in the patients who underwent an early LC. This resulted in a significantly lower incidence of drain placement and length of hospital stay in those patients who underwent an early LC. Conclusion: A delay of 2 weeks after ERCP makes the LC more difficult and is associated with a longer hospital stay. We advocate LC within 2 weeks of ERCP whenever feasible.

Context: Minimally invasive sphincter preserving procedures like ligation of intersphincteric fistula tract (LIFT) and video-assisted anal fistula treatment (VAAFT) are being increasingly used in the treatment of fistula-in-ano. The addition of adjuncts like fibrin glue has improved the results for VAAFT. Our unit has used platelet-rich fibrin (PRF) as an innovative adjunct for VAAFT. Aims: To compare the effectiveness of two different adjuncts, fibrin glue and autologous PRF, used to fill the treated fistula tracts following VAAFT. Settings and Design: Retrospective observational study on a cohort of patients undergoing VAAFT at a tertiary centre between 2015 and 2020 comparing two adjuncts used with VAAFT procedure. Subjects and Methods: Data of patients who underwent VAAFT for fistula-in-ano were obtained from the hospital database. Group A included patients treated with fibrin as adjunct and PRF as adjunct in Group B. Patients were followed up at 1, 3 and 6 months post-operatively and by a telephonic interview in 2020 to ascertain recent status. All data were entered into an excel sheet. Statistical Analysis Used: Data were analysed using SPSS V20 to test the statistical significance of the difference in the mean healing time between two groups, Mann–Whitney U-test was used and for age, Student's t-test was used. Results: There were 41 patients in Group A and 24 in Group B. There was a significant reduction in recurrence rate in Group B (p = 0.032) and in those patients who had a single internal opening (p = 0.045), single external opening (p = 0.03) and complex tracts (p = 0.033). PRF was cheaper than Fibrin glue. Conclusions: PRF is more effective and economical with lower recurrence rates.

Aim: To evaluate the protective effect of axillary channel-assisted (ACA) transoral endoscopic thyroidectomy vestibular approach on mental nerve. Materials and Methods: From August 2018 to December 2020, 126 cases of thyroid micro-carcinoma patients who underwent endoscopic thyroidectomy were recruited retrospectively. Of those, 74 cases were performed with ACA trans-oral endoscopic thyroidectomy vestibular approach (ACA_TOETVA) (V and A group), 52 cases received standard TOETVA (V group). On postoperative day 1 (POD1), nylon monofilament test and numbness visual analogue scale score were conducted to evaluate the severity of numbness within the mental area, facial expression was tested to determine the motor function of lower mandible and the thickness of cutaneous and subcutaneous layers was measured with ultrasound. The other observation parameters including the time for operation and intraoperative blood loss were carefully collected. Results: On POD1, nylon monofilament test showed that scores in the V and A group (2.9 ± 0.3) were significantly higher than V group (1.7 ± 0.5), P < 0.01, u = 254. The completion percentage of facial expression in the V and A group was 90.5% (67/74) and significantly higher than in V group (21.2%, 11/52), P < 0.01, χ² = 62.35. The thickness increment of cutaneous and subcutaneous layer was 2.2 ± 1.2 mm in the V and A group, which was significantly less than in the V group (4.0 ± 1.2 mm), P < 0.01, u = 605. Compared with V group, the operation time (113.4 ± 22.3 min vs. 127.7 ± 25.6 min, u = 1262) and intraoperative blood loss (43.5 ± 13.4 ml vs. 51.0 ± 14.1 ml, u = 1355) were also significantly less in the V and A group. Conclusions: The ACA transoral endoscopic thyroidectomy possesses the protective effect on mental nerve and motor function of lower mandible and facilitates the operative procedures of TOETVA.

A 63-year-old male presented to us with upper abdominal pain and odynophagia for 3 months. Contrast-enhanced computed tomography of the abdomen revealed hiatus hernia with ulceroproliferative growth involving the gastro-oesophageal (GE) junction and cardia of the stomach with no obvious transserosal extension. Upper gastrointestinal (GI) endoscopy was suggestive of a tumour of size 3 cm × 3 cm near the GE junction and sliding hiatus hernia. Although there are various ways described in the literature for managing GI stromal tumour (GIST), we opted for laparo-endoscopic transgastric resection with hiatus hernia repair due to obvious advantages in terms of safety and efficacy. Just a handful of cases have been described in the literature being treated in this fashion. The procedure was successfully performed as evidenced by an uneventful recovery of the patient. His histopathology report was suggestive of GIST of size 3.5 cm × 3.0 cm × 2.0 cm. The resected margins were free of the tumour.

Laparoscopic gastric clipping (LGC) is one of the bariatric surgeries that are minimally invasive and demonstrates effectiveness in reducing body weight for obese patients. However, the patients may later regain body weight and other treatments may be needed. In this case report, two cases with obesity received LGC, which initially reduced their weight. However, they presented with a progressive regaining of body weight a few years after the surgery. Thus, revisional sleeve gastrectomy was conducted in an institute to control their weight regain. Postoperative courses were smooth, and there was no complication. Thus, laparoscopic removal of gastric clipping accompanied with revisional sleeve gastrectomy is technically feasible for the patients.

Laparoscopic splenectomy has become an established standard of care in managing surgical diseases of the normal-sized spleen. Natural orifice transluminal endoscopic surgery (NOTES) is a step forward in making laparoscopic surgery even less invasive. In addition, the spleen can be accessed easily with the hybrid transvaginal approach. We present the case of a 38-year-old woman with medical refractory immune thrombocytopenic purpura. Hybrid notes splenectomy was performed using three working 5-mm abdominal trocars and a 10-mm camera port through the posterior fornix of the vagina. The organ was retrieved intact transvaginally. The patient had minimal post-operative pain and was discharged on the 1^st post-operative day. Transvaginal hybrid NOTES approach is feasible for operative visualisation, dissection, clipping and specimen extraction in patients requiring splenectomy. It may offer better cosmesis and faster recovery. Comparative studies with conventional laparoscopic approach are desirable.

Chylous ascites (CA) is a form of ascites having leakage of lipid-rich lymph into the peritoneal cavity, due to damage or obstruction in the lymphatic system. Aetiology of CA could be congenital or acquired. Primary lymphatic hypoplasia is seen commonly in children and presents with lymphoedema, chylothorax or CA. CA is initially treated conservatively with the aim to provide gut rest and decrease intestinal secretions. Surgical treatment is recommended if 1–2 months of conservative approach fails. The success of the operation depends on identifying the site of leakage of the lymphatic duct. Surgical options are ligation of leaking lymphatics, peritoneo-venous shunt, laparotomy and fibrin glue. Laparoscopy has been used for diagnosis but not for glue and mesh application in congenital CA where the lymphatic leak is unidentified. We present here the first experience of laparoscopic fibrin glue and mesh application in congenital CA with successful outcomes.

There are fewer reports of thoracoscopic surgical resection of mediastinal cysts in neonates. The aim of this article is to report on the feasibility of thoracoscopic resection of a large mediastinal cyst and the management of chylothorax after surgery in neonates.

VIPoma is an extremely rare neuroendocrine tumour. Majority of the lesions occur in the pancreas. There is usually a long and recurrent history of secretory diarrhoea. Current diagnostic methods help in diagnosing a VIPoma once it is suspected. We herein report a case of VIPoma which had the delay in diagnosis and presented at an extremely unusual location (pyloroduodenal) who underwent laparoscopic resection for the same.

Radical surgery remains the primary treatment option for gall bladder cancer (GBC). Margin-negative liver resection is a critical component of radical cholecystectomy. Anatomical segment IVb and V resection is preferred in primary GBC with liver infiltration and incidental GBC patients with puckering of gall bladder (GB) bed. Despite the initial scepticism, minimally invasive radical cholecystectomy is recommended as a treatment option in selected GBC patients. However, anatomical Segment IVb and V resection using the minimally invasive approach is scarcely reported. The standardised technique of robotic (daVinci®Xi^TM) anatomical Segment IVb and V liver resection guided by indocyanine green fluorescence is described here. The systematic fluorescence-guided anatomical resection described in this report could facilitate minimally invasive Segment IVb and V resection with radical lymphadenectomy in selected patients with GBC.

Radical excision by surgery is the main treatment method for gastric cancer and as the surgery develops, the laparoscopic treatment effect on gastric cancer is gradually being verified. The totally laparoscopic gastrectomy (TLG) with natural orifice specimen extraction surgery (NOSES) for gastric cancer has attracted people's attention by avoiding abdominal incision and further reducing surgical injury and provides ideas for the further development of minimally invasive surgical treatment on the basis of laparoscopy. Surgical technique of TLG with natural orifice (vagina) specimen extraction is detailed in the text. We have employed NOSES in 4 cases of TLG in the past year. The visual analogue scale score was low, and all patients had no complications during and after the operation. No recurrence or metastasis was found in the short-term follow-up. TLG with NOSES is feasible and has many advantages such as aesthetics, light post-operative pain.