Course Offer

5 Days Intensive Laparoscopy Training Programme.

Handling of laparoscopy Instruments and Ergonomic Principles.

Personal Tution for Theoritical and Practical Aspects of Laprosocopy.

Understanding the Newer Energy Sources in Laparoscopy. Which? When? Where?

Knowledge of Bites & KNOTS.

Handling of Needle Intracorporeally.

Hands on Training on

  •           A. Endotrainer Modules
  •           B. Live Animal tissue
    •                     >> Best Stepwise Training Method.
    •                     >> Training on Porcine Tissue and Trainer.
    •                     >> Tips and Tricks in Laparoscopy Surgery by Experts.
    •                     >> Self Paced and Flexible Programme.
    •                     >> Developement of
      •                               a. Port Placement Techniques / Insufflation.
      •                               b. Camera and Scope Manipulation.
      •                               c. Hand eye Co-ordination.
      •                               d. Manual Dexterity.
      •                               e. Depth Perception.

Ligating a Bleeding Vessel.

  •           A. Clip application
  •           B. Structuring
  •           C. Electrocautery Operation Theatre.

Avoiding CBD Injury in Laparoscopy Cholecystectomy.

Performing Laparoscopy Appendectomy, Laparoscopy Cholecysectomy in Porcine Model.

Retrieval of the Specimen Do's & Dont's.

Feast of watching Live Surgery in Operation Theater by Experts.

Laparoscopic Training Program

Successful Intensive Laparoscopic Training Programs held at Gateway Clinics and Hospital Pvt Ltd,Coimbatore, Attended by Surgeons from all over India.

Laparoscopic Hartmann Procedure Reversal (LHPR)

Laparoscopic Hartmann procedure reversal (LHPR) is the closure of a colostomy following the formation of a colorectal anastomosis.

Primary goals of LHPR are as follows:

1 ) To restore optimal digestive functionality

2) Closure of the ostomy site

3) To establish anatomic uniformity in the gastrointestinal tract through the anastomosis of the remainder of the descending colon with the rectal stump

Procedure in Brief : -

Adhesions are lysed with care to minimize electrical current use and avoid bowel injury. The mobilization of the rectal stump is done. The circular end-to-end anastomosis (CEEA) stapler is then inserted transanally and manipulated to the top of the rectal stump. The intra-abdominal colostomy is dissected and the bowel mobilized.

The proximal colon and splenic flexure are then dissected. Splenic flexure mobilization is completed as needed to ensure a tension-free anastomosis. The anvil of the stapler is then purse-stringed to the distal end of the proximal bowel and deployed. Once the anastomosis has been successfully created, the stapler should be carefully removed to avoid further bowel disruption. The anastomosis is immersed in saline solution, and air is introduced transanally to check for possible anastomotic air leakage. The pelvis is then irrigated with saline solution, and hemostasis is checked.

Case of Laparoscopic

This is a case of Laparoscopic internal drainage of Pseudocyst of pancreas by cysto gastrostomy

Impression(MRI of abdomen):- Large thick walled fluid collection (17.0cm x7.4cm x 8.3cm) containing solid debris replacing the body and tail of pancreas -pseudocyst of pancreas with walled - off pancreatic necrosis.

Indication for drainage of Pseudocyst of pancreas include the following:

a) complication

b) symptoms

c) concern about possible malignancy.

Drainage options are outlined below :

1.Percutaneous aspiration is useful only to establish a diagnosis or as a temporizing measure

2.Endoscopic drainage may be either:- a) Transpapillary (via endoscopic rectrograde cholangiopancreatography [ERCP] or b) Transmural.

3.Surgical drainage :-a)External b) Internal

Internal drainage is the procedure of choice. Laparoscopic approach has been used with good results.

Laparoscopic Right Inguinal Infected Mesh Removal

Postsurgical mesh-related infections are rare or under-reported but troublesome complication that cause considerable morbidity and necessitate mesh removal. Antibiotics and mesh-saving operations are not sufficient to eradicate the infection in the majority of cases.

A combined medical and immediate surgical approach involving intravenous antimicrobial agents and complete surgical removal of the mesh is suggested for mesh-related infections to reduce the risk of infection recurrence or severe complications, such as visceral adhesions and fistulae. Conservative surgical approaches such as abscess drainage, sinus excision or partial mesh excision can fail and result in recurrent mesh infections Complete mesh removal ensures infection eradication and rarely results in hernia recurrence if sufficient fibrous scarring remains.

Here we present a case of Laparoscopic Right inguinal mesh removal, referred from periphery where Laparoscopic TAPP repair was done 9 months ago on this young male patient. Patient presented with symptoms of High grade fever with chills and severe pain in right groin region for 2 months, for which he was managed conservatively. USG of the right inguinal region revealed "foldings" of the prosthetic mesh with abscess.

Transabdominal Preperitoneal Technique: TAPP

A laparoscopic repair where peritoneal cavity entered, the peritoneum incised, preperitoneal space entered, and mesh over the hernia defect placed; the peritoneum is then sutured or tacked.

Tips : - It is recommended that the patient empty his/her bladder before the operation.

Restrictive per- and postoperative intravenous fluid administration reduces the risk of postoperative urinary retention.

If you expect technical difficulties (e.g., after prostatic surgery, Scrotal hernia) or an extended operating time, consider using a urinary catheter during the intervention.

Here we present a Case of Reducible Left Sided Direct Inguinal Hernia for Laparoscopic TAPP Repair.

Parastomal Hernia

An ostomy is an artificial opening through the abdominal wall for the intestine or ureter in order to discharge feces or urine. Hernias that are associated with colostomies, ileostomies, jejunostomies or urostomies, where viscus penetrates the abdominal wall are called as paraostomal hernias.

A paraostomal hernia occurs in patients who have inadequate wound healing between the ostomy tunnel & the viscus that extends through the abdominal wall. Any condition that decreases wound healing in the early postoperative period will increase the incidence of paraostomal hernia. Poor nutrition, progressive cancer, obesity, and poor surgical technique that interfere with adherence of bowel wall and abdominal wall are prominent causative factors. The others are coughing, sneezing & ascites.

Today, We present case of a middle aged male patient who underwent Laparoscopic APR one year ago, and now presented with swelling with discomfort and occassional pain in parastomal region for last few months.

Incisional Hernia

Today we are presenting an interesting case of Incisional hernia in a young male who underwent Right iliac bone graft for cervical spine surgery 3 years ago, now presented with swelling over Right iliac region since 6 months. Sometimes the situation is tricky & decision is difficult ;

how to manage such case whether to go for total intraperitoneal Onlay Mesh repair, or pre peritoneal repair ?

How to fix the mesh in such situation ?

Taking various things into consideration, we decided to go for pre- peritoneal mesh repair.

Patient placed in supine position with left lateral tilt of 45' & camera port was placed on left side of umbilicus in mid- clavicular line & working ports on either sides.

The contents were reduced & peritoneal flap raised, sac was dissected, adequate space created to place the 15X15 cms POLYPROPYLENE mesh . Mesh was fix over the iliac bone and muscle above and peritoneal flap was sutured.

Chronic Ruptured Ectopic Tubal Pregnancy

30yrs old Para1 Live1 , Previous LSCS , Last Child Birth : 2yrs, admitted with severe lower abdominal pain, pelvic discomfort and irregular bleeding Per Vagina for past 1 month. Patient taken pills ( Mifegest and Misoprost ) for termination of pregnancy in January from medical shop (without medical supervision or consultation or prior ultrasound).

All her problems started after this and was evaluated and treated symptomatically for this one month in her native place but with no improvement. She was gradually becoming weaker and anaemic and referred to us with USG report of left tuboovarion mass and free fluid. On Laparoscopy there was around 500ml of blood in pelvis, ruptured tube and an organised friable mass, adhesions between tube, ovary, omentum and intestine because of the chronicity of blood leakage. Adhesions released, Left salphingectomy done, Mass removed using Endobag. Thorough lavage done.

Enterocutaneous fistula

Today we present a case of 61 years old lady with Enterocutaneous fistula with previous History of laparoscopic mesh repair (IPOM Repair for Incisional Hernia, Composite dual Mesh was used for this surgery elsewhere).This is a Low output ECF ( discharge < 200 ml per day), anatomical location - Small intestine,Cause - Mesh eroding into small bowel

Discussion :

An enterocutaneous fistula (ECF) is an abnormal connection that develops between the intestinal tract or stomach and the skin. As a result, contents of the stomach or intestines leak through to the skin.Most ECFs occur after bowel surgery. Other causes include infection, perforated peptic ulcer, inflammatory bowel disease, Crohn's disease or ulcerative colitis. An ECF may also develop from an abdominal injury or trauma, such as a stabbing or gunshot.

Unfavorable factors for spontaneous closure :-

When an ECF is associated with adverse factors, then spontaneous closure does not commonly occur, and surgical intervention, despite its associated risks, is frequently required.Factors preventing the spontaneous closure of an ECF can be remembered by using the acronym FRIEND, which represents the following :

F oreign body (eg - Mesh in our case here)

R adiation

I nflammation/infection/IBD

E pithelialization of the fistula tract

N eoplasm

D istal obstruction

In addition, lateral duodenal, ligament of Treitz, and ileal fistulas have less tendency to spontaneously close. In the postoperative period, it is necessary to ensure that the patient continues to receive full nutritional support. Adequate protein and calories must be provided to maximize healing and minimize complications.

Rectal prolapse

Rectal prolapse was described as early as 1500 BC. Rectal prolapse occurs when a mucosal or full-thickness layer of rectal tissue protrudes through the anal orifice Problems with fecal incontinence, constipation, and rectal ulceration are common.

Three different clinical entities are often combined under the umbrella term rectal prolapse:

  • Full-thickness rectal prolapse
  • Mucosal prolapse
  • Internal prolapse (internal intussusception).

Today we present a case of full thickness inacarcerated rectal proplase in elderly,which could not be reduced since 15 days and had severe pain.

Approach Consideration:

In adult patients, treatment of rectal prolapse is essentially surgical; no specific medical treatment is available. (Children, however, can usually be treated nonsurgically and by managing the underlying condition.) Which repair constitutes the best treatment is the main controversy in surgery for rectal prolapse. All of the procedures have their proponents, and there is no right answer.

A laparoscopic approach to rectal prolapse repair has become increasingly popular. This approach has intensified the controversy because it has decreased the morbidity of the abdominal approach to rectal prolapse in appropriate candidates. Long-term results of the laparoscopic approach are still being studied.

If the prolapse cannot be reduced and the viability of the bowel is in question, emergency resection is required. Rupture of the rectum also constitutes a surgical emergency. On the whole, the abdominal procedures have a lower recurrence rate but a higher morbidity. Accordingly, older, debilitated patients (whose life expectancy is shorter) are generally treated with perineal procedures, whereas younger, healthier patients are typically treated with abdominal procedures.

Looking to his comorbidity and the age we planned to do Altemeier’s procedure (Perineal Rectosigmoidectomy) for this patient.

Altemeier perineal rectosigmoidectomy

In an Altemeier perineal rectosigmoidectomy, a full-thickness circumferential incision is made in the prolapsed rectum about 1-2 cm from the dentate line .The hernia sac is entered, and the prolapse is delivered. The mesentery of the prolapsed bowel is serially ligated until no further redundant bowel can be pulled down. The bowel is transected and either hand-sewn to the distal anal canal or stapled with a circular stapler.

Many studies have concluded that this operation is relatively safe and effective in frail, older patients, with postoperative morbidity being low. However, the recurrence rate after the procedure was not negligible, and the operation was found to be unpredictable in terms of restoring continence. Recurrences can be treated with a repeat Altemeier procedure.

GERD(Gastroesophageal reflux disease)

Dr. Rudolf Nissen (1896-1981) described the first fundoplication in the 1950s for treatment of severe reflux esophagitis. His original procedure used a 360-degree wrap of the fundus of the stomach around the esophagus by plication of both the anterior and posterior walls of the gastric fundus around the lesser curvature. Although the standard Nissen fundoplication has been modified many times, laparoscopic Nissen fundoplication is now considered the standard surgical approach for treatment of GERD.

Surgical therapy for GERD is an equally effective alternative to medical therapy & should be offered to appropriately selected patients by appropriately skilled surgeons (Grade A). Laparoscopic antireflux surgery is effective at restoring the mechanical barrier to reflux with significant improvements in the LES pressure and acid reflux exposure, can be performed safely with minimal perioperative morbidity and mortality, and leads to high patient satisfaction rates and improved quality of life. Surgeons should be aware that fundoplication in patients demonstrating poor compliance or poor response to preoperative PPI treatment is associated with poorer outcomes.