Laparoscopic anti-reflux surgery is a commonly performed surgery for gastro-oesophagal reflux disease and hiatus hernia. One of the life-threatening complications post fundoplication is acute migration of the wrap, into the mediastinum thus leading to ischaemia and gangrene of the herniated stomach, the time of presentation being within 7 days from index surgery. We present a series of 10 patients who had acute trans-diaphragmatic migration of wrap (in three patients with wrap disruption, there was migration of the entire stomach). The study design is a retrospective study design. All 10 patients underwent laparoscopic management of their acute migration within 24 h of presentation following an urgent computed tomography scan to define the anatomy, the type of migration and vascularity of the stomach, as well as to rule out any concomitant collapse of the affected lung. The median age was 41 (38-70 years), and 7 were females and 3 males. All patients underwent reduction of herniated wrap, crural repair and seven patients underwent a posterior partial fundoplication, two patients underwent gastropexy and one patient had proximal gastric resection in view of non-viability of the proximal stomach in view of delayed diagnosis. Postoperatively, all patients (except one patient) were started on liquids followed by soft diet for a week. At a follow-up of 2 years, only two patients are on intermittent proton pump inhibitor use, the rest all others are free of any symptoms with no evidence of recurrence of hiatal hernias on follow-up imaging. Acute transdiaphragmatic wrap migration (<7 days from index surgery) requires a high index of suspicion with an emergent laparoscopic repair, to avoid life-threatening complications. The principles of surgery are to recognise the cause, restore the anatomy back to normal. A secure crural closure and a partial wrap with anchoring the wrap to the crura is equally important to avoid wrap migrations with gastropexy as a bailout choice. The key is to avoid postoperative retching and vomiting by suitable anaesthesia and antiemetics postoperatively. The use of indocyanine green dye can be helpful whenever vascularity is a concern. And lastly, tailored use of mesh along with PoRSHA can be used for reinforcement of crural closure when the crura are thin or when the inter-hiatal distance is >5 cms to avoid recurrences.

Laparoscopic repair has become the preferred approach for inguinal hernia due to its lower post-operative morbidity and faster recovery. However, the choice of mesh fixation remains a topic of debate. Self-adhesive meshes were developed to eliminate the need for mechanical fixation, aiming to reduce post-operative pain, though their long-term outcomes compared to traditional tacker fixation are still under investigation. This study aimed to compare recurrence rates and post-operative outcomes between self-adhesive and tacker-fixed polypropylene meshes in transabdominal preperitoneal (TAPP) inguinal hernia repair. An observational cohort study including 400 patients who underwent TAPP laparoscopic repair between 2018 and 2023 in hospitals across Rio de Janeiro, Brazil. Demographic variables, hernia laterality, mesh type, complications and recurrence were recorded. Fisher's exact test and linear regression were used. P ≤ 0.05 was considered significant. Follow-up was 3 months. The sample consisted predominantly of males (89.5%), with bilateral hernias being the most common presentation (51.25%). Self-adhesive mesh was used in 72.5% of cases, and polypropylene mesh with tacker fixation in 27.5%. The overall recurrence rate was 6%, with no significant difference between mesh types (P = 0.249). The global complication rate was 4.25%, mainly post-operative pain (3.0%) and seroma (0.75%), with no significant differences between groups. Self-adhesive and tacker-fixed polypropylene meshes demonstrated comparable recurrence and complication rates in TAPP repair. Self-adhesive meshes remain a safe alternative that eliminates the need for mechanical fixation, although longer follow-up studies are required to assess late recurrence and long-term outcomes.

The exact techniques for the extraction of thick-walled gall bladder and large calculus during laparoscopic cholecystectomy are not well described. This may require to dilate the port site or to enlarge the incision size, which has its own complications. This is a description of a simple technique that helps in easy extraction of the thick-walled gall bladder and large stone more than 1 cm during laparoscopic cholecystectomy. These cases may require to dilate the port site or to enlarge the incision size, which can lead to increased operating time, more post-operative pain, increased port site hernia and infection risk. In this technique, gall bladder is longitudinally split along its long axis and large calculus, if present, is crushed in the endobag. This endobag with specimen can be removed easily from the 1 cm port site without need for the port site dilatation. We have employed 'longitudinal gall bladder splitting Technique' in around 245 cases of laparoscopic cholecystectomy operated in the past 5 years. Only three cases of port site infection and no cases of port site hernia were noted in this study. Ease of extraction by surgeons was rated as 9.6 on a scale of 1-10. 'Longitudinal gall bladder splitting Technique' is a simple and easily reproducible technique used for the extraction of thick-walled gall bladder and large calculus which reduces complications and makes it easy for the surgeon.

The effectiveness of virtual reality (VR) simulation training for improving robotic surgical skills is not firmly established. This systematic review and meta-analysis aimed to evaluate the impact of VR simulator training on surgeons' robotic surgical performance in the operating room (OR). To synthesize evidence regarding the association between VR-based robotic surgery training and subsequent technical performance inside the OR. A comprehensive literature search was conducted in PubMed, Scopus, Embase, and CINAHL databases, adhering to PRISMA 2020 guidelines. Studies evaluating VR simulator training for robotic surgeons with subsequent performance assessment in the OR were included. Risk of bias assessment was performed using the Medical Education Research Study Quality Instrument and the modified Newcastle-Ottawa Scale for Education (NOS-E), along with funding source appraisal. A total of 294 records were screened, resulting in 13 studies (281 participants) included in the systematic review, and 4 studies (72 participants) suitable for meta-analysis. Metaanalysis was conducted using a random-effects model to pool correlation coefficients between preand post-training performance. Of the included studies, nine reported positive evidence, three found no evidence, and one found negative evidence regarding VR training's role. The meta-analysis of before-after studies revealed a significant positive correlation ( r = 0.717, P < 0.05) between simulation performance and intraoperative outcomes. The small number of studies included in the meta-analysis and methodological heterogeneity may limit generalisability of results. VR simulator training is associated with improved robotic surgical performance in the OR. Incorporation of VR simulation into robotic surgical curricula is likely beneficial for skill acquisition and operative readiness.

The duct of Luschka is the most common anatomical variation of the biliary tree. It is the second most common cause for bile leak in laparoscopic cholecystectomy. Many times, it is not identified until bile leak occurs after the operation. We routinely use hyper-diluted indocyanine green (ICG) with 0.025 mg injection on induction for overlay ICG-fluorescence cholangiography for difficult laparoscopic cholecystectomy. A 78-year-old male underwent an elective laparoscopic cholecystectomy and open left inguinal hernia repair. After resection of the gall bladder, a duct of Luschka with bile leak was identified under ICG-fluorescence cholangiography. Leakage was controlled with metal clips under real-time cholangiography.

Splenic cysts are uncommon lesions, often discovered incidentally during imaging studies. Recurrent splenic cysts pose a clinical challenge due to their potential for complications such as rupture, haemorrhage or infection. Management options range from observation and percutaneous drainage to partial or total splenectomy. Laparoscopic deroofing has emerged as a minimally invasive, spleen-preserving approach with favourable outcomes, although recurrence remains a concern, particularly in incompletely excised cysts. This report presents a rare case of recurrent non-parasitic splenic cyst that was successfully managed by laparoscopic deroofing. This case highlights the clinical utility of laparoscopic deroofing as a safe, spleen-conserving minimal invasive surgical option for recurrent splenic cysts. It offers reduced morbidity, faster recovery and lower risk of post-splenectomy complications. While the risk of recurrence persists, meticulous surgical technique and careful patient selection can optimise the outcomes. A literature review supports laparoscopic deroofing as an effective strategy in managing selected cases of recurrent splenic cysts with low complication and recurrence rates.

Laparoscopic cholecystectomy (LC) is the preferred treatment for symptomatic gallstone disease because of its minimally invasive technique and associated benefits. Surgical outcomes are influenced by wound infection, pain and scar quality. Port site infections (PSIs) are a notable issue in laparoscopic procedures, affecting around 1.4% to 6.7% of cases. The use of platelet-rich plasma (PRP) has gained interest for its ability to promote wound healing and antimicrobial property. This study evaluated the role of PRP in improving these outcomes after LC. In this randomised controlled trial, 190 patients were assigned to either the PRP group (n = 95) or control group (n = 95). Freshly prepared PRP was compared with 0.9% normal saline for port site infiltration. Follow-up was conducted on post-operative days 1, 2, 10, 30 and 90. The primary outcome, PSIs, was assessed using the Southampton Scoring System. Secondary outcomes included pain (Numerical Rating Scale [NRS]), wound healing (redness, oedema, ecchymosis, discharge and approximation [REEDA] scale) and scar quality (Vancouver Scar Scale [VSS]). Mean ages were 35.26 ± 6.40 years (PRP) and 34.84 ± 5.86 years (control) (P = 0.637). PSIs were lower in the PRP group on days 1, 2 and 10. At 1 month, the difference was marginally significant (P = 0.050), and at 3 months, not statistically significant (P = 0.115). Pain scores (NRS) were consistently lower in the PRP group from day 1 to 3 months. Wound healing (REEDA) scores were better in the PRP group at all time points. Scar quality (VSS) at 3 months favored PRP (0.68 ± 0.75) over control (1.51 ± 0.85, P < 0.001). PRP use in LC significantly reduced post-operative pain, improved wound healing and enhanced scar quality, with early reductions in infection rates. PRP shows promise as an adjunct to improve post-operative outcomes after LC.

To investigate the efficacy and safety assessment of intensive post-operative recovery during thoracoscopic-assisted radical oesophageal carcinoma (OC) treatment. The meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and English terms were searched in PubMed, Embase, Cochrane Library (2020, Issue 1) and Web of Science, and the same Chinese terms were searched in China National Knowledge Internet and Wanfang Data, with the date range set from January 2010 to January 2020. Search engines, including Google Scholar and Baidu Library, were also applied for manual searches of relevant literature. The final number of articles included was 12, 11 of which were in Chinese and one in English. The basic data of the two groups were statistically analysed. Among 1049 OC patients, 527 were treated with enhanced recovery after surgery (ERAS) and 522 were treated with conventional perioperative management (control group), comparing the operative time, intraoperative blood loss, self-rating anxiety scale (SAS), visual analog scale (VAS), post-operative first venting time, chest tube removal time, post-operative hospitalisation time, post-operative hospitalisation cost, combined complication rate, lung infection rate, anastomotic leak rate and gastric emptying disorder rate. There were statistically significant differences between the ERAS group and the control group in terms of operative day anxiety score, post-operative Visual Analogue Scale, time to first post-operative anal vent, time to chest tube removal, post-operative hospital stay, hospitalisation cost and overall complication rate (weighted mean difference [WMD] = -5.61, 95% confidence interval [CI]: -7.95 to -3.28, P < 0.00001; WMD = -1.58, 95% CI: -1.58, -1.94 to -1.22, P < 0.00001; standardized mean difference [SMD] = -1.86, 95% CI: -2.53 to -1.18, P < 0.00001; SMD = -4.97, 95% CI: -6:73 to -3.21, P < 0.00001; WMD = -3.93, 95% CI: -4.80 to -3.07, P < 0.00001; WMD = -0.65, 95% CI: -0.74~-0.55, P < 0.00001 and relative risk [RR] =0.41, 95% CI: 0.33-0.51, P < 0.00001). ERAS reduced the incidence of pulmonary infection, anastomotic leak and impaired gastric emptying with a statistically significant difference (RR =0.45, 95% CI: 0.31-0.65, P < 0.0001; RR =0.34, 95% CI: 0.16-0.74, P < 0.05; RR =0.34, 95% CI: 0.16-0.73, P < 0.05). ERAS is effective in patients with OC undergoing thoracoscopic-assisted radical OC treatment to improve patients' clinical symptoms and reduce the incidence of adverse effects.

In the modern era, laparoscopic repair of inguinal hernia has become increasingly common worldwide, with the total extraperitoneal (TEP) approach being widely utilised. Peritoneal injury during TEP repair is a recognised complication, with some studies reporting an incidence of up to 47%. Although practice and proper technique can minimise the risk, peritoneal injury remains a challenging issue. Peritoneal rents [Figure 1] can lead to the creation of pneumoperitoneum, complicating the surgical procedure. If these defects are not adequately repaired, complications such as bowel herniation, adhesion of bowel loops to the polypropylene mesh and even fistulisation may occur. In addition, herniation through unrepaired defects can result in bowel obstruction.Figure 1: Peritoneal rent with pouting of small bowelVarious techniques have been described for closing these rents, including the use of pre-tied Endoloop sutures, direct suturing or surgical staplers. However, these methods have limitations. Endoloop sutures can be challenging to place on larger defects, especially when working with only two ports. Similarly, suturing through midline ports is technically demanding and time-consuming. We describe an alternative technique for closing peritoneal rents using 5 mm non-absorbable polymer ligating clips “Hem-o-Lok®”. These interlocking clips can be deployed through 5-mm ports. The technique involves grasping the edge of the rent with a laparoscopic grasper and gently pulling it laterally and outwards. This manoeuvre aligns the edges of the defect while ensuring no intraperitoneal contents are trapped between them. The edges are then approximated and secured using Hem-o-Lok clips, effectively closing the defect [Figures 2-5]. Use of Hem-o-Lok has been previously described by Nitta et al. in their case series, which showed that it is a safe technique with shorter operative time as compared to endoscopic suturing.[1]Figure 2: Defining the peritoneal rentFigure 3: Traction on the rent from one corner to align its edgesFigure 4: Using the small Hem-o-Lok clip for closureFigure 5: Watertight closure of the rentWe have employed this technique in 25 patients with peritoneal rents ranging from 1 cm to 4 cm in size. The outcomes were favourable, with no reported complications. In addition, this method did not significantly extend the overall operative time. The limitation of this technique is that it is difficult to apply over wider peritoneal defects and difficult to close and approximate with these clips. Availability of data and material (data transparency) Available with the corresponding author. Authors’ contributions Anmol Ahuja–Involved in describing the technique Tarun Mittal–reading and editing the manuscript Shresth Manglik–reading and editing the manuscript Vinod K Malik–reading and editing the manuscript Ashish Dey–reading and editing the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Laparoscopic transabdominal pre-peritoneal (TAPP) inguinal hernia repair in patients with post-appendectomy scarring presents unique technical challenges due to adhesions, fibrosis and altered anatomy. Conventional surgical approaches require adaptation to mitigate risks such as bowel or bladder injury. Initiating dissection in unaffected medial peritoneal areas before progressing laterally allows for safer navigation. Precise, sharp dissection, complemented by controlled energy device utilisation, is essential for separating fibrotic peritoneum from underlying structures while preserving anatomical integrity. Avoiding dissection below the scar level optimises mesh placement and prevents compromise on repair. Pre-operative computed tomography imaging aids in assessing the severity of adhesion and helps in individualised surgical planning. Surgeon expertise is paramount in modifying techniques to accommodate complex anatomical variations. Literature underscores the heightened intraoperative risks associated with prior abdominal surgery, reinforcing the necessity for meticulous planning and skilful execution. With appropriate technique modifications, TAPP remains a viable and effective approach in patients with post-appendectomy scarring, ensuring safe and durable repair.