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Rationale and Objectives: Various devices are used to aid in the education of laparoscopic skills ranging from simple box trainers to sophisticated virtual reality trainers. Virtual reality system is an advanced and effective training method, however it is yet to be adopted in India due to its cost and the advanced technology required for it. Therefore, box trainers are being used to train laparoscopic skills. Hence this study was undertaken to assess the overall effectiveness of the box-training course. Study Procedure: The study was conducted during six-day laparoscopic skills training workshops held during 2006. Twenty five surgeons; age range of 26 to 45 years, of either sex, who had not performed laparoscopic surgery before; attending the workshop were evaluated. Each participant was given a list of tasks to perform before beginning the box-training course on day one and was evaluated quantitatively by rating the successful completion of each test. Evaluation began when the subject placed the first tool into the cannula and ended with task completion. Two evaluation methods used to score the subject, including a global rating scale and a task-specific checklist. After the subject completed all sessions of the workshop, they were asked to perform the same tasks and were evaluated in the same manner. For each task completed by the subjects, the difference in the scores between the second and first runs were calculated and interpreted as an improvement as a percentage of the initial score. Statistical Analysis: Wilcoxon matched-paired signed-ranks test was applied to find out the statistical significance of the results obtained. Results: The mean percentage improvement in scores for both the tasks, using global rating scale, was 44.5% + 6.930 (Mean + SD). For task 1, using the global rating scale mean percentage improvement was 49.4% + 7.948 (Mean + SD). For task 2, mean percentage improvement using global rating scale was 39.6% + 10.4 (Mean + SD). Using Wilcoxon matched-paired signed-ranks test, 2-tailed P -value<0.0001 which is extremely significant. Conclusion: This study confirms that a short-term, intensive, focused course does improve laparoscopic skills of trainees. Box-trainers can be used to change the present day didactic training into objective and competency-based. Global rating scale and checklist provide an inexpensive and effective way of objective assessment of performance of laparoscopic skills.

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Objective: To find out the safety profile of laparoscopic cholecystectomy in empyema of gallbladder. Background: Empyema of gall bladder is a severe form of acute cholecystitis with superadded suppuration. It has been considered a contraindication for the laparoscopic cholecystectomy (LC) because of fear of life-threatening complications. This study aimed to determine the safety and feasibility of LC in empyema of gallbladder. Materials and Methods: LC was attempted in 67 patients of empyema of gallbladder within 24h. However in few cases there was a delay because of reluctance for surgery or delay in giving consent etc. The procedure was performed by standard four-port technique with few changes made to facilitate dissection according to situation. Results: Between April 2003 to June 2006, 970 LC performed for gallstone disease at surgical unit-1 of LUMHS by the same surgical team. Among these, 67 (6.90%) patients were diagnosed to have empyema gall bladder. LC successfully completed in 54 (80.59%) patients. In 13 (19.40%) patients the procedure was converted to open cholecystectomy (OC) due to various operative difficulties of which the most serious injuries included bleeding from cystic artery (four cases), common bile duct injury (two cases) and duodenal injury in one case. Maximum operating time was up to 160 minutes (one case). Postoperative complications occurred in 10 (18.51%) successfully operated patients. Maximum patients (n=45, 83.33%) were discharged in 48-96 hours while three patients were discharged after two weeks. Conclusion : Laparoscopic cholecystectomy can be performed in empyema of gallbladder keeping in mind a slightly increased risk of complications even in the best hands. However, the experience of the surgeon plays a key role in the overall outcome.

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Recently, increasing number of manuscripts - original articles and case reports have attempted to provide evidence of the forays of minimal access surgery into pancreatic diseases. Many, based on the lack of Level I evidence, still believe that laparoscopy in pancreatic surgery is experimental. This article attempts to look into data exploring the existing use of minimally invasive surgery in pancreatic disease to answer a vital question - what does the evidence say on the current status of laparoscopic surgery in pancreatic tumors.

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Summary: Torsion of an epiploic appendix is a rare surgical entity. We present our experience in a thirty five year old female patient and a forty year old male patient. Materials and Methods: A 35 year old lady had presented with right iliac fossa pain of 2 days duration. Guarding and rebound tenderness was present over the area. Investigations showed mild leucocytosis and neutrophilia. Diagnostic laparoscopy revealed an inflamed epiploic appendix which was excised. Other intrabdominal organs were normal. A 40 year old male patient had presented with a history of recurrent, colicky, and paroxysmal right lower quadrant pain for 2 months. At laparoscopy, an inflamed torted epiploic appendix of the ascending colon was detected and excised. Other intrabdominal organs were normal. Results: Both the patients had an uneventful recovery and are asymptomatic at follow up of 10 and 7 months respectively. They have been followed up at 7 days, 4 wks and then 3 monthly. Discussion: The clinical presentation of an inflamed appendices epiploicae may be confusing. CT is helpful in disgnosis. Laparoscopy may be used to diagnose and treat the condition as well. Conclusion: Diagnostic laparoscopy is an useful tool for surgeons in assessing abdominal pain where the cause is elusive. It may be used to diagnose and treat torsion of an epiploic appendix effectively.

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Port site wound infection, abdominal wall hematoma and intraabdominal abscess formation has been reported after laparoscopic appendicectomy. We describe here a rectus sheath abscess which occurred three weeks after the laparoscopic appendicectomy. It was most likely the result of secondary infection of the rectus sheath hematoma due to bleeding into the rectus sheath from damage to the inferior epigastric arteries or a direct tear of the rectus muscle. As far as we are aware this complication has not been reported after laparoscopic appendicectomy.

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The authors present an early laparoscopic treatment in a newborn with biliary atresia. They describe the technical details of the Kasai laparoscopic procedure. A 10-day-old girl, weight 2.4 kg, was admitted with a history of jaundice and fecal acholia since birth, with elevated total bilirubin and abnormal hepatic test. Abdominal ultrasound showed a small gallbladder with hyperechogenicity in porta hepatis and absence of biliary principal duct. Other metabolic and hematological tests were normal. The procedure was performed at 20-day-old by laparoscopy. The cholangiography confirmed the biliary atresia and Kasai's procedure was continued by laparoscopy and transumbilical extracorporeal Roux-Y approach. The duration of the procedure was 220 min, with good tolerance of pneumoperitoneum due to the laparoscopy. Feedings of breast milk began on the third day postoperative, presenting normal colored stools, with normalization of the hepatic test. A 20 months follow-up was without complications.

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