Introduction: Currently, in the era of robotic surgery and advancement of laparoscopic technology, the place of open surgery has been reduced. However, the use of laparoscopic surgery for peptic ulcer disease is not yet a consensus. Materials and methods: All patients who had been operated for perforated peptic ulcer (PPU) disease from January 2005 to December 2014 in our hospital were reviewed retrospectively. Patient demographics, perioperative and intraoperative details, and surgical outcomes were evaluated. The objective of our study is to compare the clinical and surgical outcomes of patients who underwent either laparoscopic or open procedure as well as to demonstrate if laparoscopic repair (LR) technique has advantages to open repair (OR) in terms of morbidity and mortality. Results: We diagnosed 159 patients with PPU during the study period. LR was performed for 65 (41%) patients, and the remaining patients underwent OR. Morbidity of medical and surgical complication was higher in open groups (21 vs 2) (p value = 0.0001). The most frequent complication in both groups was medical complication. Overall, 16 patients in the OR group had medical complications vs 2 patients in the LR group (p value = 0.009). Surgical complication was higher in open groups (7 vs 0) (p value = 0.04). Mortality was statistically higher in the open group. We did not report any death in the laparoscopic group. However, six deaths were identified in the OR group (p value = 0.04). Conclusion: Our results indicate that LR for PPU was a safety option with fewer rates of morbidity, reoperation, and mortality compared to OR.

Background: Polycystic ovary syndrome (PCOS) is commonly encountered in women with anovulatory infertility. The surgical ovarian drilling procedure aims to restore spontaneous ovulatory cycles. This function is similar to the goal of clomiphene citrate and/or metformin. Objective: We conducted this study to determine the outcome of laparoscopic ovarian drilling (LOD) among patients who presented with clomiphene-resistant PCOS. Materials and methods: The study was prospective in design. We studied 43 patients with clomiphene-resistant PCOS who had laparoscopic ovarian drilling (LOD) using monopolar diathermy at the Bowen University Teaching Hospital, Ogbomoso. The study took place between January 2014 and June 2016. Clinical data recorded at different intervals of follow-up included the menstrual pattern and reproductive history. Results: We successfully performed laparoscopic ovarian drilling without any complication. Four (9.3%) of the patients were lost to follow-up. Thirty (76.9%) of the remaining 39 patients resumed regular menstrual cycles with spontaneous ovulation, while 23 (59.1%) patients achieved spontaneous pregnancy within 6 and 18 months following LOD. No record of multiple pregnancies. Factors associated with failed LOD treatment included obesity and a long duration of infertility. Conclusion: LOD is a feasible and effective first-line treatment option in patients with clomiphene-resistant PCOS in sub-Saharan Africa. Emphasis should be on weight reduction with early application of LOD to treat patients with clomiphene-resistant PCOS. This will reduce the time to achieve pregnancy and the need for gonadotropins to induce ovulation.

Purpose: This study aimed to assess safety, feasibility, complications, and time of direct first trocar insertion (DFTI) with carbon dioxide (CO₂) insufflation and operating time in laparoscopic surgery. Materials and methods: This study was a prospective cohort study (clinical original) performed at AL-Karama Teaching Hospital/College of Medicine, Wasit University, Iraq, from April 2011 to December 2017. The study enrolled 687 patients prepared for different laparoscopic procedures using direct first trocar insertion techniques for laparoscopic entry. Conversion of laparoscopic entry to Veress needle (VN) or open technique was performed when direct first trocar insertion technique failed. Recorded data were age, sex, indications for laparoscopic surgery, time of direct first trocar insertion with CO₂-insufflation, operating time, and direct first trocar insertion-related complications. Results: Direct first trocar insertion technique was successful in 684 (99.57%) patients and failed in 3 patients when trocar entry was converted to Veress needle technique. These three patients were excluded from the statistical analysis of the study data. Demographic distribution of the patients was as follows: 90 (13.2%) males and 594 (86.8%) females. This study had no major complications, while minor complication rate was 1.31%. Mean ± standard deviation (SD) of direct first trocar insertion with CO₂-insufflation time for males, females, and total patients was 2.32 ± 0.57 minute (m), 1.89 ± 0.53 m, and 1.95 ± 0.56 m, respectively. p value was 0.03 and was statistically significant. This study had no mortality. Conclusion and clinical significance: Direct first trocar insertion is a safe and cost-effective laparoscopic entry technique. It has a high feasibility rate, low complication rate, fast laparoscopic entry, and fast creation of pneumoperitoneum.

Context: Total laparoscopic hysterectomy (TLH) is a popular mode of hysterectomy in the recent times. One of the principal steps is vaginal cuff closure, with many variations in surgical technique and materials. Intracorporeal suturing and knot-tying are crucial steps and are considered to be the most technically difficult skills. To overcome these challenges and learning curve, various measures have been emerging. One among them is the introduction of barbed suture, a new class of suture material. Aim: To evaluate whether the use of barbed suture for vaginal cuff closure during TLH reduced the surgical difficulty and suturing time when compared to polyglactin 910 suture. Materials and methods: This randomized comparative study included 100 patients divided into two groups of 50 each, who underwent TLH with vault closure using either barbed sutures or polyglactin 910. Demographic details, indication for surgery, intraoperative complications, mean suturing time, surgeon difficulty, and average hospital stay were compared between the two groups. Statistical analysis: Student t test for continuous variables and Fischer exact test for categorical variables. p values ≤ 0.05 were considered significant. Results: Use of barbed suture has significantly reduced the suturing time for vaginal vault closure (5.39 vs 6.9 minutes, p value < 0.0001) as well as the technical difficulty in laparoscopic suturing (p value < 0.0001) when compared to that with polyglactin 910. Conclusion: The introduction of barbed sutures for vault closure during TLH not just reduces the suturing time but is also technically less demanding, making it a potential asset in laparoscopic hysterectomies.

Aim: Laparoscopic sleeve gastrectomy with loop duodenal switch (SLDS) surgery is a loop modification of biliopancreatic diversion with duodenal switch (BPD-DS) aimed at reducing malabsorption without compromising on the efficacy. This study aimed to analyze the safety and feasibility of SLDS surgery in Indians suffering from obesity. Materials and methods: This was a retrospective study analyzing 169 patients who underwent SLDS surgery between November 2013 and June 2020. The cohort was divided into two subgroups based on the common channel length—2.5 and ≥3 m. Weight-loss parameters, diabetes remission, and investigations at 6 months and 1 year follow-up were analyzed in the total cohort and common channel subgroups. The percentage of total weight loss (%TWL) ≥25% was considered as a successful weight-loss outcome. HbA_1C <6% without the need for antidiabetic medications was considered as complete diabetes remission. Safety was analyzed in terms of intraoperative and postoperative complications. Results: Mean preoperative body mass index was 45.39 ± 7.6 kg/m². 48.52% of the patients were suffering from type II diabetes. Mean %TWL was 30.91 ± 4.98 and 41.86 ± 7.63% and complete diabetes remission was 81.82 and 89.06% at 6 months and 1 year follow-up, respectively. The percentage of total weight loss was inversely proportional to the common channel length. Complete diabetes remission was not significantly affected by the common channel length. Serum albumin <3 gm/dL was significantly high in patients with a common channel length of 2.5 vs ≥3 m—25 vs 4.65% at 6 months and 40 vs 7.14% at 1 year follow-up, respectively. Thirty-day mortality was zero. Conclusion: Sleeve gastrectomy with loop duodenal switch surgery appears to be effective and safe in Indian patients. Malabsorption risk is greatly reduced when the common channel length is ≥3 m. Clinical significance: Sleeve gastrectomy with loop duodenal switch surgery with the common channel length ≥3 m simplifies BPD-DS, gives excellent weight loss and diabetes remission with minimal malabsorption. Restricting the biliopancreatic limb to ≤55% prevents adverse malabsorptive consequences.

Introduction: Adrenal is one of the most feared organs owing to its anatomical position. However, adrenalectomy by laparoscopic means has now been adopted as the procedure of choice to treat benign and malignant functioning and nonfunctioning adrenal tumors. We describe our experience with laparoscopic adrenalectomy (LA) in 37 patients at a tertiary institute and try to predict factors for open conversion. Materials and methods: Thirty-seven patients who underwent LA from August 2013 to February 2018 were retrospectively analyzed and factors leading to conversion to open adrenalectomy assessed. Results: Among 37 patients, 31 had pheochromocytoma on histopathology and 1 patient had adrenal hyperplasia leading to Cushing's syndrome. Five out of 37 patients had to be converted to open technique—multiple adhesions with the bowel, retrocaval tumor extensions, difficult dissection, and prolonged operative time due to large tumor size (in two patients) and severe hepatomegaly were the reasons for conversion to open. Conclusion: Laparoscopic adrenalectomy is safe and feasible for large adrenal lesions.

Introduction: The rate of transfusion associated with emergency laparoscopic general surgery has been shown to be 0.36%. A significant number of patients undergo group and antibody screening due to perceived risk of hemorrhage. All NHS hospitals have massive transfusion policies with immediate availability of O-negative blood. Blood group and antibody screening carries a cost of £35. The aim of this study was to determine the cost-effectiveness of group and antibody screening vs crossmatching where required. Materials and methods: All patients undergoing emergency appendicectomy over a 3-year period were retrospectively identified. The transfusion service then identified whether blood had been issued. Results: A total of 645 emergency appendicectomies were identified: 603 were laparoscopic and 42 open. One (0.2%) patient received a transfusion of 2 units. Discussion: Our study has shown a rate of transfusion of 0.2%. If patients were crossmatched as required rather than group and screening, this would give a cost saving of £35 per patient or £22345 across our trust. There are 50,000 appendicectomies per year in the United Kingdom. If this saving were extrapolated, it would generate a saving of £1.1M. Conclusion: Our recommendation would be to crossmatch where required. The cost saving to the NHS could be up to £1.1M with little impact on the demand for O-negative blood.

Background: Vesicovaginal fistula (VVF) is an embarrassing condition for women. Various routes of surgical intervention exist for the management of VVF. Laparoscopic repair is safe and effective. Aim and objective: To review the success rate of laparoscopic repair of VVF and to highlight the benefits/advantages of the laparoscopic approach. Materials and methods: Using various databases, previous studies of patients who underwent laparoscopic VVF repair between 2008 and 2018 were reviewed. Outcome measures from these studies were success rate, mean blood loss, mean operating time, length of hospital stay, major intraoperative complications, and conversion to open surgery. Results: Fourteen retrospective studies (full-text articles) were retrieved and reviewed. Two hundred and sixty-nine patients had a laparoscopic repair. The pooled success rate was 96.7%. Mean blood loss ranged from 30 to 400 mL, length of hospital stay ranged from 1.1 to 7.8 days while the mean operating time ranged from 54 to 229 minutes. There was only one major intraoperative complication. Only four patients had to be converted to open surgery. Conclusion: Laparoscopic repair of VVF has a high success rate and is a safe, patient-friendly, and cost-effective route for surgical management of VVF.

Aim and objective: To study the various types of laparoscopic management of antenatal ovarian torsion, their advantages, disadvantages, and its outcome in pregnancy. Background: Ovarian torsion in pregnancy occurs at a rate of about 1 in 5,000 cases. It is a life-threatening condition if not attended to and intervened promptly. Recent years have seen the advent of laparoscopy as a preferred means of management for ovarian torsion in pregnancy. This review article analyzes a series of articles over a span of 5 years from 2014 to 2018 on laparoscopic management of ovarian torsion in pregnancy and its outcome. Results: Various procedures like ovarian detorsion, cystectomy, ovarian cyst puncture, ovariopexy, shortening of the utero-ovarian ligament, and oophorectomy are performed by expert hands. While advantages include quick recovery and early discharge from hospital, disadvantages are a long learning curve and increased need for training. This has led to many uneventful pregnancies with term live births. Conclusion: Each type of laparoscopic management for antenatal ovarian torsion has its pros and cons. Nevertheless, the outcome of the pregnancy has been excellent in the majority of the laparoscopically managed cases. Clinical significance: Laparoscopic management of antenatal ovarian torsion has reduced intraoperative blood loss, improved postoperative pain, and led to a quick recovery, early discharge from hospital, and return to daily activities. Clinicians need to be adequately trained to be competent in performing various laparoscopic surgeries.

Aim and objective: To show the advantage of endoscopic approach for lateral ectopic thyroid removal. Background: Ectopic thyroid tissue lateral to midline is very rare. Because of its unusual location, lateral ectopic thyroid gland can cause diagnostic difficulties when diseased. Case description: Here we are presenting a case of a male patient with submandibular ectopic thyroid tissue with multinodular goiter and absent thyroid tissue in normal anatomic site. He underwent endoscopic-assisted total thyroidectomy. This technique for ectopic thyroid removal has not been reported in the literature so far. Conclusion: Endoscopic approach for removal of the diseased gland will allow for a magnified view of the adjoining structures and better cosmesis for the patient. Clinical significance: Lateral ectopic thyroid should be in differential diagnosis of lateral neck swelling.

Background: Postoperative issues with the vaginal vault after hysterectomy for benign or malignant conditions are not common. However, these include vault hematoma, granuloma, keloid, incisional hernia, vascular formation, and recurrence of pelvic malignancy at the vault. Case description: A 47-year-old woman with a history of breast cancer surgery under tamoxifen developed endometrial carcinoma stage 1 for which she underwent staging laparoscopy 1 year ago. She presented with a vaginal cuff tumor of 3 cm detected vaginally 3 months later which was suspicious of recurrence. Laparoscopic management was done and circumferential excision of vaginal cuff margin and repair was done. The final pathology report revealed infection and granulation tissue in the excised margin. Conclusion: Management of vaginal cuff complications following hysterectomy can be feasible by minimally invasive surgery regardless of indication of primary surgery.

Aim and objective: This article aims to conceptualize the modification in the laparoscopic port to minimize the risk of COVID-19 virus transmission through the aerosol during laparoscopic procedures. Background: A recent situation of COVID-19 pandemic has produced so many new unknown challenges for surgeons. Surgical fume is a known theoretical biohazard for the operating team. There are many suggestions from the international and national surgical societies and already available equipment which could minimize the risk transmission. Still, there is no technique available to contain and discharge surgical fume in the proper way. Here, we conceptualize a technique to reduce the risk of COVID-19 transmission in the operating team. Technique: Here, we have suggested the modification in the laparoscopic port. We advise adding an intermediate transparent, pliable, polythene/silicon bag that could able to contain the leaked surgical fume and safely discharge in an underwater seal bottle, filled with sanitizer liquid. Conclusion: The theoretical, potential risk of COVID-19 transmission during laparoscopic surgery has raised many doubts and apprehension of virus transmission through the surgical fume. There are many suggestions and available equipment to minimize the spread; however, no definite solution already out surgical fume; here, our suggestion of modification in port could be a permanent solution to the surgical fume problem. However, this is an initial concept that has the potential to addition and suggestion to improve the technique. Clinical significance: The theoretical risk of surgical fume causing COVID-19 virus transmissions completely changes our surgical practice. Here, in this article, we suggested our concept and technique contain and safely discharge of surgical fume during laparoscopic surgery.