Laparoscopic Surgery

Objective To assess the effect of virtual reality training on an actual laparoscopic operation. Design Prospective randomised controlled and blinded trial. Setting Seven gynaecological departments in the Zeeland region of Denmark. Participants 24 first and second year registrars specialising in gynaecology and obstetrics.

proportional to the severity of the surgical stress. Compared with the conventional open method, laparoscopic surgery is mini-invasive and has decreased postoperative pain and length of hospitalization. The aim of this study was to investigate the systemic inflammatory response, after laparoscopic and open stoma-adjustable silicone band application, which is thought to be mediated by cytokines. Method: 30 morbidly obese patients underwent Swedish adjustable gastric banding (SAGB). 15 patients underwent laparoscopic (group 1) and 15 open SAGB (group 2). Mean operative time for the laparoscopic group was 70-110 min and for the laparotomy group 80-120 min. Gallbladders were not removed, and there were no systemic diseases in the patients. The intensity of surgical trauma was evaluated by measurement of metabolic and hormonal responses to the surgery. Plasma levels of C-reactive (CRP), haptoglobin, ceruloplasmin, albumin, transferrin, IL-6, malonic dialdehyde (MDA) and creatinine were measured before and after the operation. Results: CRP and IL-6 levels increased during and after laparoscopic and open SAGB. However, postoperative responses were significantly greater after open SAGB (group 2) (p<0.05). MDA level, an indicator of an oxidative trauma, was elevated in group 1 at the 6th postoperative hour but was significantly higher in group 2 at the 6th and 12th postoperative hours. The results were more significant in group 2 (p<0.05). There was no statistical difference between groups 1 and 2 in terms of albumin, creatinine, and transferrin levels before and after surgery. Conclusion: The systemic inflammatory res-ponses after laparoscopic SAGB were significantly reduced compared with those after open SAGB.

Background. The purpose of this study was to determine the impact of instructor feedback and video tutorials on skill acquisition during proficiency-based laparoscopic suturing training. Methods. Performance data from a prospectively maintained database were reviewed for three groups of novices (n ϭ 34 medical students) who completed the same proficiency-based laparoscopic suturing curriculum on a Fundamentals of Laparoscopic Surgery-type videotrainer model as part of two separate institutional review board-approved, randomized controlled trials. Group I (n ϭ 9) watched the video tutorial once and received intense feedback during each training session; Group II (n ϭ 13) watched the video tutorial once and received limited feedback (Ͻ10 min per session); Group III (n ϭ

This paper presents a robotic vision system that automatically retrieves and positions surgical instruments during robotized laparoscopic surgical operations. The instrument is mounted on the end-effector of a surgical robot which is controlled by visual servoing. The goal of the automated task is to safely bring the instrument at a desired 3-D location from an unknown or hidden position. Light Emitting Diodes are attached on the tip of the instrument and a speci£c instrument-holder £tted with optical £bers is used to project laser dots on the surface of the organs. These optical markers are detected in the endoscopic image and allow to localize the instrument with respect to the scene. The instrument is recovered and centered in the image plane by means of a visual servoing algorithm using feature errors in the image. With this system, the surgeon can specify a desired relative position between the instrument and the pointed organ. The relationship between the velocity screw of the surgical instrument and the velocity of the markers in the image is estimated online and, for safety reasons, a multi-stages servoing scheme is proposed. Our approach has been successfully validated in a real surgical environment by performing experiments on living tissues in the surgical training room of IRCAD.

Background: Computer-aided simulators may increase the safety and efficiency of training in laparoscopic surgery. Before implementation of the Immersion LapSim (Gaithersburg, MD) simulator in our training curriculum, we wished to determine its construct validity (ie, whether the simulator could differentiate laparoscopic novices from trainees with greater experience). Methods: Subjects were medical students (MS), residents (RES), and laparoscopic faculty (FAC). Subjects performed 10 repetitions of 6 LapSim tasks. The LapSim measured performance in 6 to 10 parameters per task, and performance was compared between groups. Post hoc t tests were used to make pair-wise comparisons among the 3 groups using the Bonferroni technique. Statistical significance was set at P Ͻ .05. Results: The degree of prior laparoscopic experience was reflected in performance on at least 1 parameter for each task. Several patterns of performance between MS, RES, and FAC were observed. Conclusions: The LapSim has performance parameters that reliably differentiate between subjects with varying laparoscopic experience. However, some performance parameters do not differentiate between groups. To accurately measure a trainee's skill level, only parameters that sensitively measure the true level of performance should be used.

Laparoscopic surgery has been used in the treatment of early gastric cancer with low mortality and morbidity and improvement in patient&amp;amp;amp;#39;s quality of life. The purpose of the current study was to determine if these advantages persist after radical laparoscopic treatment of more advanced gastric cancer. A retrospective review of 44 patients after laparoscopic surgery for gastric cancer was performed. Tumor stage was IA in 8 patients, IB in 12, II in 9, IIIA in 6, IIIB in 1, and IV in 8. Eight total and 36 subtotal R0 gastrectomies were performed (12 D(1) and 32 D(2)). The mean number of dissected lymph nodes was 38.1 +/- 21.5. Conversion rate was 7%. Operative mortality and morbidity were 7% and 12%, respectively. Three-year survival was 75%. Laparoscopic radical total or subtotal gastrectomy with extended lymphadenectomy for gastric cancer is a feasible, safe, and oncologically effective procedure.

Background This is the largest single-centre series of single-stage laparoscopic sleeve gastrectomy (LSG) reporting on perioperative outcomes, weight loss, comorbidity resolution including urological outcomes and results in the super obese. Review of prospectively collected data for patients who underwent LSG from March 2007-August 2009. Methods There were 253 patients with a mean age of 44 years (SD, 9) and a mean preoperative body mass index (BMI) of 50 kg/m 2 (SD, 7). There were 17 (7%) major complications and no deaths. The mean follow-up was 9 months. One hundred and seventy-one patients with a mean follow-up of 12 months had a mean postoperative weight loss of 41 kg (SD, 16) and mean excess BMI (meBMI) loss of 59% (SD, 22). Results One hundred fourteen patients were super obese (BMI, >50 kg/m 2 ). The mean weight loss was 45 kg (SD, 18), and the meBMI lost was 49% (SD, 21). Super-obese patients experienced more complications (p=0.02) and lost less eBMI (49% vs. 61%; p<0.01). Fifty-three patients (46%) remained morbidly obese (BMI, >40 kg/m 2 ) postoperatively. Hypertension and diabetes improved or resolved in 73 (79%) and 73 (90%) patients, respectively. Stress urinary incontinence was reported preoperatively in 60 (32%) females, and complete resolution or improvement was reported in 54 (90%) patients.

Objective: The rotational angle of the laparoscopic image relative to the true horizon has an unknown influence on performance in laparoscopic procedures. This study evaluates the effect of increasing rotational angle on surgical performance. Methods: Surgical residents (group 1) (n = 6) and attending surgeons (group 2) (n = 4) were tested on two laparoscopic skills. The tasks consisted of passing a suture through an aperture, and laparoscopic knot tying. These tasks were assessed at 15°intervals between 0°and 90°, on three consecutive repetitions. The par-ticipantÕs performance was evaluated based on the time required to complete the tasks and number of errors incurred. Results: There was an increasing deterioration in suturing performance as the degree of image rotation was increased. Participants showed a statistically significant 20-120% progressive increase in time to completion of the tasks (p = 0.004), with error rates increasing from 10% to 30% (p = 0.04) as the angle increased from 0°to 90°. Knot-tying performance similarly showed a decrease in performance that was evident in the less experienced surgeons (p = 0.02) but with no obvious effect on the advanced laparoscopic surgeons. Conclusions: When evaluated independently and as a group, both novice and experienced laparoscopic surgeons showed significant prolongation to completion of suturing tasks with increased errors as the rotational angle increased. The knot-tying task shows that experienced surgeons may be able to overcome rotational effects to some extent. This is consistent with results from cognitive neuroscience research evaluating the processing of directional information in spatial motor tasks. It appears that these tasks utilize the time-consuming processes of mental rotation and memory scanning. Optimal performance during laparoscopic procedures requires that the rotation of the camera, and thus the image, be kept to a minimum to maintain a stable horizon. New technology that corrects the rotational angle may benefit the surgeon, decrease operating time, and help to prevent adverse outcomes.

Background: Laparoscopic techniques have been proposed as an alternative to open surgery for the treatment of peptic ulcer perforation. This study compared the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforations. Methods: A retrospective review was conducted with 134 consecutive patients treated for gastroduodenal perforations. These patients included 122 with perforated duodenal ulcers, 10 with perforated gastric ulcers, and 2 with iatrogenic duodenal perforations. Whereas 68 patients were treated laparoscopically, 66 patients underwent conventional (open) surgery.

Objective: The objective of this study is to determine the per-operative factors responsible for difficulty in performing
laparoscopic cholecystectomy and lead to conversion. Study Design: Prospective analysis study. Place and Duration of study: This
study was carried out in General Surgery Department of Dow University Hospital Ojha Campus and Civil Hospital Karachi, from Jan 2011
to July 2012. Methodology: This study consisted of one hundred & forty six patients with gallstone disease. All patients had full clinical
examination and right hypochondrium was especially examined for assessment of murphy's sign, palpable mass and visceromegaly.
Base line and specific investigations were done in all patients especially ultrasound of abdomen as diagnostic modality and for
assessment of gallstone disease. Inclusion criteria was that all patients diagnosed as case of gallstone disease. LC procedure was not
attempted in patients with history of abdominal surgery, pregnant ladies due to risk of foetal loss, carcinoma of gall bladder acute
pancreatitis, obstructive jaundice and unfit patients for general anesthesia. Results: Out of 146 patients included in this study 133 were
female (91%) and 13 male (9%); with female to male ratio of 10.2:1. The mean age was 39.21+6.20 years. Per Operative findings were
adhesions in calot's triangle 24(16.43%) cases, severe & tight adhesions around gallbladder and calot's triangle 21(14.38%) cases,
obscured anatomy in calot's triangle 17(11.64%) cases, intrahepatic gallbladder 11(7.53%) cases, adhesions around gallbladder
26(17.80%) cases, empyema 13(8.90%) cases, mucocele 9(6.16%) and anatomical variation 14(9.58%) cases. We observed out of 21
patients who had Severe & tight adhesions around gallbladder and calot's triangle, lead to difficulty in performing laparoscopic
cholecystectomy in 11(52.38%) cases followed by 17 cases of obscured anatomy in calot's triangle and 14 cases anatomical variation
also lead to performing difficult laparoscopic cholecystectomy in 6(35.29%) and 5(35.71%) cases respectively. Four (2.73%) cases out
of 146 had to be converted to the open cholecystectomy procedure. Conclusions: We conclude our study revealed that various
peroperative factors which make the difficult laparoscopic procedure and lead to open cholecystectomy are severe adhesions in calot's
triangle, severe & tight adhesions around gallbladder and obscured anatomy in calot's triangle

Background: The applications of minimally invasive surgery (MIS) and laparoscopy are rapidly expanding. Despite this expansion, our understanding of the importance of haptic feedback during laparoscopic surgery is incomplete. Although many surgeons believe that the use of minimally invasive techniques eliminates force feedback and tactile sensation (haptics), the importance of haptics in MIS has not been fully evaluated. There is considerable interest in the development of simulators for MIS even though the importance of force feedback remains poorly understood. This study was designed to determine the ability of experienced surgeons to interpret haptic feedback with respect to texture, shape, and consistency of an object.

Background: Endoscopic surgeons rely on visual feedback to control their movements but lack stereopsis, an important depth cue. Previous three-dimensional (3D) systems alternated images on a two-dimensional (2D) screen, which was uncomfortable for surgeons. A second-generation 3D system provides continuous stereoscopic images on a monitor suspended at arm's length. We studied its effect on the laparoscopic precision of novices and experienced surgeons. Methods: Experienced laparoscopic surgeons (n= 12) and novices (n= 16) performed a total of 672 tasks in 2D, 3D, and under direct vision. Precision was assessed using the Imperial College Surgical Assessment Device (ICSAD), which generates objective scores of performance by analyzing the movements of surgical instruments. Results: We found that 2D endoscopic vision impaired performance by 35–100% when compared with direct vision, whereas 3D reduced this endoscopic handicap by 41–53% in novices and experienced surgeons (p p Conclusions: Second-generation 3D significantly improved the laparoscopic precision of novices and experienced surgeons, without the side effects reported from previous systems. This technology is expected to improve the ease and safety of laparoscopic surgery.

Laparoscopic surgery requires inflation of the abdominal cavity and this offers a unique opportunity to measure the mechanical properties of the living abdominal wall. We used a motion analysis system to study the abdominal wall motion of 18 patients undergoing laparoscopic surgery, and found that the mean Young's modulus was 27.774.5 and 21.073.7 kPa for male and female, respectively. During inflation, the abdominal wall changed from a cylinder to a dome shape. The average expansion in the abdominal wall surface was 20%, and a working space of 1.27 Â 10 À3 m 3 was created by expansion, reshaping of the abdominal wall and diaphragmatic movement. For the first time, the elasticity of human abdominal wall was obtained from the patients undergoing laparoscopic surgery, and a 3D simulation model of human abdominal wall has been developed to analyse the motion pattern in laparoscopic surgery. Based on this study, a mechanical abdominal wall lift and a surgical simulator for safe/ergonomic port placements are under development. r

Abstract
Background: To determine the effect of injection bupivacaine instillation in gall bladder fossa on post-op pain relief after laparoscopic cholecystectomy.
Methods: In this randomized controlled trial 80 patients, diagnosed as having gall-stones, were divided into 2 groups for laparoscopic cholecystectomy. Group A received injection bupivacaine instillation in gall-bladder fossa, while Group B did not receive any injection.
Results:Out of 40 patients enrolled as bupivacaine group, 30 were female and 10 were male patients with mean age of 45.45 ± 9.86 years, whereas in control group, there were 33 female and 07 male patients in a total of 40 patients, and the mean age was 45.22 ± 11.62 years. Mean VAS scores in bupivacaine group at 8, 16 and 24 hrs were 4.43, 2.98 and 1.35 respectively, while they were 6.30, 3.15 and 1.43 in controls at 8, 16 and 24hrs respectively. VAS scores tended to be higher in females . Need for post-op analgesia in 1st 8hrs was more in the controls(70%). The need for post-op analgesia at 16hrs and 24hrs after surgery was almost equal in both groups. Post-op pain relief in 1st 8hrs was better in the bupivacaine group i.e. 30% vs. 15% .
Conclusion: The early post-op VAS scores and pain intensity after 8hrs is decreased with the use of intra-peritoneal instillation of injection Bupivacaine, but it offers no added benefit in terms of post-operative pain relief and need for analgesia post-operatively.
Key Words: Bupivacaine, Gall bladder fossa, post-operative pain relief, Laparoscopic Cholecystectomy.

Background: Carbon dioxide insufflation of the peritoneal cavity for laparoscopic surgery offers a unique opportunity to measure some mechanical properties of the human abdominal wall that hitherto have been difficult to obtain. Methods: The movement and change of the abdominal wall during insufflation to a pressure of 12 mmHg was studied in 18 patients undergoing laparoscopic surgery using a remote motion analysis system that does not compromise the sterility of the operative filed. These data together with the known abdominal wall thickness of each patient (measured by preoperative ultrasound scanning) enabled estimates of mechanical stiffness. Results: The findings showed that the abdominal wall changes from a cylinder to a dome during inflation, and that its area is increased by 15%. A volume, averaging 1.27 • 10)3 m 3 , results from expansion, reshaping of the abdominal wall, and displacement of the diaphragm. The abdominal wall is stiffer in the transverse plane than in the sagittal plane (YoungÕs modulus, 42.5 ± 9.0 kPa vs 22.5 ± 2.6 kPa; p = 0.03; paired t-test). Conclusions: Measurements of mechanical properties of the abdominal wall in patients undergoing laparoscopic surgery were obtained using a remote motion analysis system.

Objective: To analyze short term outcomes of laparoscopic ventral mesh rectopexy in the management of complete rectal prolapse (CRP). Method and Material: From July 2017 to Dec 2019 all patients admitted with a diagnosis of rectal prolapse were included in the study. Patients underwent D hoore technique of laparoscopic ventral mesh rectopexy. Prolene mesh was used in all cases. Patients were followed for improvement in bowel function, post operative complications and early recurrences. Results: 12 patients were admitted with a diagnosis of rectal prolapse. Two underwent perineal resections and were not included in the study. 10 patients were included in the study. Median age was 38.6 years (16-50). Male: Female ratio was 1:1. Median operative time was 130min (90-150) Median postoperative stay was 3 days (2-5). All 10 patients had full thickness rectal prolapse and 2 patients had associated vaginal vault prolapse. 8 patients had associated constipation; 1 had incontinence and 1 had per rectal bleed. All patients were discharged on laxatives for three weeks.

Study Objective. To assess the benefits of the combination of a gas drain and the instillation of local anesthetic on the incidence of pain after operative gynecologic laparoscopy. Design. Randomized control trial (Canadian Task Force classification I). Setting. Tertiary referral center. Patients. One hundred twenty-eight patients undergoing operative gynecologic laparoscopy procedures lasting less than 105 minutes. Interventions. Postoperatively, one group received a blocked drain and saline placed intraperitoneally; a second group was given a blocked drain and ropivacaine; a third group received a patent drain and saline; and a fourth was given a patent drain and ropivacaine. Measurements and Main Results. Visual analogue pain scores (VAS) were measured at 1, 2, 4, and 12 hours and day 1 to day 7. Also measured was opioid consumption at 4 hours, nausea, and activity scores. We found a statistically significant improvement in pain scores at 2 and 4 hours in the group allocated to receive a patent drain and ropivacaine. Conclusion. We recommend the use of a gas drain and ropivacaine to reduce postoperative pain.

Case report Ovarian pregnancy is a rarely seen form of ectopic pregnancies. We present a 34-year-old women who had a diagnosis of ovarian ectopic pregnancy based on clinical and laboratory Wndings. Laparoscopic surgery was performed for conservative management of the case. Risk factors are outlined and vaginal douching as a possible cause for ectopic pregnancies have been discussed. Conclusion We suppose that frequent vaginal douching may be a risk factor for the development of ovarian ectopic pregnancies.

Laparoscopic total mesorectal excision (TME) is being used in rectal cancer more frequently. The aim of this study was to analyze the differences in short-term outcomes between open and laparoscopic TME. In this nonrandomized consecutive study, the short-term outcomes of 100 patients undergoing TME for proven rectal cancer were analyzed. Two groups of 50 patients underwent an open or laparoscopic TME for rectal cancer. Both groups were comparable. Laparoscopic surgery took longer to perform (250 vs. 197.5 min, p &amp;amp;amp;amp;amp;amp;amp;lt; 0.01), but was accompanied by less blood loss (350 vs. 800 ml, p &amp;amp;amp;amp;amp;amp;amp;lt; 0.01). Enteric function recovered sooner after laparoscopy. The numbers of major and minor complications were comparable between both groups, although fewer patients had major complications in the laparoscopic group (6 vs. 15 patients, p = 0.03). Hospital stay was shorter for patients who underwent a laparoscopic abdominoperineal resection (10 vs. 12 days, p = 0.04). Median follow-up was 17 months for the laparoscopic group and 22 months for the open group. Survival analyses between the groups showed no statistical difference in disease-free and overall survival. This study shows that laparoscopic TME for rectal cancer is a safe and feasible technique with some short-term benefits over open TME.

In 2011, laparoscopic sleeve gastrectomy (LSG) became the most commonly performed bariatric procedure in France [1] and 2 years later also in the United States [2]. Its frequency has been constantly increasing worldwide. This growth can be explained by several advantages that LSG carries over more complex bariatric procedures, such as Roux-en-Y gastric bypass or duodenal switch, including the absence of most side effects of bypass procedures such as dumping syndrome, marginal ulcers, malabsorption, small bowel obstruction, and internal hernia, and a better quality of life over gastric banding .

To perform single-incision laparoscopic colectomy (SILC) safely while maintaining the minimal invasiveness of SILC and the quality of the lymph node dissection, we have used hybrid single-incision laparoscopic colectomy (H-SILC). Preliminary experience with H-SILC in advanced colon cancer is reported. First, a multi-flap gate was inserted through a 4.0 cm transumbilical incision, and three 5 mm ports were placed in the converter sheet. The procedures were much the same as in usual laparoscopic colectomy excluding a lateral to medial approach. The initial identification or exposure of the ileocolic vessels was performed through a small incision, and lymphadenectomy was mainly achieved using laparoscopic technique. In the course of laparoscopic procedures, whenever we felt stress, we used the techniques of open surgery through the small incision. The procedure was completed successfully without any perioperative complication and no need to extend the skin incision. The operative time was 191 min. Postoperative follow-up did not reveal any umbilical wound complication or any recurrence. Our experience indicates H-SILC is safe and feasible for selected patients with colon cancer with improved cosmesis.

Background: Laparoscopic procedures are increasing in number and extensiveness. Many patients undergoing laparoscopic surgery have coexisting disease. Especially in patients with cardiopulmonary comorbidity, pneumoperitoneum and positioning can be deleterious. This article reviews possible pitfalls related to the combination of anesthesia, positioning of the patient, and the influence of pneumoperitoneum in the course of laparoscopic interventions. Methods: A literature search using MedlineÕs MESH terms was used to identify recent key articles. Crossreferences from these articles were used as well. Results: Patient positioning and pneumoperitoneum can induce hemodynamic, pulmonary, renal, splanchnic, and endocrine pathophysiological changes, which will affect the entire perioperative period of patients undergoing laparoscopic procedures. Conclusion: Perioperative management for the estimation and reduction of risk of morbidity and mortality due to surgery and anesthesia in laparoscopic procedures must be based on knowledge of the pathophysiological disturbances induced by the combination of general anesthesia, pneumoperitoneum, and positioning of the patient.

Background: From 1993 to 1999, 172 patients underwent adjustable silicone gastric banding (ASGB) or laparoscopic adjustable silicone gastric banding (LASGB). In 109 patients the adjustable band was placed via laparoscopy; in the other patients it was placed via laparotomy (prelaparoscopic era, conversions from other bariatric operations, conversions for laparoscopic failure). The conversion rate from laparoscopy to laparotomy was 9.3%, occurring in the early part of our experience.

Background Reports of iatrogenic thermal injuries during laparoscopic surgery using new generation vessel-sealing devices, as well as anecdotal reports of hand burn injuries during hand-assisted surgeries, have evoked questions about the temperature safety profile and the cooling properties of these instruments. Methods This study involved video recording of temperatures generated by different instruments (Harmonic ACE [ACE], Ligasure V [LV], and plasma trisector [PT]) applied according the manufacturers' pre-set settings (ACE setting 3; LV 3 bars, and the PT TR2 50W). The video camera used was the infrared Flex Cam Pro directed to three different types of swine tissue: (1) peritoneum (P), (2) mesenteric vessels (MV), and (3) liver (L). Activation and cooling temperature and time were measured for each instrument. Results The ACE device produced the highest temperatures (195.9°± 14.5°C) when applied against the peritoneum, and they were significantly higher than the other instruments (LV = 96.4°± 4.1°C, and PT = 87°± 2.2°C). The LV and PT consistently yielded temperatures that were \100°C independent of type of tissue or ''on''/ ''off'' mode. Conversely, the ACE reached temperatures higher than 200°C, with a surprising surge after the instrument was deactivated. Moreover, temperatures were lower when the ACE was applied against thicker tissue (liver). The LV and PT cooling times were virtually equivalent, but the ACE required almost twice as long to cool. Conclusions The ACE increased the peak temperature after deactivation when applied against thick tissue (liver), and the other instruments inconsistently increased peak temperatures after they were turned off, requiring few seconds to cool down. Moreover, the ACE generated very high temperatures (234.5°C) that could harm adjacent tissue or the surgeon's hand on contact immediately after deactivation. With judicious use, burn injury from these instruments can be prevented during laparoscopic procedures. Because of the high temperatures generated by the ACE device, particular care should be taken when it is used during laparoscopy.

Wilms tumor is the most common renal malignancy in children. In the 1930s, overall survival for children with Wilms tumor was approximately 30%. Use of multidisciplinary therapy, guided by results from multiinstitutional, randomized trials, has substantially improved overall survival to about 90%. Management of Wilms tumor differs substantially between Europe and the US. In Europe, the International Society of Pediatric Oncology protocols call for management of patients with presumptive Wilms tumor with neoadjuvant chemotherapy followed by nephrectomy and further chemotherapy. In the US, protocols developed by the National Wilms Tumor Study Group advise primary nephrectomy followed by a chemotherapy regimen tailored to the pathologic tumor stage. Despite these disparate strategies, overall survival is similar in patients managed according to European and US protocols. Patients with Wilms tumor now have excellent survival. Therefore, current goals aim to reduce the morbidity associated with therapy. Important complications of treatment for Wilms tumor include cardiomyopathy, renal failure, and increased risk of a secondary malignancy. Currently, the role of laparoscopic surgery in management of Wilms tumor remains extremely limited.

This presentation was prepared by RUTAYISIRE François Xavier and ISHIMWE Diane, Medical students in Year 4(Doctorate 2) at University of RWANDA school of medicine and Pharmacy, Department of Medicine and Surgery. we did the work under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA

The invention consists of three parts made to work together to ensure safe, fast and effective deployment to the end users, which include but are not limited to surgeons and doctors in emergency and operating rooms, occupational hazards equipment goggles, visors and shields, defensive protective armors and high impact vision wear, high performance athletic equipment, and avionics surfaces. The three parts are the anti-fog coating materials composition, their methods of preparation and processing in large, medium or small scale manufacturing, and a single unit delivery device with the coating materials to apply on any existing surface, lens, scope, tools or dials, as a wet or quickly drying coating.

Objectives: This article describes 2 cases of collateral meridian acupressure (shiatsu) therapy (CMAT) for treatment of shoulder tip pain after laparoscopic cholecystectomy (LC). Both cases showed marked pain relief with reduction of skin temperature (1°C) of the affected shoulder after CMAT. Clinical Features: A 32-and a 53-year-old female presented with right shoulder tip pain after LC surgery. The repeated dose of intravenous ketorolac 30 mg and meperidine 50 mg did not improve the pain. Because of persistent pain and episodes of nausea and vomiting after intravenous nonsteroidal anti-inflammatory drugs and opioid medications, patients refused to take more analgesics, and we were consulted for pain management. Intervention and Outcome: After informed written consent obtained, CMAT was performed using acupoints located on the contralateral (left) kidney meridian to treat affected (right) shoulder pain. Postoperatively, patients' pain intensity was measured using a numeric pain scale. The infrared thermography of shoulder tip was obtained before and after the CMAT. Both patients reported immediate pain relief after the CMAT, with pain scores decreased from 5 to 1 of 10 and 5 to 0 of 10, respectively. Moreover, the local skin temperature of affected shoulders were significantly decreased in both patients after the CMAT. Similarly, the temperature difference between patients' affected and nonpainful shoulders were also significant after the CMAT. Conclusion: The results of these 2 cases suggest that the CMAT may be effective in reducing patients' post-LC shoulder tip pain without medication. An associated reduction of skin temperature of the painful shoulder with CMAT warrants further investigation. (J Manipulative Physiol Ther 2008;31:484-488)

In this clinical study hyperbaric ropivacaine in spinal anaesthesia for lower limb and hip surgery was evaluated and results obtained were compared with those using hyperbaric bupivacaine. Methodology: Two hundred patients scheduled for lower limb and hip surgery were randomly divided into two groups of 100 patients each. These patients received a spinal injection of either 3ml (15mg) of 0.5% hyperbaric ropivacaine or 3ml (15mg) of 0.5% hyperbaric bupivacaine using 25G Quincke type spinal needle. The parameters studied were -onset and total duration of sensory block, onset and total duration of motor block, quality of intraoperative anaesthesia, hemodynamic alterations, and any intraoperative and postoperative complications. Results: The mean onset of sensory block (6±1.3min vs. 3±1.1min; p value<0.05) and motor block (13±1.6min vs. 9±1.3min; p value< 0.05) was significantly slower in ropivacaine group as compared to bupivacaine group. The total duration of sensory block was significantly shorter in ropivacaine group (160±12.9min) than in bupivacaine group (260±16.1min; p value <0.05). The mean duration of motor block was also shorter in ropivacaine group compared to bupivacaine group (126±9.2min vs. 174±12.6min; p value<0.05). Conclusion: The quality of anaesthesia was excellent in both the groups. In conclusion, a solution of ropivacaine (hyperbaric) can be used for spinal anaesthesia and is comparable with hyperbaric bupivacaine in terms of quality of block, but has shorter recovery profile.

Condensation on the scope lens as a result of differences between room and intraabdominal temperatures is a disturbing problem for laparoscopic surgeons. Despite the use of anti-lens condensation solutions, this cannot be entirely avoided. The authors report a simple, cheap, and effective method for preventing lens condensation by lens heating using a sterilized thermos flask filled with hot water.

INTRODUCTION
Operative biliary tract injury (TOVB) is a complication encountered mainly after cholecystectomy (CH), whether laparoscopic (CH-L) or open (CH-O), the incidence of TOVB is close to 2 for 103 CH.
MATERIALS AND METHODS
An analytic study carried out including all patients admitted and treated for TOVB at the hepatobiliary surgery and liver transplant department of EHU-1 November 1954, Oran, from January 2010 to May 2018. The objectives were: the study of the epidemiological characteristics of patients, the description of the factors favoring the occurrence of TOVB, the description of the anatomic lesions caused by TOVB, and the analysis of the postoperative morbidity and mortality of patients receiving biliary repair for TOVB.
RESULTS
During this period, 63 patients were admitted for TOVB, the sex ratio was 0.23 with an average age of 45.52 ± 14.02, TOVB was due to CH-L in 50.8%, CH-O in 39.7%, common bile duct lithiasis in 3.2%, liver hydatid cyst surgery in 3.2% and surgery for gallbladder cancer at 3.2%. More than 36% of our patients had undergone a repair before reference and
14.3% were urgently treated at admission for intraperitoneal biliary collection. The most important contributing factor found was acute cholecystitis (42.6%). The biliary lesions were classified according to the "Strasberg" classification, Type A accounted in (3.2%) of the cases,
B (0%), C (3,2%), D (1.6%), E1 (6.3%), E2 (36.3%), E3 (31.7%), E4 (14.3%), E5 (3.2%),
vascular injury was present in 8.8 % of patients. The median repair time was 06 months [0-171 months].
Fifty-seven patients had biliary repair, immediate postoperative mortality was 3.5%, postoperative complications were found in 31.6% of patients, median postoperative stay was 8 days. All of our patients had grade I and grade II repair results according to the Terblanche classification. The mean recoil in our patients was 36.12 ± 25.99 months.
CONCLUSION
The epidemiological characteristics of our patients are similar to those of the international publications, the results of our repairs are good and that would be explained by the respect of the recommendations by our team to ensure a good repair, the low rate of vascular lesion, and the retreat considered to be average. The long repair delay is due to the delay of transfer.

Electrosurgery is the most commonly used and misunderstood technology by all surgical and medical disciplines. A lack of basic knowledge or ignorance of principles of electrosurgery and equipment among obstetricians and gynecologists is reported. As a result, thermal injuries during laparoscopic electrosurgery occur, which frequently lead to significant morbidity and mortality and medicolegal actions. Surveys indicate that up to 90% of general surgeons and gynecologists use monopolar radiofrequency (RF) during laparoscopy, 18% have experienced visceral burns, and 13% admitted 1 or more ongoing cases of litigations associated with such burns. This article describes the basics of electrosurgery beginning with the generation of electrons and their physical characteristics and governing laws before their arrival in the operating room where they are fed to an electrosurgical unit (ESU) to boost their frequency with step-up transformers from 60 Hz to .500 000 Hz. This RF creates heat, resulting in dissection, desiccation, coagulation, and fulguration of tissues without neuromuscular stimulation, pain, or burn to the patient. The ESU delivers power (wattage 5 volts ! amps) in monopolar or bipolar (1 vs 2 high-density electrodes) configuration. Because of RF, monopolar electrosurgery compared with other energy sources is associated with unique characteristics, inherent risks, and complications caused by the requirement of a return/dispersive electrode, inadvertent direct and/or capacitive coupling, or insulation failure of instruments. These dangers become particularly important with the popular and frequent use of monopolar electrodes (hook, needle, and scissors) during cholecystectomy; robot-assisted surgeries; and the re-emergence of single-port laparoscopy, which requires close proximity and crossing of multiple intraabdominal instruments outside the surgeon's field of view. Presently, we identify all these potential risks and complications associated with the use of electrosurgery and provide suggestions and solutions to mitigate/minimize these risks based on good clinical practice and sound biophysical principles.

Objective Takayasu’s Arteritis (TA) is a rare inflammatory disease of medium and large size arteries that affects women of reproductive age. This study aims to highlight the antenatal management and analyze the obstetric outcome in women with TA. Methods This retrospective study was carried out in the Department of O&G, Cardiology and Rheumatology—IPGME&R, Kolkata from June 2002 to July 2010. Sixteen patients with 29 pregnancy events were compared with 60 matched controls. Results Clinical presentation of study population at admission included unequal or absent pulse, hypertension, congestive cardiac failure, retinopathy, aortic regurgitation and cerebrovascular accident (CVA). Mode of delivery was cesarean in 20 pregnancies (71.49%) and vaginal in nine pregnancies (31.03%). Significant maternal complications included pregnancy induced hypertension (100 vs. 1.66%; P < 0.001), preeclampsia (92.85 vs. 0%; P < 0.001), postpartum hemorrhage (17.24 vs. 1.66%; P < 0.001) and preterm labor (17.24 vs. 3.33%; P < 0.001). One maternal mortality was present due to CVA. Neonatal outcome showed 26 live births with increased incidence of intrauterine growth restriction (51.72 vs. 1.66%; P < 0.001) and neonates requiring NICU admissions (58.62 vs. 5.0%; P < 0.001). Conclusion Although conception was spontaneous in all these pregnancies, antenatal and intrapartum control of blood pressure played a pivotal role in pregnancy outcome. High rate of operative interference was present. All subsequent pregnancies had similar outcome due to slow progression of the disease. Although pregnancy was complicated by hypertension and its sequelae, successful outcome could be achieved with timely admission, judicious medication and multidisciplinary approach.

Background: Nonobese patients undergoing laparoscopic procedures present a dilemma as to the correct mode of entry into the abdominal cavity because the Veress needle (VN) technique seems to be associated with a high risk of vascular and visceral injuries. Direct trocar insertion (DTI) has been reported as an alternative to the VN for creation of the pneumoperitoneum.

Background Although laparoscopic appendectomy has some advantages over open appendectomy, some reports do show more postoperative intraabdominal abscesses. Methods A retrospective review of complicated appendicitis managed surgically by eight surgical groups from six countries was undertaken. Among 3,433 patients with appendicitis, 1,017 (29.5%) had complicated appendicitis, which included perforated or gangrenous appendicitis with or without localized or disseminated peritonitis. There were 74 preoperative abscesses (7.4%) and 5 small bowel obstructions. Results One patient died. There were 29 postoperative intraabdominal abscesses (2.8%) and 112 mostly minor complications. Conversion to laparotomy was necessary for 28 patients (2.7%). The surgical time ranged from 32 to 132 min (mean, 62 min), and the hospital stay ranged from 1 to 18 days (mean, 3.5 days). Conclusions The morbidity rates, particularly for intraabdominal abscesses, were less for laparoscopic appendectomy in complicated appendicitis than those reported in the literature for open appendectomy, whereas operating times and hospital stays were similar.

Background: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. Methods: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. Recommendations: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. Conclusions: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Development of miniinvasive surgery determinates a rapid improvement in laparoscopic regional anatomy. As laparoscopy is becoming common in most surgical departments, basic laparoscopic anatomy is mandatory for all residents in general surgery. Successful general surgery starts in the anatomy laboratory. Successfully minim invasive surgery starts in the operative theatre with laparoscopic exploration. The initial laparoscopic view of the right upper quadrant demonstrates primarily the subphrenic spaces, abdominal surface of the diaphragm and diaphragmatic surface of the liver. The falciform ligament is a prominent dividing point between the left subphrenic space and the right subphrenic space. The ligamentum teres hepatis is seen in the free edge of the falciform. Upward traction on the gallbladder exposes the structures of Calot's triangle and the hepatoduodenal ligament. The liver is divided into anatomic segments based on internal anatomy that is invisible to the laparoscopist. Surface landmarks include the falciform ligament and the gallbladder fossa. The surgical procedures performed laparoscopically currently include liver biopsy, wedge resection, fenestration of hepatic cysts, laparoscopic approach of the hidatid hepatic cyst, and atypical hepatectomy. We present the laparoscopic anatomy of extrahepatic biliary tract. Once the gallbladder is elevated, inspection reveals Hartmann's pouch and the cystic duct. The typical angular junction of the cystic duct on the common duct actually occurs in a minority of patients and the length and course of the cystic duct are highly variable. The boundaries of Calot's triangle are often not well seen. The cystic artery is often visible under the peritoneum as it runs along the surface of the gallbladder. The variations of the structures of the hepatoduodenal ligament may occur to injuries during laparoscopic cholecystectomy. Cholangiography increases the safety of dissection of biliary tract by providing a "road map" and generally precedes the dissection in cases of anatomical variations. Intraoperative evaluation represents a strong argument for above dates.

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce lessthan-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a "liver suspension tape" that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P<0.001). Patients treated with the fiveport method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P=0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P=0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.