Recent Concepts in Minimal Access Surgery: Deborshi Sharma Priya Hazrah

Recent Concepts
in Minimal
Access Surgery
Volume 1
Deborshi Sharma
Priya Hazrah
Editors
Recent Concepts in Minimal Access Surgery
Deborshi Sharma • Priya Hazrah
Editors
Recent Concepts in
Minimal Access Surgery
Volume 1
Editors
Deborshi Sharma Priya Hazrah
Department of Surgery Department of Surgery
Lady Hardinge Medical College Lady Hardinge Medical College
New Delhi, India New Delhi, India
ISBN 978-981-16-5472-5 ISBN 978-981-16-5473-2 (eBook)

https://doi.org/10.1007/978-981-16-5473-2
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Foreword
It gives me great pleasure to write a foreword for the first volume of ‘Recent
Concepts in Minimal Access Surgery’ edited by Dr. Deborshi Sharma, Co-editor Dr.
Priya Hazrah and published by Springer Nature which has expressed a few impor-
tant recent concepts of minimally invasive laparoscopic, robotic, and endoscopic
surgical procedures that have evolved in the past decade. The book is a compilation
of contributions from various renowned authors and experts in the field of minimal
access surgery and is arranged into 21 chapters.
The topics in this first edition of recent concept series encompass a variety of
subjects from basic concepts of ergonomics and meshes to advanced techniques
such as robotic and laparoscopic oncological resections, advanced bariatric surgery,
organ transplantation and retroperitoneal adrenalectomy. Endoscopic interventions
in arenas of surgical practice such as third space endoscopy and endoscopic man-
agement of pancreatic fluid collections are also notable attractions of the edition.
Catering to this evolving era of cooperative laparoscopic, robotic and endoscopic
surgery, written in a simple language with more than 250 illustrations and operative
pictures demonstrating the different techniques followed by compilation of recent
meta-analysis in the respective subjects. This publication can be of immense aid to
students and budding surgeons as also to surgeons/physicians in the field of minimal
access surgery.
I congratulate everyone associated with the compilation, edition and publication
of the book and extend my best wishes for its successful publication.
Prof (Dr.) Vijay Kumar Shukla, MS, MCh

Ex HOD, Department of Surgery
Institute of Medical Sciences
Banaras Hindu University
Varanasi, India
Rector & Acting Vice Chancellor
Banaras Hindu University
Varanasi, India
v
Preface
Learning is like rowing upstream, not to advance is to drop back....
The above proverb holds true in the field of minimal access surgery which is in
the process of constant rapid metamorphosis.
“Recent Concepts in Minimal Access Surgery” (RCMAS) is an annual publication
which aims to highlight the newer evolving concepts and ideas with their current results,
in arenas of laparoscopic, robotic and endoscopic surgery. The chapters of this publica-
tion are a concise assimilation of knowledge with their concepts and techniques as prac-
ticed by experts in the respective arenas. The publication also intends to bring forth the
evolving techniques and technological advances to help keep abreast in knowledge and
provides a common platform to students, surgeons, and physicians, both trainees and
trainers alike, interested in the field of minimal access surgery. With 21 recent topic
chapters written by renowned faculty, more than 250 operative photographs and sche-
matic illustrations along with the latest results of relevant meta-analysis on the particular
topics tabulated in the “editors note” section of the book can serve as an easy reference
guide. It provides step-by-step descriptions accompanied by numerous helpful photo-
graphs and anatomical drawings. It also includes the controversies and gives a cumula-
tive opinion on the changes developing in minimal access surgery (MAS). It includes
system wise topics and separate chapters on the different topics within the system.
RCMAS is conceptualized as an annual publication with intend to bring forth a
yearly update on newer topics in every and subsequent volumes, as also about
changes and latest developments on earlier addressed issues.
Editors (RCMAS)
vii
viii Preface
New Delhi, India Deborshi Sharma

New Delhi, India Priya Hazrah
Acknowledgements
“it always seems impossible until its done”— Nelson Mandela
The very first volume of RCMAS would not have been impossible to complete
without the expertise, dedication and hard work of each of our expert authors. I
would like to thank each of the authors for their vision, expertise and enormous
dedication in bringing work to this project. I am deeply indebted to them for sharing
their knowledge and enthusiasm about their topic, concluding in an outstanding
overall product. My thanks to our senior faculty for teaching laparoscopic surgery
and their motivation towards this work.
Late (Dr.) U C Biswal, Ex HOD, PGIMER and Dr. RMLH
Dr. V K Ramteke, Ex HOD MAMC and Ex Faculty LHMC
Dr. P K Ganguly, Ex Faculty PGIMER and Dr. RMLH
Dr. K N Srivastava, Ex Faculty PGIMER and Dr. RMLH
Dr. Ajay Kumar, Ex HOD, LHMC
Dr. C K Durga, Ex HOD, PGIMER and Dr. RMLH
Dr O P Pathania Ex HOD, LHMC
Dr. Romesh Lal, HOD, LHMC
Dr. Rana A K Singh, Director, PGIMER and Dr. RMLH
Dr. Chintamani, Faculty, HOD, VMMC and Safdarjung Hospital
Dr. Sanjeev Kumar Tudu, Faculty, LHMC
Dr. Ashok Kumar, Faculty, LHMC
Dr. Munish Guleria, Faculty, PGIMER and Dr. RMLH
and all other faculty and colleagues in LHMC and RMLH.
I must also thank our residents Dr. Akshay Kumar, Dr. Ankit Raj, Dr. Parikshith
Manjunatha, Dr. Ashutosh Nagpal and Mr. S. Gupta for their help in proofreading
the chapters, arranging references, designing the images and tables.
I would also like to thank the publishing team at Springer, who again has been
instrumental in making this volume a reality.
ix
x Acknowledgements
Dr Deborshi Sharma and Dr Priya Hazrah, Editors RCMAS

Contents

Laparoscopic Nissen’s Fundoplication for GERD:
Current Perspective �� 1
Rajinder Parshad and Aditya Kumar

Recent Advances in Laparoscopic Gastrectomy for Gastric Cancer
with Special Reference to D2 Lymphadenectomy�� 33
Rakesh Shivhare, Manish Khasgiwale, Mohit Gangwal, and
Akshat Dhanuka
Laparoscopic Subtotal Cholecystectomy �� 63
Kalpesh Jani and Samir Contractor

Prediction and Grading Methods of a Difficult
Laparoscopic Cholecystectomy�� 83
Nikhil Gupta, Priya Hazrah, and Gautam Anand
Robotic Assisted Pancreaticoduodenectomy �� 111
Brij B. Agarwal and Neeraj Dhamija

Laparoscopic Surgery for Rectal Prolapse�� 133
Manash Ranjan Sahoo, Suyash Bajoria, and Ankit Sahoo

Laparoscopic Lymphadenectomy for Colorectal Cancers:
Concepts and Current Results�� 155
Saumitra Rawat, Chelliah Selvasekar, and Saurabh Bansal

Ergonomics in Laparoscopic Surgery: An Appraisal of Evidence�� 193
Priya Hazrah, Deborshi Sharma, Gautam Anand, and
Kayenaat Puran Singh Jassi

Surgical Meshes Used in Laparoscopic Procedures�� 219
Anubhav Vindal, Yashika Gupta, and Piyush Kumar Agrawal

Staging Laparoscopy in Intra-Abdominal Cancers�� 247
Sudhir Kumar Singh, Farhanul Huda,
Rajkumar Kottayasamy Seenivasagam, and Somprakas Basu
xi
xii Contents

Role of ICG Fluoroscence Imaging in Laparoscopic
Bowel Anastomosis�� 267
Deborshi Sharma, Sanjay Meena, Amanjeet Singh, and Priya Hazrah

Minimizing Pain in Laparoscopic Hernia Surgery �� 283
Naveen Sharma, Deborshi Sharma, and Sanjay Meena
Extended-View Totally Extraperitoneal Approach (eTEP)
for Inguinal Hernia Repair �� 293
Deborshi Sharma, Gautam Anand, and Priya Hazrah
Mini Gastric Bypass�� 305
Anshuman Poddar, Om Tantia, and Tamonas Chaudhuri

Robotic Roux-en-Y Gastric Bypass�� 331
Vivek Bindal
Third Space Endoscopy�� 351
Ashok Dalal, Ujjwal Sonika, and Amol S. Dahale

Endoscopic Management of Pancreatic Fluid Collection�� 371
Vaishali Bhardwaj and Vikram Bhatia

Management of Solitary Pulmonary Nodule�� 401
Kamran Ali and Sabyasachi Bal
Minimally Invasive Thymectomy�� 419
Aloy J. Mukherjee, Mohsin Khan, and Charu Gauba
Retroperitoneoscopic Minimally Invasive Adrenalectomy�� 443
Sameer Rege
Laparoscopic Donor Nephrectomy�� 469
Umesh Sharma and Hemant Goel
About the Editor
Priya Hazrah graduated from the Institute of Medical Sciences, Banaras Hindu

University, India. She further pursued training in surgical oncology from Gujarat
Cancer Research Institute, Ahmedabad and Tata Memorial Hospital, Mumbai,
India. Currently, she is working as a Professor in the Department of Surgery, Lady
Hardinge Medical College, New Delhi under the Ministry of Health and Family
Welfare, Government of India and affiliated with the University of Delhi. With a
keen interest to consolidate her training in minimal access surgery, she completed
her diploma in minimal access surgery (HPB surgery) from the college of Association
of Minimal Access Surgeons of India (AMASI). She has several publications and
has been a peer reviewer of many national and international journals. She has also
delivered numerous CME lectures and presentations in various national and interna-
tional conferences/meetings.
Deborshi Sharma is presently Director Professor of surgery in the department of

surgery, Lady Hardinge Medical College and Associated with Dr. RMLH, New
Delhi with a teaching experience of more than 20 years. He is a past faculty of the
Institute of Medical Sciences, Banaras Hindu University, Varanasi. Dr. Sharma is
examiner and expert in various commissions, committees and universities around
the country. He has 57 publications on surgery and minimal access surgery in peer-
reviewed journals. Over the years, he has presented numerous scientific papers and
delivered lectures in India and abroad. Dr. Sharma has made immense contribution
to minimal access surgery in the central government sector in Delhi, treating the
poor and underprivileged and is a pioneer of many minimal access procedures in
these hospitals. He has been the Vice President (CZ) for last 4 years and joint secre-
tary, the preceding 2 years of the Association of Minimal Access Surgeons of India.
He is also the past secretary of Delhi state chapter of the Association of Surgeons of
India (ASI) in 2016–2017. Since 2012, he also has served as an associate editor of
the Indian Journal of Surgery (IJOS) and since 2019 he is an editorial board mem-
ber of IJOS.
xiii
Laparoscopic Nissen’s Fundoplication
for GERD: Current Perspective
Rajinder Parshad and Aditya Kumar
Introduction
Fundoplication is a surgical technique used as a treatment modality for GERD with

or without hiatus hernia, large symptomatic hiatus hernias and as an adjunct to
Heller’s cardiomyotomy in patients of achalasia cardia. Since its inception in 1991
[1], Laparoscopic Nissen’s Fundoplication (LNF) has gained popularity and has
largely replaced open fundoplication. Before proceeding with the description of
LNF, a brief introduction of GERD, the most common indication of LNF, is in order.
GERD is a condition causing troublesome reflux of stomach contents or associ-
ated complications. The prevalence of GERD is variable, with rates of up to 20% in
the west and less than 5% in Asia [2]. Studies from India show a prevalence ranging
from 7.6 to 18.7% [3].
Some degree of postprandial reflux is physiological and may be asymptomatic
[2]. Pathological reflux occurs consequent to disruption of the anti-reflux barrier
between the stomach and esophagus and is associated with symptoms or mucosal
injury. GERD may or may not co-exist with an associated hiatus hernia [4].
Hiatus hernias have been classified as: Type 1 (Sliding hernia) where the GEJ
(gastroesophageal junction) migrates above the diaphragm with the stomach in its
normal longitudinal axis and fundus in its normal location. Type II (Rolling) where
the GEJ is in its normal position and the fundus of the stomach herniates. Type III
(Mixed) where both the GEJ and fundus herniates through the hiatus (Combination
of types I and II). Type IV is characterized by the presence of structures other than
the stomach such as omentum, colon and small bowel [5].
A recent review published in 2017 addressed the historical practice of routine
repairing of incidentally found hiatus hernia. This view has been challenged since
R. Parshad (*) · A. Kumar

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 1
D. Sharma, P. Hazrah (eds.), Recent Concepts in Minimal Access Surgery,
https://doi.org/10.1007/978-981-16-5473-2_1
2 R. Parshad and A. Kumar
studies have shown that probability of developing symptoms needing emergent

repair is only around 1% per year and watchful waiting can be safely adopted in
83% of symptomatic patients. Type I hiatal hernias associated with GERD however
need fundoplication with hiatal repair to prevent reflux [6, 7]. For asymptomatic
paraesophageal hernia the risk of progression to symptoms is estimated to be
approximately 14% per year and the need for emergency surgery is about 2% per
year. Further, it has been suggested that that elective laparoscopic repair of asymp-
tomatic paraesophageal hernia may even be detrimental in patients over 65 years of
age. Recommendations are to consider the patients age and co-morbidities prior to
planning intervention [7, 8]. Symptomatic para-esophageal hernia however should
be repaired.
Clinical Presentation
The patients with GERD, classically present with heartburn and regurgitation. Other
symptoms include chest pain, dysphagia, waterbrash, globus sensation and odyno-
phagia. Another spectrum of symptoms includes the extraesophageal symptoms
such as cough, wheeze and hoarseness. A summary of symptoms associated with
GERD is included in Table 1.
For the successful outcome of fundoplication, it is important to establish GERD
as the cause of patient’s symptoms. It is common to find a small hiatus hernia and
to operate on such patients without establishing the symptom correlation, is bound
to result in a disgruntled patient.
The following investigations help in establishing the diagnosis, correlation with
symptoms and planning the surgery.
1. Barium Esophagogram: Barium studies are losing favour in western literature

with the advent of newer modalities for diagnosing GERD. It is suggested that
they are now limited to evaluate the complications of GERD (e.g. peptic stric-
ture) and in cases of post-operative dysphagia [9]. However, they are useful in
setups where these advanced diagnostic modalities are not available.
Table 1 Montreal Consensus definition of symptoms of GERD

Esophageal Symptoms Extraesophageal Syndromes
Symptomatic Syndromes with Esophageal Established
Syndromes Injury Associations Proposed Association
Typical Reflux Reflux esophagitis Cough Pharyngitis
Reflux Chest Pain Reflux stricture Laryngitis Sinusitis
Syndrome
Barret’s Esophagus (BE) Asthma Idiopathic Pulmonary
Fibrosis
Esophageal Dental Erosion Recurrent Otitis
Adenocarcinoma (EAC) Media
Laparoscopic Nissen’s Fundoplication for GERD: Current Perspective 3
Apart from GERD, they are helpful in locating GEJ in relation to the hiatus
and help in estimating the size and reducibility of hiatus hernias. It is recom-
mended as a key investigation in the diagnosis of Hiatus Hernia’s [7].
2. CT Scans: A CT Scan may be useful in hiatus hernia to demonstrate cephalad
migration of the GEJ and fundus especially on oral contrast films [7]. They are
also useful in emergency cases of paraesophageal volvulus.
3. Upper Gastrointestinal Endoscopy (UGIE): It is used to evaluate symptom-
atic patients and especially those with alarm symptoms or suspected associ-
ated esophageal syndromes (peptic strictures, Barrett’s esophagus and
esophageal adenocarcinoma). Biopsies can be taken in presence of any abnor-
mal mucosa or mass. Grading of esophagitis according to Los Angeles
Classification is done. LA-C/D are considered indications for surgery in GERD
[10]. UGIE also is useful to visualize hiatal hernias and remains the mainstay
in its diagnosis [7].
4. Ambulatory pH monitoring: It provides confirmatory evidence of GERD. It is
especially useful in patients with normal UGIE findings and in patients with
atypical symptoms. This test provides the number of reflux episodes and acid
exposure times (AET) of the esophagus. Increased yield is seen with the wireless
capsule study which may be used for 48–96 h. Esophageal reflux is defined as a
pH value<4 and a composite pH score or deMeester score >14.72.
Reflux monitoring is possible in both ‘off PPI (proton pump inhibitor)’ and
‘on PPI’. The Lyon Consensus states that testing always be performed off ther-
apy to demonstrate baseline AET in ‘unproven GERD’, which includes no (or
low-grade) oesophagitis at endoscopy, and no prior positive pH testing. ‘On PPI’
testing is recommended in patients with ‘proven GERD’ (prior LA grade C or D
oesophagitis, long segment Barrett’s oesophagus or prior abnormal pH-metry)
and should be evaluated on double-dose PPI therapy to establish correlation
between refractory symptoms and reflux episodes and/or to exclude inadequate
acid suppression or poor compliance as the mechanism of persisting symp-
toms [11].
5. High Resolution Manometry (HRM): It is usually performed to place leads for
impedance pH monitoring. Other uses include, diagnosing additional motor dis-
orders or when symptoms don’t improve with PPI.
Recent interest has arisen on the use of HRM in GERD due to understanding
of the complex anatomical and pathophysiological aberrations leading to
GERD. Assessment of transient LES relaxation, GEJ location and morphology,
esophageal motor function and contraction reserve have been evaluated through
HRM in patients who don’t respond to empiric medical therapy and have normal
UGI Endoscopy [12].
Various therapeutic modules have been described in managing these patients
which starts from lifestyle modification (raise head end of bed, avoid bedtime meals,
weight loss) to medical therapy (proton pump inhibitors, H2 receptor antagonists,
antacids and prokinetics), surgical techniques (laparoscopic fundoplication, mag-
netic ring implants) and endoluminal techniques (transoral incisionless fundoplica-
tion and radiofrequency ablation).
Medical vs Surgical Therapy
Use of proton pump inhibitors is the backbone of medical therapy for GERD [13]
but its use is limited by long term use, patient compliance, costs, relapse of symp-
toms on discontinuation and side effects of long term use. Two metanalysis have
been published comparing medical therapy with surgical management. The first
metanalysis by Rickenbacher et al included 11 publications, 7 trials concluded that
patients under the surgical arm had a better quality of life, improved symptoms and
were more satisfied as compared to the medical arm. However, a considerable pro-
portion (16–62%) of patients needed medical therapy post-surgery. They concluded
that surgery is an equivalent alternative to medical therapy [14]. This study however
did not include a subgroup analysis based on follow up time. Another metanalysis
published a year later found similar findings to the previous study and also con-
ducted a subgroup analysis on follow up. They observed that surgery had signifi-
cantly better results in the short-term period (<3 year) but did not find statistically
significant improvement on long term over medical management. De-Meester
scores were lower in patients in the surgery arm. This metanalysis also favoured
surgical therapy over medical therapy, especially in a follow up of three years [15].
Fundoplication
Introduction
The first fundoplication was described by Rudolf Nissen in 1955 and included a
360° 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.
Several modifications to his original technique have been described and the modi-
fied Nissen’s Fundoplication (NF) is the most widely performed surgical procedure
for GERD [16].
Laparoscopic Nissen’s Fundoplication (LNF) was first described in 1991 by
Dallemagne, following which, it has gained popularity and largely replaced the open
techniques [1]. LNF is commonly performed in patients of GERD and Hiatus Hernia’s.
Antireflux Barrier Mechanism and Fundoplication
An intricate valve mechanism is present at the level of the GEJ that counteracts the
positive gastric pressure and the negative thoracic pressures. A lack of balance in
this natural antireflux mechanism is thought to be the primary cause of
GERD. Components of this barrier mechanism is postulated to include [17]:
(a) Lower Esophageal Sphincter (LES) tone, length and intra-abdominal length.
These may be defective in GERD and hiatus hernias.
(b) Pinchcock action of the crural diaphragm on the GEJ.
(c) Intact phreno-esophageal membrane.

(d) Acute “Angle of His” leading to a longer distance between the gastric fundus,
where the food is stored, and the EGJ
(e) Intact esophageal motility contributes to adequate clearance of acid that may
enter esophagus due to transient LES relaxations (TLESR). These are physio-
logical LES relaxations occurring in the absence of swallowing, lasting more
than 10 s. They are probably secondary to gastric distension, and are associated
with crural inhibition.
The aim of fundoplication is to correct the defective hiatal anatomy in the hope
of restoring anti reflux barrier.
Indications of Surgery
After objective confirmation for GERD and evaluation for associated problems, sur-
gical therapy is recommended in patients with [6]:
• Failed medical management (inadequate symptom control, severe regurgitation

not controlled with acid suppression, or medication side effects)
• Patient opts for surgery despite successful medical management (due to quality
of life considerations, lifelong need for medication intake, expense of medica-
tions, etc.) or
• Complications of GERD (e.g., Barrett’s esophagus, peptic stricture) or
• Extra-esophageal manifestations (asthma, hoarseness, cough, chest pain, aspira-
tion) attributable to reflux
Apart from these indications individual evaluation of patients is important for

improved outcomes. Results have been better in healthy, thin patients with typical
symptoms. Patients who are partial responders to PPI may not have satisfactory
results post fundoplication [18]. Although there has been no difference seen with
age, female patients have shown worse outcomes than males [19]. Morbid obesity,
psychological conditions such as depression and underlying motility disorders are
some other factors which affect outcomes adversely. In presence of any of these risk
factors, further evaluation and discussion with the patient is advisable prior to pro-
ceeding with surgery in order to set realistic and achievable outcomes.
The Preferred Approach: Open vs Laparoscopic?
Laparoscopic Nissen’s fundoplication (LNF) was first described following the suc-
cess of laparoscopic cholecystectomy. Following which several studies were per-
formed to evaluate its advantages over open surgery. Two metanalysis including 12
RCT’s (randomized controlled trials) with over 500 procedures have clearly favoured
the laparoscopic approach over open technique. Advantages of the technique included
short hospital stay, early return to work, reduced risk of complications and higher
patient satisfaction rates. The drawbacks seen included longer operating time and
higher long-term reoperation rates. Similar outcomes were noted with both tech-
niques in terms of safety, efficacy and dysphagia rates [20, 21]. The laparoscopic
approach is hence preferred and is recommended as approach of choice [6].
Role of Fundoplication in NERD
Non-erosive reflux disease (NERD) is a spectrum of GERD defined as troublesome

reflux associated symptoms without mucosal breaks on endoscopy [2]. Confirmation
of reflux in these patients is done through 24 h pH monitoring or a positive response
to PPI’s. Poor response to PPIs have been seen in this subset of patients along with
higher relapse rates [22].
Initially NERD was thought to be a milder form of GERD due to absence of
endoscopic findings and physicians would be reluctant to refer patients for surgical
management. However, the poor response to medical therapy supports an important
role of surgery. Recent studies have shown similar benefit of laparoscopic fundopli-
cation in NERD vs GERD patients in short and long term follow up [23, 24].
Role of Fundoplication in Obesity
Obesity has been seen to be associated with increase in GERD, erosive esophagitis
and esophageal adenocarcinoma. It has been seen to increase with increasing weight
(BMI >30 kg/m2) [25, 26]. The safety and long term of effectiveness of fundoplication
in this population is controversial. A recent metanalysis published on the outcomes of
fundoplication in non-obese patients (n = 6246) compared to obese patients (n = 1753)
included 13 studies and found no difference in rates of operative morbidity, redo sur-
gery, need for endoscopic dilation, conversion to open surgery or return to theatre.
However, recurrence of reflux was higher in the obese group (11.4%) compared to
non-obese group (3.4%). This led them to conclude that laparoscopic fundoplication
is safe in obese patients but risk of recurrence of GERD is higher, making it important
to counsel the patients regarding the possibility of poor outcomes [27]. They were
unable to perform a subgroup analysis on the best technique of fundoplication due to
heterogeneity and absence of technique reporting in some studies.
LF (laparoscopic fundoplication) has been thought to improve GERD in morbidly
obese patients (BMI >35 kg/m2), however, it does not help treat the underlying dis-
ease i.e. obesity. Hence, studies have compared laparoscopic gastric bypass (LGB) with
laparoscopic fundoplication (LF). It has been seen that both these techniques have simi-
lar safety and efficacy in reducing symptoms of GERD but LGB provides additional
health benefits by acting as a bariatric procedure for weight loss [28–30]. SAGES (Society
of American Gastrointestinal and Endoscopic Surgeons) too recommends use of LGB
in morbidly obese patients while suggesting further study in the obese group [6].
urrent Controversies Related to the Technique

C
of Laparoscopic Fundoplication
There is some variation in the technique of fundoplication seen amongst different

surgeons. This led to difficulty in comparison of outcomes of LNF with other meth-
ods such as oral therapy, due to heterogeneity in samples. In 2008 LOTUS trial
formed a consensus document with standardized steps and found high degree of
conformity amongst participating surgeons for objective assessment and compari-
son [31]. The same study was incorporated later to formulate guidelines by SAGES
for standardization of the steps.
he Key Components of Fundoplication as Recommended Are

T
as Follows:
• Opening the phreno-esophageal ligament to approach the hiatus and the distal
esophagus from the left to the right with preservation of the hepatic branch of the
anterior vagus nerve where possible.
• Complete dissection of both crura.
• Generous transhiatal mobilization of the esophagus to allow approximately 3 cm
of intra- abdominal length of the distal esophagus.
• Division of short gastric vessels to allow a tension-free wrap.
• Posterior crural repair using nonabsorbable sutures. In case of a very large hiatal
defect, a few anterior crural sutures may be placed.
• Creation of short (1.5–2 cm) and floppy wrap with the most distal suture (nonab-
sorbable) incorporating the anterior wall musculature of the esophagus.
• At the time of the construction of the wrap, introduction of a large bougie through
the esophagus is recommended but not defined as essential
he images of the aforementioned steps as performed: (Figs. 1, 2,

T
3, 4, 5, 6 and 7)
omplete vs Partial Wrap

C
Partial wraps have been described to avoid the complications associated with
complete 360° Nissen’s fundoplication. These include 270° Toupet fundoplica-
tion and anterior wraps such as Dor (180–200°). In the era of laparoscopic sur-
gery, the issue of complete vs partial wrap has been revisited.
A systematic review in 2011 suggested significantly lesser dysphagia and inabil-
ity to belch with partial wraps without any statistical difference in outcomes related
to treatment failure when compared with complete wrap. However, the studies ana-
lyzed had heterogeneity in surgical procedure and approach, poor methodology,
unclear outcome measures and publication bias [32].
Fig. 1 Hiatal Dissection
Fig. 2 Mobilization of the

esophagus well into the
mediastinum
A more recent metanalysis in 2016 compared the Laparoscopic Nissen fundopli-

cation (LNF) with Laparoscopic Toupet Fundoplication (LTF). It included 8 RCTS
with 625 LNF and 567 LTF. There was no difference in postoperative dysphagia,
gas-bloating, inability to belch or dilatation for dysphagia between the 2 groups.
Reoperation rates were seen to be higher after LNF but specific reasons could not be
elucidated [33]. Another metanalysis in 2017 compared LNF (n = 266) with
Laparoscopic anterior 180° fundoplication (n = 265) including 6 RCT’s. The authors
concluded that both methods were equally effective in reducing reflux and
Fig. 3 Division of Short

Gastric Vessels
Fig. 4 Complete crural

mobilization and creation
of retroesophageal window
providing patient satisfaction, but there is a higher risk of reoperation for recurrent
symptoms with anterior wrap [34].
ivision vs Non-Division of Short Gastric Vessels

D
Mobilization of the fundus and cardia by division of the short gastric was added as
a modification to Nissen fundoplication by Donahue [35] and De Meester [36] inor-
der to create a tension free floppy fundoplication and reduce some of the trouble-
some side effects of Nissen fundoplication.
Fig. 5 Crural
Approximation
Fig. 6 Shoe shine

maneuver
Six RCT’s have been performed comparing division vs non-division of short

gastric with a follow-up of up to 20 years. The findings suggest that routine division
of short gastric do not confer any functional or clinical advantages and was associ-
ated with increased surgery time and persistent epigastric bloat syndrome [37–43].
This has been postulated to arise due to absence of the Belch reflex due to division
of afferent nerves along with short gastric vessels [44]. SAGES recommends divi-
sion to be undertaken when a tension free fundoplication can’t be achieved with a
Grade B recommendation [6].
Fig. 7 Creation of
Floppy Wrap
Crural Closure
Closure vs non-closure of crura is a controversial topic with some reporting benefits
while others showing no benefit. No Metanalysis or RCT’s are available and recom-
mendations made are based on case series. General recommendation is to close
crural when hiatal opening is large and mesh reinforcement may benefit in decreas-
ing wrap migration [6].
One RCT comparing anterior (n = 47) vs posterior closure (n = 55) did not show
any difference in dysphagia with soft solids/liquids, need for medication and overall
satisfaction at 10 years follow up [45]. They concluded that anterior repair was at
least as good as posterior repair.
esh vs Suture Closure of Hiatus Hernia

M
A widened hiatus or a hiatus hernia (HH) is frequently associated with GERD and
has been tackled using simple suture repair. Few studies showed radiological recur-
rence on long term follow up which brought about an interest in the use of mesh for
repair of large hiatus hernias. Recurrences were usually small and asymptomatic
making the routine use of mesh controversial. A recent systematic review and meta-
nalysis of 11 studies compared mesh (n = 719) vs suture closure (n = 755). Mesh
repair was associated with lesser recurrence rates on short term follow up (<12
months), had similar patterns of complications, but increased dysphagia. QOL (qual-
ity of life) scores were similar with some improvement seen in patients with biologi-
cal mesh. A major limitation was a short term follow up which does not bring out
the mesh associated problems that are expected on long term [46]. So the routine
use of mesh has to be considered with caution.
A systematic review of 16 studies compared use of biological mesh (n = 385)
versus synthetic mesh (n = 704) with a median follow up of 53.4 months. It found
that recurrence rates in synthetic mesh (6.8%) was much lower than biological mesh
(16.1%) with no significant difference in complication rates of 5.1% vs 4.6%

respectively on short term. This suggested no additional advantage on the use of
biological mesh [47].
ole of Bougie Dilators

R
Another addition to Nissen’s Fundoplication was the use of bougie dilators to pre-
vent dysphagia. Several studies have investigated use of dilator from 39-60F to pre-
vent dysphagia [48, 49]. However, certain studies have shown no advantage in the
use of bougie dilation, especially in short term follow up [50]. Use of bougie dila-
tors has been seen to be associated with problems such as prolonged surgery,
esophago-gastric mucosal damage and perforations.
Nevertheless, an RCT on the effect of bougie on dysphagia with 171 patients was
conducted and revealed that use of large caliber bougie (56F) decrease long term
risk of dysphagia albeit increasing risk of injury [49]. We can conclude that the use
of bougie seems to have improved outcomes on dysphagia postoperatively despite a
small risk of complications.
Redo Fundoplication
Although laparoscopic fundoplication has satisfactory outcomes postoperatively,
some patients have persistent or recurrence of symptoms. Another problem noted
with the procedure is development of dysphagia. Apart from these there is a heter-
ogenous cause of complications associated with the procedure needing reoperation.
Several systematic reviews have been performed on the best method of treating
these and outcomes associated. Recurrent reflux and dysphagia were found to be the
most common reason for redo fundoplication. The most common causes of failure
were seen to be wrap migration, wrap disruption and tight wrap accounting to nearly
half the patients. Most of the patients were dealt with redo fundoplication and lapa-
roscopy was the commonly used approach. Morbidity, mortality, longer operative
times and conversion to open was higher in redo fundoplication when compared to
index surgery. Most commonly witnessed complications were esophago-gastric
perforations and bleeding. Symptomatic outcomes of redo fundoplication were
good to excellent. Technically this surgery is more complex and should be per-
formed by experienced surgeons [51–53].
Therefore laparoscopic redo fundoplication is safe, feasible and effective with
higher complication rates than index surgery and due to its complexity should be
performed by experienced surgeons [6].
Newer Modalities
Robotic Fundoplication
With the advent of robotics in late 1990s and identification of its distinct advantages
of improved 3D vision, precise movements, added dexterity and improved
ergonomics, it didn’t take time for surgeons to implement it in performing antireflux

surgeries. Several RCT’s were conducted evaluating its outcomes. A metanalysis of
6 RCT’s including 226 patients compared robotic fundoplication to LNF. Results
from this study showed no difference in operative complications, length of hospital
stay, need for reoperation or postoperative dysphagia between the two procedures.
However, robotic fundoplication was found to be expensive and had longer opera-
tive times. Although results were largely comparable robotic fundoplication offered
no advantage over LNF [54]. Larger scale RCT’s are needed to definitively assess
the role of robotics in antireflux surgery.
Magnetic Ring Implants (LINX™ Procedure)
The LINX magnetic implant system was approved for use in GERD in 2012 by the
FDA. This device works through a ring of magnets implanted laparoscopically
around the LES. They augment LES pressure upto 15–25 mm of Hg to prevent
reflux but at same time allow passage of food through it. This device was found to
be safe in patients for GERD and the changes it brought were evaluated via manom-
etry and published in a study of 121 patients. Results have been tabulated in Table 2
[55] (Fig. 8).
Table 2 Manometry changes in magnetic ring implants

Parameter Preoperative Value Postoperative value p Value
Median LES Resting pressure 18 mmHg 23 mmHg 0.0003
Residual Pressure 4 mmHg 9 mmHg <0.0001
Distal esophageal contraction 80 mmHg 90 mmHg 0.02
amplitude
Percentage of Peristalsis 94% 87% 0.71
Fig. 8 Schematic diagram

showing LINX™ magnetic
device applied at Lower
oesophageal sphinter
Apart from this, the study also showed that patients with a manometrically
defective LES were restored 67% of the time to a normal sphincter and those with
a structurally defective or severely defective LES improved to a normal LES in
77% and 56% of patients, respectively. Only 18% of patients with a normal preop-
erative manometric LES deteriorated to a lower category. The results of this study
were very promising with significant improvement in LES tone without deleterious
effects on the body and it managed to restore a manometrically defective LES to
normal sphincter and leaving a normal sphincter stable.
The excitement following this procedure led to comparisons with the traditional
surgical method of fundoplication.
Two metanalysis and systemic review comparing early outcomes of LINX vs
LNF were published with the latter including 7 observational studies including
1211 patients [56, 57]. In both the metanalysis LINX and LNF were both seen to be
safe and effective at 1 year follow-up. PPI suspension, need for endoscopic dilata-
tion and QOL rates were similar for both groups with LINX procedure associated
with less gas/bloat symptoms and increased ability to vomit and belch. LNF was
found to take longer operative times and was technically challenging needing skilled
surgeons. The findings need to be assessed with caution as these included only
observational studies and no RCT’s were available. Long term safety, efficacy and
durability are yet to be ascertained for the LINX procedure.
Conclusion
Although newer modalities such as robotics, magnetic sphincter implants and also the
advent of endoscopic fundoplication bring excitement to the field of antireflux sur-
gery, the definite role, safety and reliability are yet to be ascertained on long term
follow up studies. Laparoscopic Nissen’s Fundoplication remains a tested modality
for over four decades and can be considered to be the gold standard surgical approach.
LNF remains the alternate therapy of choice for long term/refractory medical
management.
Key Clinical Points

1. Laparoscopic Nissen’s Fundoplication (LNF) has gained popularity since 1990s
and has largely replaced open fundoplication.
2. Postprandial physiological reflux is quite common and may be asymptomatic.
Pathological reflux occurs consequent to disruption of the anti-reflux barrier
between the stomach and esophagus and is associated with symptoms or muco-
sal injury.
3. Elective laparoscopic repair of asymptomatic paraesophageal hernia may even
be detrimental in patients over 65 years of age.
4. The role of barium esophagogram is currently limited to evaluation of the com-
plications of GERD and is helpful in locating the GEJ in relation to the hiatus,
thereby helping in estimating the size and reducibility of hiatus hernias.
5. CT Scan is useful to demonstrate cephalad migration of the GEJ and fundus

especially on oral contrast films. It is also useful in emergency cases of parae-
sophageal volvulus.
6. Ambulatory pH monitoring is especially useful in patients with normal UGI
Endoscopy findings and in patients with atypical symptoms.
7. Proton pump inhibitors are the backbone of medical therapy for GERD, but its
use is limited by long term use, patient compliance, costs and relapse of symp-
toms on discontinuation and side effects of long term use.
8. Laparoscopic fundoplication bestows a shorter hospital stay, early return to
work, reduced risk of complications and higher patient satisfaction rates. The
drawbacks are longer operating time and higher long-term reoperation rates.
9. Complete and partial fundoplication have no difference in postoperative dys-
phagia, gas-bloating, inability to belch or dilatation for dysphagia.
10. Routine division of short gastric do not confer any functional or clinical advan-
tages and is associated with increased surgery time and persistent epigastric
bloat syndrome.
11. Mesh repair of the hiatus is associated with lesser recurrence rates on short term
but had similar patterns of complications with increased dysphagia.
12. Presence and size of a bougie may define the incidence of dysphagia. It should
be weighed against the risk of possible oesophageal injury and prior consent for
it needs to be taken.
13. Laparoscopic redo fundoplication is safe, feasible and effective with higher
complication rates than index surgery and due to its complexity should be per-
formed only by experienced surgeons.
14. Robotic fundoplication is expensive and has a longer operative time. No differ-
ence has been noted in operative complications, length of hospital stay, need for
reoperation or postoperative dysphagia in robotic vs laparoscopic
fundoplication.
Editor’s Note1
Insertion of the Bougie Across the Esophageal Junction
Insertion of a bougie is often recommended in numerous guidelines including

SAGES (Grade B). Few randomized trials have shown significant lower dysphagia
rates 12 months later after using bougies, however the size of bougie used made the
most important impact in dysphagia rates [1]. Reports are so varied and complex to
interpret with many variables, that the results are frequently suggested to have a
relation between post-operative dysphagia to undiagnosed pre-operative dysmotil-
ity, timing of dysphagia assessment (months after surgery) and scoring system used
in assessing post-operative dysphagia [2].
There is definite evidence, which suggest that the presence and size of a bougie
may define the incidence of dysphagia. It is always weighed against the risk of pos-
sible oesophageal injury and prior consent for it needs to be taken [2].
Incidence of perforation during LF is around 0.8% which is attributed to lack of
direction at the tip of bougie and thought to be aggravated due to anterior angulation
of the GE junction after posterior crural repair.
LES Electrical Stimulation
It is a novel technique that has been designed to be a successful, minimally invasive

and minimal disturbing approach to GERD than laparoscopic fundoplication [3].
Temporary LES stimulation leads to durable increase in LES pressure, without
impairing LES relaxation and esophageal peristalsis [3]. It has 3 different compo-
nents: a bipolar electrical stimulation lead, implantable pulse generator and external
programmer. It delivers stimulation waves in sessions which can be adjusted in non-
invasive fashion.
Procedure: Anterior right side of esophageal wall is exposed laparoscopically
and electrodes are superficially implanted and fixed into LES 1 cm apart along the
longitudinal axis of the esophagus. Correct position of electrode is checked under
endoscopy at the LES level and to rule out esophageal perforation. Subcutaneous
pocket is created for the generator and is attached to the pulse generator.
High success rate is claimed by the proponents, suggesting normalization or a
decrease of 50% of more of acid exposure of the distal esophagus in 71% of patients
and complete cessation of PPI use in 76% of patients. LES electrical stimulation
might have promising results in GERD patients. Robust data will confirm the pre-
liminary outcomes.
Laparoscopic Sleeve Fundoplication
Laparoscopic sleeve gastrectomy has been noted to increase gastroesophageal reflux. It

may be beneficial in GERD with concomitant obesity. Therefore, authors have
References: Main chapter references are included after the “References Editor’s Note” section.
1
investigated the concept of adding a fundoplication to laparoscopic sleeve gastrectomy

termed as laparoscopic sleeve fundoplication (Fig. EN1). Though weight loss and
GERD resolution has been promising in the short term, long term results are awaited.
A higher incidence in perforation and complications has also been observed [4].
Endoscopic Fundoplication/Transoral Incisionless Fundoplication
TIF (Transoral incisionless fundoplication) is being investigated as a minimally

invasive technique for treatment of GERD refractory to PPI and small hiatal hernia
(<2 cm). The recommended technique consists of esophagogastric plications in the
region of intraabdominal esophagus with fundus being wrapped around the distal
Fig. EN1 Schematic
diagram of Laparoscopic
sleeve fundoplication
Fig. EN2 Schematic
diagram showing the end
result of Endoscopic
Fundoplication/Transoral
incisionless fundoplication
esophagus and secured with fasteners above the Z line (Figure EN2). Though it
appears to be promising in PPI refractory GERD in the short term, its long-term
efficacy is yet to be evaluated and when compared with LNF currently TIF appears
to have an inferior outcome [5–8].
Stretta Procedure
Stretta is a procedure by which radiofrequency treatment is delivered to the lower

esophageal sphincter by endoscopic balloon mounted needles. It remodels LES and
gastric musculature at cardia and thus improves symptoms of GERD. A recent
meta-analysis on the procedure concluded that Stretta improved subjective and
objective parameters of GERD. It decreased (improved) health related quality of life
score and pooled heartburn score. Only 49% patients receiving PPI required to con-
tinue the medicine after the procedure. It reduced erosive esophagitis by 24%,
decreased lower esophageal acid exposure, and increased lower esophageal sphinc-
ter basal pressure [9]. An earlier metaanlysis however did not find any difference in
outcome after Stretta procedure for GERD [10].
Quality of Life
GERD-Health Related Quality of Life Questionnaires convey that heartburn and

regurgitation due to GERD is relieved in 84% to 97% after laparoscopic fundoplica-
tion [11, 12] and 86% to 96% are well pleased with the end result [13]. No change
or worsening related to bloating and swallowing is reported after Laparoscopic fun-
doplication [11].
Comparison of various meta-analyses has been done and data is included in the
following tables:
Table EN1: Meta-analysis on efficacy and safety of endoscopic, transoral inci-
sionless fundoplication
Table EN2: Meta-analysis comparing magnetic sphincter augmentation versus
fundoplication in GERD
Table EN3: Meta-analysis comparing robotic with laparoscopic fundoplication
Table EN4: Meta-analyses comparing total and partial laparoscopic
fundoplication
Table EN5: Meta-analyses comparing short gastric division versus non division
in laparoscopic fundoplication
Table EN1 Metanalysis on efficacy and safety of endoscopic, transoral incisionless

fundoplication
Study, first author, year Result/conclusion
Transoral Incisionless Fundoplication (TIF TIF subjects at 3 years had improved esophageal
2.0): A Meta-Analysis of Three pH, a decrease in PPI utilization & improved
Randomized, Controlled Clinical Trials quality of life.
Lauren Gerson, 2018 [5]
Efficacy of Laparoscopic Nissen • LNF had greatest ability to improve physiologic
Fundoplication vs Transoral Incisionless parameters of GERD, including increased LES
Fundoplication or Proton Pump Inhibitors pressure and decreased percent time pH <4.
in Patients With Gastroesophageal Reflux • TIF produced the largest increase in health-
Disease: A Systematic Review and related quality of life, this could be due to the
Network Meta-analysis. Richter JE, 2018 shorter follow-up time of patients treated with
[6] TIF vs LNF or PPIs.
Efficacy of transoral incisionless TIF success rate 99% (95% confidence interval
fundoplication for refractory (CI) 97 to 100; P < 0.001),
gastroesophageal reflux disease: a adverse event rate of 2% (95%CI 1 to 3;
systematic review and meta-analysis. P < 0.001).
Thomas R Mc Carty, 2018 [7] Following parameters improved significantly
post-TIF
• GERD HRQL, GERSS and RSI
• Hernia reduction occurred in 91% of patients
(95%CI 83 to 98; P < 0.001).
• DeMeester scores improved significantly
(mean difference 10.22, 95%CI 8.38 to 12.12;
P < 0.001).
• PPI therapy was discontinued post-procedure in
89% of patients
(95%CI 82 to 95; P < 0.001).
Efficacy of transoral incisionless TIF vs PPI sham
fundoplication (TIF) for the treatment of The pooled relative risk of response rate to TIF
GERD: a systematic review with versus PPIs/sham was 2.44 (95% CI 1.25–4.79,
meta-analysis p = 0.0009. The total number of refluxes was
Xiaoquan Huang, 2017 [8] reduced after TIF compared with the PPI sham
group.
Following parameters did not improve after TIF:
•Esophageal acid exposure time and acid reflux
episodes
• Proton-pump inhibitors (ppis) usage in
long-term follow-up. T
Total satisfaction rate after TIF was about
69.15% in 6 months. The incidence of severe
adverse events consisting of gastrointestinal
perforation and bleeding was 2.4%. TIF is an
alternative intervention with comparable
short-term patient satisfaction. Long-term results
showed decreased efficacy with time.
TIF Transoral incisionless Fundoplication, GERD Gastroesophageal Reflux Disease, HRQOL
Health Related quality of life, GRESS Gastroesophageal reflux Symptom score, RSI Reflux
Symptom Index, PPI Proton pump inhibitor, LNF Laparoscopic Nissen Fundoplication, LES
Lower Esophageal Sphincter
Table EN2 Meta-analysis comparing magnetic sphincter augmentation versus fundoplica-

tion in GERD
Study, first author, year Result/Conclusion
Laparoscopic magnetic sphincter MSA had:
augmentation versus • Less gas bloating (POR = 0.34; 95%CI 0.16–0.71)
fundoplication for • Greater ability to belch (POR = 12.34; 95%CI
gastroesophageal reflux disease: 6.43–23.7).
systematic review and pooled No significant difference in:
analysis. Guidozzi N 2019 [14] • Postoperative PPI therapy
• GERD-HRQOL score
• Dysphagia
• Reoperation
Early results of magnetic MSA group had less:Gas/bloat symptoms, 0.39 (95% CI
sphincter augmentation versus 0.25–0.61; p < 0.001),
fundoplication for MSA group had better:
gastroesophageal reflux disease: • Ability to vomit 10.10 (95% CI 5.33–19.15; p < 0.001)
Systematic review and meta- • Ability to belch 5.53 (95% CI 3.73–8.19; p < 0.001).
analysis. Aiolfi A 2018 [15] No significant difference:
• Dysphagia requiring endoscopic dilatation, p = 0.119.
• Postoperative GERD-HRQL (p = 0.101).
• PPI suspension (p = 0.548),
• Endoscopic dilation (p = 0.119)
• Reoperation p = 0.183.
LINX(®) magnetic esophageal No statistically significant difference between MSA and
sphincter augmentation versus LNF in
Nissen fundoplication for • Gas/bloating (26.7 vs 53.4%, p = 0.06),
gastroesophageal reflux disease: • Postoperative dysphagia (33.9 vs 47.1%, p = 0.43)
a systematic review and • Proton pump inhibitor (PPI) elimination (81.4 vs 81.5%,
meta-analysis. Skubleny D 2017 p = 0.68).
[16]
Efficacy of Magnetic Sphincter MSA had less:
Augmentation versus Nissen • Operative time (MSA and NF: RR = −18.80, 95% CI:
Fundoplication for −24.57 to −13.04, and P = 0.001)
Gastroesophageal Reflux Disease • Length of stay (RR = −14.21, 95% CI: −24.18 to −4.23,
in Short Term: A Meta-Analysis. and P = 0.005).
Chen MY 2017 [17] • Postoperative gas or bloating (RR = 0.71, 95% CI:
0.54–0.94, and P = 0.02)
Similar results in
• Proton-pump inhibitor use,
• Complication
• Severe dysphagia for dilation
• Number of adverse events,
• Ability to belch and ability to vomit.
MSA magnetic sphincter augmentation, LF Laparoscopic Fundoplication, LNF Laparoscopic
Nissen Fundoplication, GERD HRQL gastroesophageal reflux Disease Health related quality of
life, RR risk ratio, POR pooled odds ratio
Table EN3 Meta-analysis comparing robotic with laparoscopic fundoplication

Study, first author, year Result / Conclusion
Meta-analysis of robot-assisted versus RALF had longer
conventional laparoscopic Nissen Operative time of fundoplication (WMD 3.17
fundoplication for gastro-oesophageal reflux (95% confidence interval. 2.33–4.00) min;
disease. P < 0.00001).
Wang Z 2012 [18] No difference in
• Operative complication,
• Antisecretory medication use,
• Patient satisfaction with intervention,
• Time needed for hiatal dissection,
• Time from incision to completion of sutures,
• Total operation time
• Total cost
Robotic vs. laparoscopic Nissen No significant difference in rates of:
fundoplication for gastro-oesophageal reflux • Re-operation
disease: systematic review and meta- • Postoperative dysphagia
analysis. Markar SR 2010 [19] • Hospital stay
• Operative complications
Significantly reduced total operative time in the
laparoscopic group (weighted mean
difference = 4.154; 95% CI = 1.932–6.375;
p = 0.0002). Higher costs in roboti
Whether robot-assisted laparoscopic RALF had lower postoperative complication
fundoplication is better for gastroesophageal rate (OR = 0.35, 95% CI = [0.13, 0.93],
reflux disease in adults: a systematic review p = 0.04)
and meta-analysis. Mi J 2010 [20] RALF had higher total operating time
(WMD = 24.05, 95% CI = [5.19, 42.92],
p = 0.01)
No significant difference in
• Perioperative complication rate (OR = 0.67,
95% CI = [0.30, 1.48], p = 1.00)
• Length of hospital stay (WMD = 0.00, 95%
CI = [−0.25, 0.26], p = 0.04).
Robot-assisted laparoscope fundoplication RAF and conventional laparoscopic
for gastroesophageal reflux disease: a fundoplication (CLF) were similar in
systematic review of randomized controlled • Postoperative antisecretory medication
trials. Zhang P 2010 [21] (p = 1.0),
• Intraoperative conversion to open surgery
(p = 0.94),
• Postoperative dysphagia (p = 1.0),
• Pneumothorax (p = 1.0),
• Total intraoperative complications (p = 0.24),
• Time of hiatal dissection (p = 0.98),
• Time of incision to completion of sutures
(p = 0.95),
• Total operation time (p = 0.16),
• Hospital stay (p = 0.97),
• Total cost (p = 0.25).
RALF/RAF Robotic assisted fundoplication, CLF conventional laparoscopic fundoplication, OR
odds ratio, WMD weighted mean difference
Table EN4 Meta-Analyses comparing total and partial laparoscopic fundoplication

Study, first author, year Result/ conclusion
Assessing the efficacy and safety Laparoscopic 270°, anterior 180°, and anterior 90° were
of laparoscopic antireflux equally effective as 360° for control of heartburn.
procedures for the management of The odds were lower after 270° and anterior 90° compared
gastroesophageal reflux disease: a to 360° as follows:
systematic review with network • Dysphagia 270° (OR 0.38, 95%, CI 0.24–0.60),
meta-analysis. Andreou A 2020 • Gas-bloat were 270° (OR 0.51, 95% CI 0.27, 0.95)
[22] • Regurgitation, morbidity, and reoperation were similar
across treatments.
Laparoscopic Nissen (total) LNF & 180° LAF:
versus anterior 180° • Equally effective in controlling reflux symptoms
fundoplication for gastro- • Comparable prevalence of patient satisfaction.
esophageal reflux disease: A 180° LAF:
meta-analysis and systematic • Reduced incidence of postoperative dysphagia
review. Du X 2017 [23] • Higher risk of reoperation for recurrent symptoms.
A meta-analysis of long Higher prevalence in LNF of:
follow-up outcomes of • Postoperative dysphagia,
laparoscopic Nissen (total) • Gas-bloating,
versus Toupet (270°) • Inability to belch,
fundoplication for gastro- • Dilatation for dysphagia
esophageal reflux disease based • Reoperation
on randomized controlled trials • Higher les sphincter pressure
in adults. Du X, 2016 [24] (differences with respect to dysphagia disappeared over
time)
No significant differences between LNF and LTF in:
• Hospitalization duration,
• Perioperative complications,
• Patient satisfaction,
• Postoperative heartburn,
• Regurgitation,
• Postoperative demeester scores,
• Esophagitis.
3. A shorter operative time with LNF.
4. Subgroup analyses did not support “tailored therapy”
according to preoperative esophageal motility.
Laparoscopic anterior versus LAF vs LPF:
posterior fundoplication for • Significant reduction in the odds ratio for dysphagia in
gastro-esophageal reflux disease: the LAF
a meta-analysis and systematic • Significant reduction in the odds ratio for heartburn in LPF
review Comparable effects for both groups for other variables:
Memon MA 2015 [25] • Redo surgery,
• Operating time,
• Overall complications,
• Conversion rate,
• Visick’s grading, patients’ satisfaction,
• Length of hospital stay, and
• Postoperative 24-h ph scores.
Table EN4 (continued)
A Meta-Analysis of Randomized No difference between the procedures in the following:
Controlled Trials to Compare • Operative time,
Long-Term Outcomes of Nissen • Perioperative complications,
and Toupet Fundoplication for • Postoperative satisfaction,
Gastroesophageal Reflux • Recurrence,
Disease. Tian ZC 2015 [26] • Rates of medication adoption
• Re-operation due to recurrence
Significantly higher following parameters after LNF:
• Dysphagia,
• Gas-bloat syndrome,
• Inability to belch
• Re-operation due to severe dysphagia
Laparoscopic anterior 180-degree 180° LAF vs LNF 1 and 5 years:
versus Nissen fundoplication for Dysphagia and gas-related symptoms are lower after LAF
gastroesophageal reflux disease: No difference in:
systematic review and meta- • Esophageal acid exposure
analysis of randomized clinical • Esophagitis
trials. Broeders JA 2013 [27] • Heartburn scores,
• Dilatations
• Reoperation rate
A meta-analysis comparing LPF:
laparoscopic partial versus • Less post-operative dysphagia (OR = 0.44, P < 0.0001) and
Nissen fundoplication. Ma S • Less inability to belch (OR = 0.41, P < 0.005)
2012 [28] LNF:
• Significant reduction of post-operative heartburn
(OR = 1.94, P < 0.01).
• Patient satisfaction comparable between the two groups.
Laparoscopic anterior versus LAF vs LPF short term (6−12 months)
posterior fundoplication for Higher after LAF
gastroesophageal reflux disease: • Esophageal acid exposure time (3.3% vs. 0.8%: wmd
systematic review and meta- 2.04; 95% confidence interval [ci] [0.84–3.24]; p < 0.001),
analysis of randomized clinical • Heartburn (21% vs. 8%; rr 2.71; 95%ci [1.72–4.26];
trials. Broeders JA 2011 [29] p < 0.001)
• Reoperation rate (8% vs. 4%; RR 1.94; 95%CI [0.97–
3.87]; P = 0.06)
Lower after LAF:
• Dakkak dysphagia score (2.5 vs. 5.7; WMD −2.87;
95%CI [−3.88 to −1.87]; P < 0.001).
No short-term differences in prevalence of
• Esophagitis,
• Regurgitation
• Perioperative outcomes.
LAF vs LPF long term (2−10 years)
Higher after LAF
• Heartburn (31% vs. 14%; RR 2.15; 95% CI [1.49–3.09];
p < 0.001)
• More PPI use (25% vs. 10%; RR 2.53; 95% CI [1.40–
4.45]; p = 0.002).
• Reoperation rate (10% vs. 5%; RR 2.12; 95% CI
[1.07–4.21]; p = 0.03).
No long term difference
Long-term Dakkak dysphagia scores, inability to belch, gas
bloating and satisfaction were not different.
(continued)
Meta-analysis of laparoscopic LNF versus LTF:
total (Nissen) versus posterior • Control of reflux was good
(Toupet) fundoplication for • Occurrence of heartburn similar
gastro-oesophageal reflux disease • Lower early and late post-operative dysphagia ltf group.
based on randomized clinical • Patient’s satisfaction similar
trials.Tan G 2011 [30]
Systematic review and meta- LNF vs LTF higher prevalence in LNF of:
analysis of laparoscopic Nissen • Postoperative dysphagia (RR 1.61 (95 per cent confidence
(posterior total) versus Toupet interval 1.06 to 2.44); P = 0.02)
(posterior partial) fundoplication • Dilatation for dysphagia (RR 2.45 (1.06 to 5.68);
for gastro-oesophageal reflux P = 0.04).
disease. Broeders JA 2010 [31] • Surgical reinterventions (RR 2.19 (1.09 to 4.40);
P = 0.03),
• Inability to belch (RR 2.04 (1.19 to 3.49); P = 0.009)
• Gas bloating (RR 1.58 (1.21 to 2.05); P < 0.001
No differences regarding:
• Recurrent pathological acid exposure (RR 1.26 (0.82 to
1.95); P = 0.29),
• Oesophagitis (RR 1.20 (0.78 to 1.85); P = 0.40),
• Subjective reflux recurrence,
• Operating time
• In-hospital complications
LNF Laparoscopic Nissen Fundoplication, LAF Laparoscopic anterior fundoplication, LPF
Laparoscopic posterior fundoplication, LTF Laparoscopic Toupet fundoplication, OR Odds ratio,
RR Relative risk, LES Lower esophageal Sphincter, WMD Weighted Mean difference, PPI Proton
Pump Inhibitors
Table EN5 Meta-analysis comparing short gastric division versus non division in laparoscopic
fundoplication
Laparoscopic Nissen fundoplication with or SGVD had longer:
without short gastric vessel division: a meta- • Operative time
analysis. Khatri K 2012 [32] • Hospital stay.
No difference in terms of functional
outcomes for 1- and 10-year follow-up
Systematic review and meta-analysis of No statistically significant effect on rates of:
laparoscopic Nissen fundoplication with or • Reoperation,
without division of the short gastric vessels. • Postoperative dysphagia
Markar SR 2011 [33] • Reflux.
• Length of hospital stay,
• Postoperative complications,
• Postoperative gas bloat syndrome
• Demeester score.
SGV division was associated with:
• Longer duration of operation
• Reduced postoperative lower oesophageal
sphincter pressure.
Meta-analysis of two randomized controlled No significant differences in:
trials to identify long-term symptoms after • Heartburn
division of the short gastric vessels during • Dysphagia,
Nissen fundoplication. Engström C 2011 [34] • Ability to belch or vomit,
• Use of antisecretory medications.
Division of the short gastric vessels was
associated with a higher rate of bloating
symptoms (72 versus 48 per cent;
P = 0.002) at 10-12 years follow up
SGV/SGVD short gastric vessel division
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Recent Advances in Laparoscopic
Gastrectomy for Gastric Cancer
with Special Reference to D2
Lymphadenectomy
Rakesh Shivhare, Manish Khasgiwale, Mohit Gangwal,

and Akshat Dhanuka
Introduction
Gastrectomy with negative margin and adequate lymphadenectomy is the hallmark

of treatment for operable gastric cancer. As the extent of gastric resection largely
depends upon tumour location within the stomach, the common types of gastric
cancer resection can be classified as: total gastrectomy, partial gastrectomy, and
esophago-gastrectomy. Generally total gastrectomy is done for proximal gastric
cancer, total or partial gastrectomy for tumours of the middle third, and subtotal
gastrectomy for cancers of the distal third.
Adoption of minimally invasive approaches in laparoscopic gastrectomy aims at
improvement of the quality of life of patients, without compromising on oncologic
adequacy [1]. In this chapter we discuss relevant aspects of laparoscopic gastrec-
tomy with special reference to D2 lymphadenectomy.
R. Shivhare (*)
Department of Surgical Gastroenterology, Minimal Access Surgery & Renal & Liver
Transplant Unit, Eminent Hospital, Indore, India
M. Khasgiwale
GI Surgery & Transplant Unit, Apollo Hospitals, Indore, India
M. Gangwal
GEM Hospital, Coimbatore, India
A. Dhanuka
Index Medical College, Indore, India
https://doi.org/10.1007/978-981-16-5473-2_2
34 R. Shivhare et al.
Table 1 Gastrectomy classified by extent of resection

Wedge excision
Partial/Subtotal gastrectomy:
Distal gastrectomy, Antrectomy, Proximal gastrectomy, Middle segment gastrectomy,
Segmentectomy, Hemigastrectomy, subtotal gastrectomy
Total gastrectomy
Esophago-gastrectomy
Resection of gastric remnant (completion gastrectomy/subtotal gastrectomy)
Table 2 Different approaches Hand assisted laparoscopic gastrectomy (HALG)

and advances in techniques Laparoscopic assisted gastrectomy (LAG)
of minimally invasive gastrectomy
Totally laparoscopic gastrectomy (TLG)
Laparoscopic function preserving gastrectomy
Single incision distal gastrectomy (SIDG)
Robotic gastrectomy
xtent of Gastrectomy and Different Minimally Invasive

E
Approaches of Laparoscopic Gastrectomy
Table 1 enumerates the different types of gastric resection based on the extent of
excision of the stomach. Table 2 enlists the various minimally invasive approaches
of gastrectomy reported in literature.
and-Assisted Laparoscopic Gastrectomy (HALG)/LADG

H
Laparoscopic Assisted Digital Gastrectomy
In HALG one of the hands of the surgeon (commonly the non-dominant hand)
is inserted, into the abdominal cavity, through a small abdominal incision across
a special sleeve appliance or hand port system, designed to maintain the pneu-
moperitoneum during the process. The other components of the surgery are per-
formed like a laparoscopic procedure viz.: creation of pneumoperitoneum for
workspace, visualization through laparoscopic camera system and insertion of
other ports.
An early report of HALG with double stapling and quadruple stapling technique
for anastomosis demonstrated equivalent curative results to that of open surgery and
was found to be less invasive [2]. Other reports on hand assisted distal gastrectomy
in early distal gastric cancers found it to be not as beneficial and has been proposed
to be a steppingstone in the learning curve during transition to totally laparoscopic
gastrectomy [3].
The advantages of hand assisted laparoscopic techniques are that the inserted
hand improves tactile sensation, has a greater degree of freedom of movements as
compared to laparoscopic instruments inserted through fixed trocars and can
Recent Advances in Laparoscopic Gastrectomy for Gastric Cancer with Special… 35
somewhat aid in depth perception. It can help in gentle blunt dissection as well as
retraction and apply immediate haemostasis [4].
However, there are some disadvantages of HALG, pertinent amongst which are:
(1) the hand inserted in the abdomen can compromise the intra-abdominal working
space (2) there can be hand shoulder and forearm muscle fatigue (3) The need for
an incision of 7–8 cm which can offset the advantages of minimal access techniques
(4) added cost of hand port system [2–4].
Laparoscopy-Assisted Gastrectomy (LAG)
In LAG, mobilization of the stomach is done entirely by laparoscopic approach but

resection of the stomach and anastomosis is performed extra-corporeally [5]. The
procedure has advantages of better localization of the lesion and presumably a safer
reconstruction. However, it may pose difficulty in obese patients.
Totally Laparoscopic Gastrectomy (TLG)
In TLG mobilization of the stomach, resection, as well as anastomotic reconstruc-

tion is done totally by the laparoscopic approach. The principles of laparoscopic
resection should achieve the same standards as that of open surgery including R0
resection and D2 lymphadenectomy [6]. A totally laparoscopic gastrectomy may be
particularly beneficial in the obese [7].
Performance of an intracorporeal anastomosis remains an important step of
totally laparoscopic gastrectomy. Several intra-corporeal anastomotic techniques
have been reported as tabulated in Table 3 [1, 8–13]. The techniques need standard-
ization with respect to reproducibility, safety, and simplicity. Laparoscopic total
gastrectomy for remnant gastric cancer has been reported to be feasible and compa-
rable to open approach [14].
Table 3 Commonly used anastomotic techniques for restoration of bowel continuity after totally
laparoscopic gastrectomy
Anastomosis after distal Billroth I/Delta anastomosis/Overlap Method
gastrectomy Billroth II
Roux en Y/Beta shaped Roux En Y reconstruction
Uncut Roux En Y
Anastomosis after proximal Esophagogastrostomy
gastrectomy/Total Esophagogastrostomy with antireflux procedure
gastrectomy Esophagojejunostomy can be performed with linear or circular
stapler: (functional end to end anastomosis/overlap method/
inverted T shaped anastomosis)
Jejunal interposition with pouch or without pouch
Double tract reconstruction
Laparoscopic Function-Preserving Surgery
Function preserving gastrectomy aims to reduce post gastrectomy syndromes that

are associated with conventional distal/total gastrectomy and thus improve quality
of life without compromising oncological adequacy. They are primarily indicated
for node negative early gastric cancers. The common procedures performed in func-
tion preserving gastric resection are: (1) pylorus preserving gastrectomy (2) middle
segment gastrectomy (3) vagus nerve preserving gastrectomy and (4) proximal gas-
trectomy (5) local excision (6) minimally invasive endoscopic techniques (7) senti-
nel node navigation techniques in early gastric cancer along with endoscopic
mucosal resection and endoscopic submucosal dissection. Described below are the
various function preserving gastrectomies that are performed laparoscopically.
1. Pylorus-Preserving Gastrectomy (PPG): Node negative early gastric cancers

(T1N0M0) located in the middle third of the stomach are suitable for pylorus
preserving gastrectomy. The tumor should be at least 4.0 cm away from the pylo-
rus to ensure an adequate distal margin. Preservation of hepatic branch of vagus
and right gastric artery with its accompanying nerve as also the infrapyloric ves-
sels is important and raises concerns regarding adequate lymphadenectomy [15].
Laparoscopy-assisted PPG (LAPPG) scores better in the domains of functional-
ity preservation, of particular note is the nutritional benefits and reduced inci-
dence of gall stones as compared to laparoscopic assisted distal gastrectomy
[LADG] [15]. Postoperative gastric stasis is an issue of concern in PPG and
preserving an adequate length of remnant stump near pylorus has been suggested
to decrease the complication [1].
2. Middle Segment Gastrectomy/Segmentectomy: Middle segment gastrectomy
is a type of function preserving gastrectomy performed in early middle and high
body tumors, particularly T1N0M0 tumors <4 cm where endoscopic submuco-
sal dissection/resection is not applicable. It constitutes a circumferential resec-
tion of the midsegment of the stomach preserving pylorus and cardia and differs
from PPG with respect to preservation of a longer pyloric antral remnant and
lesser lymphadenectomy [16]. Middle segment gastrectomy has been reported
primarily from east Asian countries where early gastric cancers are common.
The proposed advantage of middle segment gastrectomy is the lower incidence
of early dumping syndrome and reflux gastritis. The limited lymphadenectomy
associated with the smaller gastric resection appears to have no adverse effect
particularly in early gastric cancers [16]. However, the procedure is still
investigational.
3. Vagus Nerve-Preserving Gastrectomy (VPG): In VPG the vagus nerve
branches to hepatic, coeliac and mesenteric plexus are retained which reduces
the chances of diarrhoea and post-gastrectomy syndromes thus improving the
quality of life [17]. The relative disadvantages are the concerns regarding inad-
equate lymphadenectomy and increased operative time.
Table 4 Procedural Modification Fundoplication

after proximal gastrectomy to Gastric tube formation
reduce reflux
Pyloroplasty
Esophagopexy with crural repair
Double flap technique
Jejunal loop interposition
Jejunal pouch interposition
Double tract repair (Roux en Y anastomosis) (Fig. EN2)
4. Laparoscopic Proximal Gastrectomy (LPG): In proximal gastric cancer the

choice exists between proximal gastrectomy and total gastrectomy. Proximal gas-
trectomy though oncologically safe has been reported to have higher reflux esoph-
agitis and anastomotic strictures particularly if esophago-gastrostomy is used as a
method of restoration of bowel continuity. Addition of antireflux procedures after
esophagogastrostomy have been tried in an effort to reduce the incidence of anas-
tomotic stricture and reflux esophagitis but the results remain far from satisfactory
[18–20]. Jejunal interposition and double tract repair are two alternatives to esoph-
agogastrostomy proposed to reduce reflux and its complications [21–23]. Table 4
lists the various available procedural modifications after proximal gastrectomy to
reduce reflux. The double tract repair has certain advantages as compared to jeju-
nal interposition, the latter being a complex procedure and difficult to perform
laparoscopically. The additional procedure of gastrojejunostomy in double tract
repair takes minimal extra time and provides an alternative drainage route for the
gastric stump and thus prevents delayed gastric emptying.
5. Local Excision: Non circumferential excision or wedge resection can be per-
formed laparoscopically particularly with laparoscopic endoscopic cooperative
techniques in early gastric cancer.
6. Endoscopic Surgery: Endoscopic surgery (endoscopic mucosal resection/endo-
scopic submucosal dissection) is indicated for T1a tumors confined to mucosa
that are ≤2 cm well differentiated and non-ulcerated as lymphnode metastasis in
such tumors is practically absent [24].
7. Laparoscopic Sentinel Node Navigation Surgery: Sentinel node navigation
surgery (SNNS) is an important concept of laparoscopic function preserving sur-
gery projected to improve quality of life in early gastric cancer and is being
investigated [25].
Single-Incision Distal Gastrectomy (SIDG)
SIDG needs advanced techniques and there is sparse evidence of oncological safety
and therefore has not been generalized. Thereby safety and oncologic outcomes of
SIDG needs validation in large scale studies.
Robotic Gastrectomy
Robotic gastrectomy/robot assisted gastrectomy has been proposed to overcome the

inherent difficulty of laparoscopic gastrectomy and is reported to score better in
performance of D2 lymphadenectomy particularly in dissection of difficult areas for
example near major vessels, infra-pyloric region close to the pancreas, splenic hilar
nodes and hiatal area dissection. It is also valuable in performance of complex gas-
trointestinal reconstruction particularly in placement of the purse string suture
around the anvil inserted in lower esophagus while performing a circular stapled
anastomosis. The learning curve of robotic surgery is steep due to its simplicity and
early adaptability [26–28].
D1 Versus D2 Lymphadenectomy
Peri gastric nodes that are located closest to primary are designated as N1, whereas
distant peri gastric nodes as also nodes situated along major arterial supply of the
stomach are denoted as N2. En bloc removal of the stomach along with N1 level
nodes is termed as gastrectomy with D1 lymphadenectomy whereas D2 lymphade-
nectomy entails enbloc removal of N1 and N2 nodes along with gastrectomy. The
Japanese classification of nodes assigns numbers according to various stations.
Figure 1 depicts common lymph node stations around the stomach.
The Japanese view of a survival benefit with D2 lymphadenectomy stems from
the fact that the initial spread of gastric cancer is largely localized to lymphnodes
Fig. 1 Lymph node

stations around the
stomach. (reproduced from
Zhang et al. Progress of
preoperative and
postoperative radiotherapy
in gastric cancer World.
Journal of Surgical
Oncology. 2018;16:187.
https://doi.org/10.1186/
s12957-018-1490-7)
around the stomach. Proponents of the western non-radical view believe that more
radical lymphadenectomy increases accuracy of pathologic staging, rather than con-
ferring an improved survival. Most east Asian (Japanese, Chinese and Korean) stud-
ies report a better outcome of gastric cancer surgery when compared to their Western
counterparts and project a beneficial role of D2 dissection however they are largely
nonrandomized trials because the already accepted benefits of D2 dissection raises
ethical concerns in conducting comparative analysis of D1 versus D2. The Dutch
and the MRC studies failed to demonstrate a survival advantage and conversely
noted increased morbidity with D2 dissection as opposed to D1 dissection. A recent
Italian trial has projected a trend towards improved disease-free survival with D2
dissection for node positive T2-T4 tumors [24]. Earlier pancreatico-splenectomy
was routinely added to D2 gastrectomy to ensure a full nodal clearance along the
splenic artery however it was associated with increased morbidity which called for
modification to spleen preserving D2 gastrectomy. Moreover, contamination and
non-compliance to the standards of D1 and D2 lymphadenectomy often confounds
comparisons between reported trials [29]. A recent review on various trials on extent
of lymphadenectomy for gastric cancer observed benefits of pancreas and spleen
preserving D2 lymphadenectomy as compared to D1 lymphadenectomy particu-
larly in node positive advanced gastric cancers [30]. Conversely the AJCC (American
Joint Committee on cancer) eighth edition classification grades prognosis based
upon the number of nodes involved rather than the station/location and recommends
removal of ≥16 regional nodes for reliable prognostic staging, albeit a greater
lymph node yield is expected in D2 lymphadenectomy [30]. A metanalysis of ran-
domized controlled trials noted a benefit regarding disease specific survival with D2
lymphadenectomy and though there was no noted survival benefit regarding overall
survival or disease-free survival, subgroup analysis by country did show a benefit
[31]. The current western consensus is that D2 lymphadenectomy should be per-
formed in high volume centres where the expertise is available [24]. Extended D3
lymphadenectomy entails a more radical en bloc resection including N3 nodes
which are considered to be situated outside normal lymphatic pathways from stom-
ach but may be involved due to retrograde lymphatic flow resultant to blockage of
normal routes in advanced malignancies and may prove beneficial if N2 nodes are
positive however its benefits over D2 is not proven [32].
Comparison of Open Vs Laparoscopic Gastrectomy
Laparoscopic surgery has been advocated in early gastric cancer and merits on
aspects related to safety, feasibility, oncologic parameters and better short-term out-
comes than those of open gastrectomy. A metanalysis comparing laparoscopic and
open surgery for early gastric cancer observed that laparoscopic gastrectomy rever-
berated the benefits of laparoscopic surgery viz.: less blood loss, smaller incision
length, reduced postoperative pain and shorter hospital stay besides fewer serious
complications. However, it displayed relative demerits of longer operative time and
fewer harvested nodes [33]. A concurrent metanalysis on laparoscopic gastrectomy
for advanced gastric cancer suggests an equivalent survival outcome both in arenas
of overall and disease-free survival as compared to open surgery [34]. The crux of
performing a laparoscopic D2 gastrectomy lies in performance of an adequate
lymphadenectomy. Several randomized clinical trials with multicentre participation
and a few systematic review and meta-analysis are being conducted to study the
safety and efficacy of laparoscopic D2 gastrectomy in the context of early as well as
long-term outcome. One must highlight the fact that as laparoscopic experience has
been accumulated between surgeons of the eastern countries, the indications for
laparoscopic approaches have included also more ‘difficult’ and demanding cases
with advanced gastric cancer patients.
Surgical Technique
atient Position, Trocar Location and Performance

P
of Staging Laparoscopy
The patient is placed in a supine reverse Trendelenburg position with legs apart,
under general anaesthesia. The surgeon has two assistants: one assistant stands on
the right side of the patient and holds the laparoscope, and other stands on the left
side of the patient. Carbon dioxide is used for insufflation. Pneumoperitoneum is
established through Hassan technique. An initial 10-mm port is inserted around the
umbilicus. Staging laparoscopy is performed and adequacy to continue further
established. Subsequently four other trocars are inserted a 12 mm port in left upper
flank, a 5 mm port near the xiphisternum and two 5 mm working ports in either flank.
2 Lymphadenectomy and Specimen Resection for Distal

D
and Total Gastrectomy
Lesser sac entry: The initial step constitutes of gaining entry into the lesser sac by
dissecting the greater omentum along the border of the transverse colon with the
dissection being continued towards the left exposing the tail of pancreas and
splenic hilum.
Division of left gastroepiploic vessels and dissection of 4sb nodes: The left
gastroepiploic vessels are identified, dissected and divided in between ligatures or
clips. The 4sb nodes are also taken down at the same time.
Dissection of gastrocolic omentum, ligation of right gastroepiploic vessels
and dissection of nodal stations 4d & 6: Gastrocolic omentum/ligament is contin-
ued to be divided proximally beyond the level of gastric dissection. In case of proxi-
mal gastrectomy or total gastrectomy the short gastric vessels are also taken down.
Further dissection of gastrocolic omentum is continued to the right side in the same
plane. Stomach is flipped up at the same time and lymph nodes (No. 4d,6) are also
Fig. 2 Showing the

stomach flipped up and the
infra-pyloric group 6 and
4d greater curve nodes
dissected along the greater curvature (Fig. 2). The superior leaf of the mesocolon
and the anterior leaf of the pancreas are dissected towards the pylorus along with the
gastric specimen.
In classic D2 dissection the lymph nodes in front of the superior mesenteric vein
(No. 14v) are not included routinely however in D2 plus dissection for advanced
cancer or if they appear to be involved, they may be included. Dissecting along the
right colic vein/Henle’s trunk helps in identification of the superior mesenteric vein
at the neck of pancreas. Further upward dissection, close to the upper border of
pancreatic head leads to identification of the right gastroepiploic artery which is
identified clipped and ligated at its origin from the gastroduodenal artery, along with
dissection of station 6 nodes (infrapyloric group).
Duodenal mobilization and transection: The dissection is continued further
towards the right until the duodenum is visualized. The duodenum is pulled inferi-
orly so that the hepatoduodenal ligament gets tense, where a window is created and
a communication between the dissection planes is established behind the duode-
num. The first part of the duodenum is mobilized by clearing off tissue of its wall
and after properly creating the window a linear stapler is inserted and duodenum is
divided just distal to the pylorus.
Dissection of the hepatoduodenal ligament, ligation of right gastric artery &
vein and dissection of lymph node stations 12a, 8a and 9: The dissection in the
hepatoduodenal ligament proceeds sequentially in right to left fashion. The right
gastric artery is identified divided and cut at its origin. The proper hepatic artery is
laid bare along with dissection of lymph node station 12a. Hepatoduodenal ligament
structures are dissected with removal of lymph nodal stations 8a (along common
hepatic artery) and 9 (coeliac group) as shown in (Fig. 3). In the process the lym-
phnode stations 5 (suprapyloric group) and station 3 are included in the specimen.
Dissection of posterior gastric attachments and station 7, 11p nodes:
Subsequently the stomach is dissected from anterior surface of pancreas, the lymph
nodes near the left gastric artery (station 7), and the splenic artery (No. 11p; Fig. 4)
are dissected.
Fig. 3 Dissection of
hepatoduodenal ligament
(12 a), common hepatic
artery (No 8a) and celiac
(No 9) lymph nodes
Fig. 4 Clearance of
proximal splenic artery
lymph node (No 11p)
Transection of the stomach: In distal or subtotal gastrectomy the stomach is

transected at a 5 cm distance from the superior margin of the mass and reconstruc-
tion done.
Total Gastrectomy with dissection of additional nodal stations 1, 2: If
total gastrectomy is contemplated, after completing the dissection as described
above, the stomach and omentum are placed back in its natural position, the left
lobe of the liver is retracted and thereafter the stomach is stretched downward
creating traction on the lesser omentum. Resection of the lesser omentum along
the edge of the liver leads to the esophagogastric junction, where the right para-
cardiac lymph nodes (station No 1) are addressed along with others on the path
(No. 3a). The left gastric vein and artery are ligated in the process (Figs. 5 and
6). The hiatal dissection is done posteriorly with exposure of right and left crus
and aorta which is then continued anteriorly with dissection of the left para
cardiac nodes (station 2). (Dissection of additional groups, 4sa would have been
addressed initially at the time of lesser sac division with short gastric division
and the 11 d nodes during dissection of the posterior attachments of the stomach
from the pancreas). Total gastrectomy is completed by dividing the esophagus
or the proximal stomach using a stapler. Stay sutures may be applied to prevent
retraction of cut end of the esophagus into the thorax.
Fig. 5 In cases of total

gastrectomy the left gastric
artery is also ligated along
with clearance of lymph
nodes
Fig. 6 Right para cardiac

dissection
Specimen extraction: The specimen is extracted using a specimen bag by

extending the 10 mm umbilical port incision. In case of laparoscopic assisted gas-
trectomy where an extracorporeal anastomosis is planned the specimen is extracted
through an incision in the epigastrium.
Gastrointestinal Reconstruction after Distal Gastrectomy
The periumbilical incision is sutured back after retrieval of the specimen and the
pneumoperitoneum re-established.
Billroth II reconstruction: A stapled antecolic Bilroth II side to side gastrojeju-
nostomy is constructed as described below. An access opening is created in the
antimesenteric border of an efferent jejunal loop (at 15–20 cm from duodenojejunal
flexure) and the other in the posterior wall of the gastric stump 2 cm proximal to
transection staple line. An endoscopic linear stapler is inserted with one limb in the
jejunum and the other in the stomach lumen (Fig. 7) and an ante colic Billroth II
side-to-side gastrojejunostomy is created. Some surgeons prefer to fix the jejunum
and gastric stump with stay sutures before applying endoscopic linear staplers, how-
ever it can angulate the jejunum and restrict its mobility thereby hampering proper
placement of staplers. Experienced surgeons prefer placing one arm of the
Fig. 7 Stappled ante-colic

iso-peristaltic
gastrojejunostomy
being done
Fig. 8 Closure of common

opening
endoscopic linear stapler into the jejunal opening then clamping the two arms with-
out stapling thus drawing the jejunum close to the rear of the gastric stump, and
stapling after proper opposition is confirmed. The common opening can be closed
by intracorporeal suturing (Fig. 8) or staplers.
A Laparoscopic Roux-en-Y reconstruction is also preferred by some surgeons,
its advantages being less reflux gastritis and esophagitis as also decreased probabil-
ity of gastric cancer recurrence. Nevertheless, the procedure is complex, time-con-
suming, and requires a greater number of anastomosis thus a higher cost is incurred
consequent to use of endoscopic linear staplers.
Billroth I reconstruction: The main advantage of Billroth I reconstruction
method is its technical simplicity of maintaining physiological intestinal continuity
involving only one anastomotic site. Main disadvantage of the anastomosis is its
sequelae of gastroesophageal and duodeno-gastric reflux and its complications
thereof. Moreover, the procedure may be difficult to perform in obese patients or in
patients with large tumours in the distal or mid stomach where large portions of the
stomach is resected making Billroth I reconstruction not possible.
Sutured anastomosis: As regards the anastomotic methodology, intracorporeal
suturing is relatively difficult and time consuming to perform laparoscopically
despite its low cost.
Drain Placement and Closure
An abdominal drain is placed preferably from the right side and port sites are closed.
Perioperative Management
In malnourished, cachectic and obstructed patients, preoperative parental nutrition

is administered. Mechanical bowel preparation is not routinely advocated. Patients
are kept nil per oral for 8 h for solids prior to surgery. Some advocate a stomach
wash with nasogastric tube. Prophylactic antibiotics are used as per standard recom-
mendation. Use of TAP block, epidural analgesia and wound block vary depending
on the choice of the anaesthetist. Nasogastric tubes are generally retained for 1 day
in the postoperative period. Early alimentation is started as tolerated by the patient.
Patients are discharged when they can tolerate semiliquid diet, are afebrile and their
blood parameters are normal. Adherence to ERAS guidelines is advisable to ensure
perioperative optimization to improve outcome in minimally invasive gastric cancer
surgery.
Complications
Enlisted below are some of the specific quoted postoperative complications after D2
gastrectomy (both initial and late).
• Haemorrhagic/Ischaemic complications: Intra-abdominal bleeding, anasto-

motic bleeding, gastric remnant ischaemia.
• Anastomotic complications/Leaks/Fistula: Anastomotic leaks, duodenal blow-
out, colonic fistula, anastomotic strictures, dumping syndrome, marginal ulcer,
bile reflux gastritis.
• Pancreatic complications: Pancreatitis, pancreatic fistula.
• Bowel obstruction/perforation: Bowel obstruction, perforation, ileus, internal
hernia, intussuception, Roux Loop stasis
• Splenic complications: Injury to the spleen and post splenectomy
complications.
• Lymphatic complications: Chyle leak.
• Venous complications: Portal vein thrombosis, splenic vein thrombosis, deep
vein thrombosis.
• Infective complications: Intrabdominal abscess, pulmonary infection, wound
infection.
• Other complications: Cholecystitis, diarrhoea.
In a study evaluating laparoscopic D2 gastrectomy in 1332 patients, postopera-

tive complications occurred in 16.7% while major complications occurred in 2.9%
including 1 death (0.1%) [71]. In a large volume (2966 patients) single center
retrospective study evaluating complications after laparoscopic and open gastrec-

tomy, incidence of a significantly higher overall complication was observed in the
open group, 20.8%, as opposed to 15.4% in laparoscopic group (P = 0.003). Severe
complication rates being similar, 5.8%, in each group. The authors also evaluated
possible risk factors and the following variables emerged significant in multivariate
analysis viz.: age ≥60 years, ASA classification IIIc and estimated blood loss
≥200 mL [35].
Anastomotic leak rates: A meta-analysis comparing laparoscopic and open
total gastrectomy for gastric cancer has observed a higher wound infection rate in
the open group and a higher but not significant anastomotic leak rate in the laparo-
scopic group. Most meta-analyses published earlier however do not report increased
leak rates in laparoscopic group [36].
Postoperative pancreatic fistula: Pancreatico-splenic injury was the main
deterrent to performance of open D2 gastrectomy. Postoperative pancreatic fistula
after open gastrectomy in certain series was high, reported to the tune of 30% in
1997 and has currently reduced to <1% after robotic gastrectomy. The rates of pan-
creatic fistula after laparoscopic D2 gastrectomy has been low varying from 0.4% to
2% [37]. A better magnified visualization in laparoscopic and robotic surgery per-
haps is the reason for the noted difference.
Conclusion
Gastrectomy for gastric cancer is increasingly evolving with adoption of minimally

invasive approaches viz.: laparoscopic and robotic procedures in an attempt to
improve quality of life without affecting oncologic adequacy. Laparoscopic gastrec-
tomy is safe, feasible, with acceptable oncologic outcomes and better short-term
outcome parameters than those of open gastrectomy albeit a longer operative time.
Survival outcomes of laparoscopic and open approaches are comparable.
Key Clinical Notes

1. Laparoscopic gastrectomy is gaining popularity with increased adoption of
minimally invasive approaches in the treatment of gastric cancer that enable the
improvement of the quality of life of patients, without compromising on onco-
logic adequacy.
2. Hand-assisted gastrectomy appears to be a bridge in the learning technique of
laparoscopic gastrectomy particularly in novices, however the inserted hand
compromises the intra-abdominal working space and is relatively more
expensive due to the additional cost of hand port device/sleeve utilized for
maintaining the pneumoperitoneum.
3. The use of endoscopic staplers has revolutionized the performance of intracor-
poreal anastomosis and totally laparoscopic gastrectomy.
4. Laparoscopic function preserving surgery is an attractive option for node nega-
tive early gastric cancer (T1N0M0).
5. Various technical modifications have been suggested after laparoscopic proxi-

mal gastrectomy in order to reduce reflux.
6. Robotic gastrectomy as compared to laparoscopic procedures may be beneficial
particularly in construction of intracorporeal anastomosis.
7. Randomized-controlled trials and metanalysis have robustly confirmed that
laparoscopic gastrectomy is safe, feasible, with efficient oncologic outcomes
and better short-term outcomes than those of open gastrectomy in patients with
early gastric cancer.
8. En bloc removal of the stomach along with N1 level nodes is termed as gastrec-
tomy with D1 lymphadenectomy whereas D2 lymphadenectomy entails enbloc
removal of N1 and N2 nodes along with gastrectomy.
9. The extent of D2 gastrectomy varies with the type of gastrectomy viz.: total/
distal/proximal gastrectomy.
10. D2 lymphadenectomy is the standard of care for gastric cancer treated in east
asian countries due to its perceived survival benefits. The current western con-
sensus is that D2 lymphadenectomy should be performed in high volume cen-
tres where the expertise is available.
11. Pancreatico-splenectomy along with D2 gastrectomy increases morbidity and
should be avoided.
12. D3 lymphadenectomy has not shown to be beneficial over D2 lymphadenec-
tomy nevertheless its role in N2/N3 positive nodal disease is being investigated
13. Various ongoing multicentre trials on laparoscopic D2 gastrectomy suggests it
to be an attractive alternative to open procedure.
14. Wound complications are significantly higher with open procedure, a few stud-
ies suggest that laparoscopic procedure has a slightly higher leak rate compared
to open however most studies do not corroborate such findings.
15. Postoperative pancreatic fistula after open gastrectomy in certain series was
high reported to the tune of 30% in 1997 and has currently reduced to <1% after
robotic gastrectomy.
Editor’s Note1
Open gastrectomy with D2 lymphadenectomy for gastric cancer has been a standard
of practice in east Asian countries however due to increased morbidity particularly
when associated with pancreatico-splenectomy it had failed to gain a similar
approval amongst surgeons in the west. Noncompliance and contamination with the
D2 lymphadenectomy extent and difference in disease biology amongst western as
compared to eastern population were thought to have been the reasons for poor
outcome especially in patients from the west. Lately long-term results emerging
from the Italian trial has shown a trend towards improved survival benefit with D2
over D1 lymphadenectomy for gastric cancer.
Laparoscopic Versus Open D2 Gastrectomy
With the advent of laparoscopic surgery, the safety and efficacy of laparoscopic D2
gastrectomy as compared with open procedure is being investigated. Several clini-
cal trials randomized clinical trials with multicentre participation and a few system-
atic review and meta-analysis have been studying on safety and efficacy of
laparoscopic gastrectomy. Prominent results of a few RCT and metaanalysis com-
paring laparoscopic and open D2 gastrectomy is tabulated below (Table EN1).
Most trials conclude a non-inferiority of laparoscopic D2 gastrectomy over open
D2 gastrectomy as regards the number of nodes harvested, morbidity mortality and
short-term survival benefits. A recent meta-analysis shows an increase trend for
positive proximal resection margin in laparoscopic as compared to open gastrec-
tomy [8]. Laparoscopic D2 gastrectomy has been stated to be safe with low rates of
complications and demonstrate the benefits of minimally invasive surgery viz.: a
lower blood loss and enhanced postoperative recovery albeit a relative disadvantage
of increased operative time [1–11].
Table EN1 Studies comparing laparoscopic and open D2 gastrectomy

Name of Study Results
Laparoscopy-assisted Versus Open D2 Distal No significant differences in:
Gastrectomy for Advanced Gastric Cancer: • postoperative complication
Results From a Randomized Phase II Multicenter • surgical stress response
Clinical Trial (COACT 1001) [1] • noncompliance of D2
lymphadenectomy
(LADG = 47.0%, ODG = 43.2%,
P = 0.648).
• 3 year disease free survival
(LADG =80.1%, ODG = 81.9%;
P = 0.448)
1
Short-term Outcomes of a Multicenter LDG better than ODG in following
Randomized Controlled Trial Comparing parameters:
Laparoscopic Distal Gastrectomy With D2 • Early morbidity
Lymphadenectomy to Open Distal Gastrectomy (LDG 16.6%, ODG 24.1%; P = 0.003).
for Locally Advanced Gastric Cancer (KLASS- • Day of flatus passage:
02-RCT) [2] (LDG 3.5 days, ODG 3.7 days
P = 0.025).
• Pain score and postoperative analgesic
requirement significantly lower after
LDG group:
• Postoperative hospital stay
(LDG vs ODG 8.1 vs 9.3 days
respectively P = 0.005).
No difference LDG vs ODG in:
• 90 days’ mortality rate
(LDG = 0.4%, ODG = 0.6%,
p = 0.682).
• Mean retrieved lymph nodes
(LDG = 46.6, ODG = 47.4, p = 0.451)
Effect of Laparoscopic vs Open Distal No difference in:
Gastrectomy on 3-Year Disease-Free Survival in • 3 year DFS
Patients With Locally Advanced Gastric Cancer: LDG = 76.5%, ODG = 77.8%
The CLASS-01 Randomized Clinical Trial [3] • Three-year OS,
LDG = 83.1%,ODG = 85.2%;
• Cumulative 3-year recurrence rate
LDG = 18.8%, ODG = 16.5%
Morbidity and Mortality of Laparoscopic Versus No difference in:
Open D2 Distal Gastrectomy for Advanced • D2 lymphadenectomy compliance:
Gastric Cancer: A Randomized Controlled LG = 99.4%, OG = 99.6%; P = 0.845.
Trial [4] • Postoperative morbidity
LG = 15.2% OG = 12.9%, 2.3%; 95%
P = .285.
• Mortality rate
LG = 0.4% OG = zero P = .249).
Laparoscopic Versus Open Gastrectomy With D2 LGD2 vs OGD2, Following parameters
Lymph Node Dissection for Advanced Gastric were significant lower in LGD2:
Cancer: A Systematic Review [5] • Intraoperative blood loss,
• Duration of analgesic administration,
• Times to first ambulation
• Time to first flatus
• Time to oral intake,
• Length of postoperative stay,
• Incidence of nonsurgical complications.
LGD2 vs OGD2, no significant differences
were observed between:
• Postoperative in-hospital mortality,
• Retrieved nodes,
• Tumor recurrence,
• 5-year DFS
• Five and three-year OS.
LGD2 had longer operative time.
(continued)
Laparoscopic Versus Open Gastrectomy for LG vs OG:
Locally Advanced Gastric Cancer: A Systematic • Operative time more in LG,
Review and Meta-Analysis of Randomized • Estimated intraoperative blood loss
Controlled Studies [6] lower in LG
LG vs OG similar outcome in:
• Length of hospital stay
• Time to flatus passage
• Number of retrieved nodes
Long-term Oncologic Outcomes of a No difference in:
Randomized Controlled Trial Comparing • Survival in Kaplan Meier
Laparoscopic Versus Open Gastrectomy With D2 • 5-year OS:
Lymph Node Dissection for Advanced Gastric (LG = 49.0%, OG = 50.7%)
Cancer [7] • 5-year DFS
(LG = 47.2% OG =49.6%)
• 5-year tumor recurrence rate no
difference
Long-term and short-term outcomes after In RCTs, LG were better than OG in terms
laparoscopic versus open surgery for advanced of:
gastric cancer: An updated meta-analysis [8] • Estimated blood loss,
• First oral intake day
• First day to pass flatus
LG fared worse than OG as regards:
• Operation time
• Proximal margin positivity
• Overall survival
• Disease-free survival (DFS)
LGD2,LGD,LG Laparoscopic D2 gastrectomy, OGD2,OGD,OG Open D2 gastrectomy, RCT
Randomized Controlled Trials
Variations in Extent of Resection
Gastrectomy
Various function preserving partial gastrectomy reported in literature are: distal gas-
trectomy, proximal gastrectomy, pylorus preserving gastrectomy, middle segment
gastrectomy, segmentectomy and local resection which provide good oncological
outcome in early gastric cancer
Lymphadenectomy
Variations in extent of lymphadenectomy described has been D1, D1 + alpha, D1 + Beta,
D2, D2 plus dissections and D3. The definitions of D1, D1 plus and D2 gastrectomy
varies according to the site of tumor and gastrectomy viz.: total gastrectomy, distal gas-
trectomy, pylorus preserving gastrectomy and proximal gastrectomy.
D1 and D1 + alpha, D1 + beta lymphadenectomy: In classic D1 gastrectomy
perigastric lymph nodes station 1–6 nodes are removed. In D1 alpha additional
groups removed are level 7 (left gastric) or 8a (common hepatic). In D1 beta dissec-
tion additional 7, 8a and 9 (coeliac) are removed.
D2, modified D2 and D2 + lymphadenectomy: A typical D2 lymphadenectomy

in total gastrectomy involves removal of 1–12 nodes i.e. perigastric nodes and
lymph nodes along vessels viz.: left gastric, common hepatic, celiac, splenic and
hepatoduodenal. The original D2 lymphadenectomy involved removal of pancreatic
tail and spleen. A modified D2 with splenic preservation and removal of splenic
hilar nodes is recommended for tumors not directly involving the spleen and has
been shown to have non inferior outcomes [10]. A D2 plus lymphadenectomy
involves removal of additional groups over and above D2 viz.: 12p, 13, 14 (retro
pancreatic nodes and along superior mesenteric vessels). A recent study has shown
propensity for improved survival with D2 plus lymphadenectomy in distal gastric
cancer with serosal involvement [12].
The extent of lymphadenectomy varies according to the extent of gastrectomy. Cited
below is the definition of D1, D1 plus and D2 dissections classified according to
Japanese gastric cancer treatment guidelines defined upon the extent of gastrectomy [13].
Total gastrectomy
• D0: Lymphadenectomy less than D1.
• D1: 1–7.
• D1+: D1 + 8a, 9, 11p.
• D2: D1 + 8a, 9, 11p, 11d, 12a.
Distal gastrectomy
• D1: 1, 3, 4sb, 4d, 5, 6, 7.
• D1+: D1 + 8a, 9.
• D2: D1 + 8a, 9, 11p, 12a.
Pylorus-preserving gastrectomy
• D1: 1, 3, 4sb, 4d, 6, 7.
• D1+: D1 + 8a, 9.
Proximal gastrectomy
• D1: 1, 2, 3a, 4sa, 4sb, 7
• D1+: D1 + 8a, 9, 11p
D3/D4 lymphadenectomy, periaortic/paraaortic lymph node dissection: D2

lymphadenectomy plus the removal of nodes in periaortic regions and porta hepatis
(stations 1–16) is the traditional definition of D3 lymphadenectomy. Paraaortic
lymphadenectomy is termed as D4 dissection [14]. A review on published random-
ized controlled trials and metanalyses analyzing results of D3 lymphadenectomy in
gastric cancer concluded that there was no survival benefit of the procedure with
added drawbacks of increased iatrogenic trauma reflected as higher blood loss, lon-
ger operative time, relaparotomies and increased morbidity [15].
Compliance in lymphadenectomy: Compliance with lymphadenectomy is met

when not more than one station of the defined groups for the particular lymphade-
nectomy is missed. Non compliance (removing less than the recommended stations)
and contamination (removing more than the indicated nodes for the level of dissec-
tion) can confound comparisons amongst trials [16].
dditional Organ Excision

A
Omental excision: Excision of the lesser omentum is controversial. The Japan
Gastric Cancer Association have recommended omental resection only in patients
with serosal involvement. On the other hand routine omental resection has not found
to be beneficial in T3 T4 cancers and studies have found that if gastric cancer has
spread to omentum then there are chances of distant abdominal spread [17].
Pancreatico-splenectomy in Laparoscopic D2 gastrectomy: Prophylactic
splenectomy increases morbidity and does not improve survival in gastric cancer. In
a study comparing spleen preserving laparoscopic D2 total gastrectomy with lapa-
roscopic D2 total gastrectomy and splenectomy no difference was found in outcome
complications and retrieved nodes. The group with splenectomy had a higher blood
loss [18]. However it may be beneficial in advanced cancers and recent reports of
laparoscopic total gastrectomy with pancreatico-splenectomy for advanced T4b
cancers have found it to be safe and effective [19].
Laparoscopic Bursectomy along with D2 lymphadenectomy: Bursectomy is
a recent manoevure introduced in advanced gastric cancer. It entails removal of
peritoneal lining over the pancreas and anterior surface of transverse mesocolon.
Recent reports are emerging of the performance of bursectomy along with radical
D2 gastrectomy laparoscopically [20]. However, bursectomy in addition to D2 gas-
trectomy may not improve survival [21].
Techniques in Anastomosis
nastomotic Techniques after Distal Gastrectomy

A
Performance of an intracorporeal anastomosis is a key requirement for total laparo-
scopic gastrectomy. The options of restoration of gastrointestinal anastomosis that
are usually performed after distal gastrectomy are: Billroth I, Roux-en-Y, Billroth II
reconstruction and jejunal interposition. The Roux en Y anastomosis can be per-
formed as a traditional procedure or an uncut Roux en Y procedure using linear or
circular stapler, in an isoperistaltic or antiperistaltic fashion and ligated or stapled
with a stapler without cutting [22–27] (Fig. EN1).
A metanalysis comparing the above four techniques of reconstruction viz.:
Billroth I (BI), Billroth II (BII), Roux-en-Y (RY) and uncut Roux-en-Y (URY)
reconstruction, concluded as follows:
• RY anastomosis had longer operative time than BI and BII.

• More blood loss with RY than URY or BI
Fig. EN1 Schematic diagram depicting uncut Roux-en-Y Gastrojejunostomy
• Risk of gastrointestinal motility dysfunction greater with RY than URY or BI.

• URY had less retained food residue than other three anastomosis
• Remnant gastritis more common in BI and BII than URY and RY
• Bile reflux less with RY and URY than BI and BII [28].
In another meta-analysis comparing Roux en Y (RY) and uncut Roux en Y (URY)

after distal gastrectomy, URY had several advantages over RY viz.:
• Shorter operative time

• Reduced incidence of reflux gastritis/esophagitis
• Less delayed gastric emptying
• Lower incidence of roux stasis syndrome
• Increased serum albumin [29].
The Delta anastomosis which is a linear side to side gastroduodenostomy is one

of the common reconstruction technique after distal gastrectomy (Fig. EN2) but has
concerns regarding ischaemia and subsequent identification of tumor margins. The
other method commonly used is the overlap method [27].
Fig. EN2 Schematic
diagram showing the Delta
anastomosis
Stomach
Stapler
Duodenum
Delta Shaped Anastomosis

Side to Side Gastroduodenostomy
econstruction after Proximal Gastrectomy

R
The common anastomotic techniques described after proximal gastrectomy:
• Esophagogastrostomy (EG)
• Esophagogastrostomy plus fundoplication
• Esophagogastrostomy plus angle of his repair
• Esophagogastrostomy plus double flap technique (DFT)
• Double tract reconstruction (DTR) (Fig. EN3)
• Jejunal pouch interposition (JPI)
• Jejunal interposition (JI)
In a metanalysis comparing five techniques of reconstruction (double flap tech-

nique, double tract repair, jejunal interposition, jejunal pouch interposition, and
esophagogastrostomy) after laparoscopic or open proximal gastrectomy it was
observed that double flap reconstruction had lowest rate of complication, whereas
double tract repair, jejunal interposition, jejunal pouch interposition, and esophago-
gastrostomy groups showed higher incidence of anastomotic leakage, anastomotic
stricture, and retained residual food. Esophagogastrostomy group had less operative
time, lower blood loss, and shorter length of hospital stay [30].
Fig. EN3 Schematic diagram showing double tract repair
econstruction after Laparoscopic Total Gastrectomy

R
The common method of restoration of gastrointestinal continuity after laparoscopic
total gastrectomy are Roux En Y esophagojejunostomy, jejunal interposition and
double tract reconstruction. Esophagojejunostomy after total laparoscopic gastrec-
tomy can be done similarly with linear or circular staplers in end to side or side to
side fashion. Novel techniques described for insertion of the anvil are: use of Endo
PSI (endoscopic purse string suture instrument), trans oral insertion of anvil and use
of hand sewn purse string suture [24]. Hunt Lawrence jejunal pouch reconstruction
after open total gastrectomy has been considered to improve quality of life when
compared to Roux en Y esophagojejunostomy. Pouch reconstructions are not com-
mon in totally laparoscopic approaches however reports of jejunal pouch construc-
tion after laparoscopic total gastrectomy are emerging [31].
Emerging Use of Laparoscopic Techniques in Early Gastric Cancer
A number of newer laparoscopic techniques are emerging in early gastric cancer

which includes:
• Laparoscopic local resection,

• Endoscopic full thickness resection with laparoscopic closure (EFTR),
• Laparoscopic endoscopic cooperative surgery (LECS).
The “non touch lesion lifting method” is a new emerging concept in this regard
for small early gastric cancers. Intraperitoneal spillage being a concern especially in
non touch technique and further modifications are proposed to overcome it [32].
Sentinel Node Navigation Surgery
Studies are emerging on feasibility of sentinel node biopsy in gastric cancers.

Sentinel node biopsy techniques have been reported to have high identification
sensitivity and specificity rates in gastric cancer. They can be done using the dye
method fluorescein dye and visible light fluorescence or indocyanine green and
infra-red imaging technique. The use of indocyanine green with infra-red imaging
system has been reported to have a high identification rate. Several fluorescence
imaging systems have been used in various studies prominent amongst which are
the infra-red ray electronic endoscopic, fluorescent imaging and infra-red ray lapa-
roscopic imaging systems. Alternatively use of radiocolloid has been proposed.
The disadvantage of radiocolloid method is need for gamma camera. Current evi-
dence suggests that a dual technique consistent with use of radioactive isotope
(technetium 99 colloid) and dye agents (isosulfan blue/indocyanine green ICG)
can improve sentinel node identification rate. The dye injection can be made under
endoscopic guidance in submucosal aspect or subserosal intraoperatively.
Pathological detection method include hematoxylin eosin stain, immunohisto-
chemistry and one step nucleic acid amplification technique. One of the concerns
raised in the use of sentinel node biopsy in gastric cancers is the presence of skip
metastasis. Authors have proposed that sentinel node basin dissection technique
rather than the traditional node pickup technique can circumvent the problem of
skip metastasis and improve identification rates. However, sentinel node basin dis-
section technique yields higher number of nodes and the pathological analysis of it
is time consuming particularly if multiple nodal basins are sampled. Concerns have
been voiced regarding effectiveness of sentinel node identification following non
curative endoscopic submucosal dissection, however recent emerging studies sug-
gest that it may be feasible [33–37].
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Laparoscopic Subtotal Cholecystectomy
Kalpesh Jani and Samir Contractor
Introduction
In the Western world, 10–15% of the population suffers from gallstone disease in
their lifetime, affecting nearly 1–4% of the people annually [1]. While a majority
are managed conservatively or by straight forward cholecystectomy, in about 6%,
the operative procedure is rendered difficult due to ongoing inflammatory process
that makes the dissection and delineation of local anatomy difficult, e.g., acute
cholecystitis, gangrenous gallbladder, empyema of the gallbladder, perforation
of the gallbladder and Mirizzi’s syndrome or cirrhotic liver with portal hyperten-
sion, that increases the risk of hemorrhage during dissection [2, 3]. The term ‘dif-
ficult gallbladder’ has been coined to describe procedures in such pathologies
[2]. Depending on the inflammation of the gallbladder, the ease of dissection of
the cystic pedicle and the amount of adhesions, Nassar et al have developed an
ascending scale to grade the difficulty of the gallbladder surgery [4]. Various
techniques have been promulgated for carrying out safe surgery in such difficult
situations, including the fundus-first approach, cholecystostomy and subtotal
cholecystectomy [5, 6]. Subtotal cholecystectomy (SC) removes the gallbladder
partially, leaving some portion of the gallbladder in situ, usually, when dissection
of the hepato-cystic triangle or separating the gallbladder from the liver bed is
likely to be dangerous [7]. Table 1 enumerates the various bailout procedures in
difficult laparoscopic cholecystectomy.
As Strasberg points out in his review, a lot of confusion is created by using
both the terms subtotal and partial cholecystectomy interchangeably, and both
the terms often describe the same operation as well as the same term is being
used to describe operations with variable portions of gallbladder left behind [8].
K. Jani (*) · S. Contractor

VIGOS Hospital, Vadodara, India
https://doi.org/10.1007/978-981-16-5473-2_3
64 K. Jani and S. Contractor
Table 1 Bailout procedures Antegrade fundus first technique

in difficult gallbladder during Cholecystostomy
laparoscopic cholecystectomy
Subtotal cholecystectomy/partial cholecystectomy
Conversion to open
Essentially, SC creates a gallbladder remnant, which has been defined as the

wider part of the free end of the cystic duct that appears like a miniature gall-
bladder [9].
History
The first reported SC was an unplanned modification, performed by Hans Kehr in

1898, some 16 years after the first reported cholecystectomy done by Langenbuch
[10]. While operating on a young woman with severe acute cholecystitis, he divided
the gallbladder leaving the posterior wall and the part of the bladder lying next to
the cystic duct behind. He then closed the remnant, using a strip of gauze as a drain.
The next modification to catch the popular fancy was described by Pribram from
Berlin, to avoid hemorrhage and bile leak from the liver bed. He split the gallbladder
along its longitudinal axis, remove the stones and then destroyed the mucosa and
submucosa using thermal energy [11]. The flaps of serosa were sutured together
while the cystic duct and artery were ligated medial to the gallbladder. It is notewor-
thy that he did not actually remove any part of the gallbladder from the body of the
patient. Subsequent modifications to this technique, described by Thorek in USA as
well as Bailey and Love in England, became prevalent, which included removing
the majority of the gallbladder except the posterior wall that was attached to the
liver and ablating the mucosa of the remnant, reinforced with a graft of omentum or
falciparum ligament which was sutured over it [12, 13]. In these variations, just like
Pribram’s original description, the cystic duct and artery were dissected and ligated
outside the gallbladder.
‘Partial cholecystectomy’ as a planned strategy to deal with difficult dissection in
the region of the hepato-cystic triangle was first mooted by Estes [14]. In his series
of gangrenous cholecystitis, he described the procedure where the gallbladder was
divided on its long axis up to its neck and removed leaving the part attached to the
liver and cystic duct behind. The cut edges of the remnant on the liver were over
sewn and the mucosa treated with iodine. He specified that no attempt was made to
occlude the cystic duct nor was any part of the remnant sutured together to produce
a closed cystic structure. Lerner modified this technique by observing that the cystic
artery could be divided on the inferior wall of the gallbladder near the cystic duct
and can be over sewn at that point and thus, easily controlled [15]. Similarly, the
concept of leaving a portion of the gallbladder to the right of the cystic duct to act
as a “shield” for the vulnerable structures in the hepato-cystic ligament was elo-
quently described by McElmoyle [16].
Laparoscopic Subtotal Cholecystectomy 65
Types of Subtotal Cholecystectomies
Subsequent, published literature shows that the terms subtotal and partial cholecys-
tectomy were used interchangeably to describe three types of resections, firstly
where only a strip of gallbladder was left behind, secondly where a portion of the
gallbladder adjacent to the cystic duct was left behind but none on the liver bed and
thirdly, where part of the gallbladder was left behind on the liver bed as well as
adjacent to the cystic duct. Also, the size of gallbladder remnant adjacent to the
cystic duct was variable, ranging in size from millimeters from the internal opening
of the cystic duct to one where only the fundus was excised, leaving a major portion
of the gallbladder intact [1, 7, 15, 17–26].
Palanivelu et al., in 2006, described three variants of laparoscopic subtotal cho-
lecystectomy (LSC) in a paper describing their experience in patients with cirrhosis
and portal hypertension [27]. When the cystic duct and artery were ligated and
divided outside the gallbladder and the organ was removed leaving a strip of it on
the liver bed, it was termed as LSC I (Fig. 1). The mucosa was either stripped off or
destroyed using electrosurgery. This was typically needed where the hepato-cystic
triangle was non-inflamed, but the liver was cirrhotic and there was a danger of
bleeding from the liver bed. However, when the primary danger was of bleeding
during dissection in the hepato-cystic triangle, due to neovascularity and caverno-
matous transformation of the portal vein, the gallbladder was divided at the neck,
just to the right of the cystic duct insertion into it and the stump closed. The distal
organ was removed in its entirety. This was termed as LSC II (Fig. 2). A combina-
tion of the above two, i.e., leaving a stump of gallbladder attached to the cystic duct
as well as a strip of its posterior wall on the liver bed, was defined as LSC III
Fig. 1 Palanivelu LSC

Type I (Posterior wall of
Gall bladder left on liver
bed and mucosa stripped or
fulgurated

Type II & Strasberg
reconstituting type (Partial
GB removed)

Type III (Posterior wall of
Gall bladder left on liver
bed and mucosa stripped or
fulgurated) GB stump
reconstructed
(Fig. 3). Eventually, they extended the same terminology to these modifications
when performed for other indications like acute inflammation, empyema, etc.
[Personal communication]. Table 2−4 enlists the various nomenclatures and classi-
fications used in subtotal cholecystectomy.
In a 2016 paper, Strasberg et al. suggested a different nomenclature. Removal of
less than half of the distal gallbladder should be termed as fundectomy while the
term partial cholecystectomy should be abandoned, the rest being called SC [8].
These were further sub-classified into the ‘fenestrating’ variety, when the proximal
stump of gallbladder is left open and not sutured closed to produce a remnant cystic
structure, and a ‘reconstituting’ variety, in which a cystic remnant is closed (Figs. 2
and 4). Combining both the proposed classification or types of LSC, Type II & Type
III can be of fenestrating and reconstituting types (Tables 2, 3 and 4).
Fig. 4 Palanivelu type II

&Strasberg Fenestrating
type (Partial GB removed)
Table 2 Nomenclature used Partial cholecystectomy

interchangeably with subtotal Fundectomy
cholecystectomy Subtotal cholecystectomy
Table 3 Types of Type I A strip of posterior wall of gallbladder left on the liver
Laparoscopic Subtotal bed
Cholecystectomy Type II A residual stump of gall bladder left in situ
[Palanivelu et al]
Type III combination of I and II
Table 4 Strasberg Fenestrating type

Classification of subtotal Reconstituting type
cholecystectomy
Incidence
The incidence of LSC varies in different series depending on the expertise and lapa-
roscopic skills of the surgeon. While many surgeons would opt to convert to an open
cholecystectomy on encountering difficult situations, data from centers performing
a large volume of laparoscopic cholecystectomies report adopting the LSC tech-
nique in 5.6–10.6% of cases, thus reducing the conversion to open in these number
of cases [23, 28, 29]
Indications
The various indications for performing subtotal cholecystectomy, both open as well
as laparoscopic, were summarized in a review which studied literature from 1954 to
2013 [1]. These are as follows:
1. Severe cholecystitis, inflammation and fibrosis at the Calots triangle [72.1%]

2. Cholelithiasis in liver cirrhosis and portal hypertension [18.2%]
3. Gangrene, empyema or perforated gallbladder [6.1%]
4. Mirizzi syndrome [3.0%]
5. Intrahepatic gallbladder or accidental damage to the gallbladder [0.6%]
Technical Variations
Both Palanivelu’s technical variations of LSC I, II & III as well as Strasberg’s

‘fenestrating’ and ‘reconstituting’ SC have been described above. Closure of the
gallbladder remnant seems to cause lower incidence of bile fistula [1, 7]. The
mucosa on the strip of gallbladder wall left on the liver bed may be stripped or
may be destroyed using electrocautery, argon beam or radiofrequency ablation
[8, 27]. The cut edge of the gallbladder wall on the liver may be over sewn [14]
Similarly, the edges of the gallbladder attached to the cystic duct may over sewn
[15] or left as such [8]. The gallbladder portion to the right of the cystic duct
may be sutured by an intracorporeal stitch from the mucosa side within [30],
sutured close [27], closed with an endo-loop [31], stapled [32] or left open [33,
34]. Also, the remnant at the right of the cystic duct should be kept as small as
possible. Remnants larger than 1 cm in size have been reported to become symp-
tomatic, requiring a second procedure for excision [7]. Subtotal cholecystec-
tomy may be more approachable with laparoscopic techniques rather than open
due to the magnification afforded and the proper angle of view that can be
obtained with a 30-degree telescope. However, suturing the remnant closed may
require skills sets which may not be attained by many laparoscopic surgeons [1].
The various approaches to address the gall bladder remnant/stump has been
depicted in Figs. 5, 6 and 7; Tables 5 and 6.
Fig. 5 Subtotal
cholecystectomy with
suturing of gall bladder
stump (Arrow) with
continuous sutures. [Image
courtesy: Dr. Deborshi
Sharma]
Fig. 6 Subtotal
cholecystectomy with
inside out suturing of gall
bladder stump (Arrow)
(Palanivelu LSC Type II,
Strasberg’s Reconstitution
type) [Image courtesy: Dr.
Deborshi Sharma]
Fig. 7 Gall bladder (GB)

being dissected off the
liver bed after
Laparoscopic subtotal
cholecystectomy[Image
Sharma]
Table 5 Management options Stripping

for mucosa left adherent to Electrocautery coagulation
liver bed
Argon beam coagulation
Radiofrequency ablation
Table 6 Management options Intracorporeal suturing from within the mucosal side
for gallbladder stump remnant Intracorporeal sutured closure of the stump
after LSC Stapling
Use of endo loop
Impact of LSC
In the meta-analysis of patients undergoing subtotal cholecystectomy, hemorrhage

from the liver bed was seen in just 0.2% patients when the strip of posterior gall-
bladder wall was left over the liver bed [1]. Similarly, CBD injury occurred in
0.09% of patients when a gall bladder remnant was left behind. Bile leak after
subtotal cholecystectomy is expected and it occurred with a higher frequency with
the fenestrating type (42%) than with the reconstituting type (16.5%). Wound
infections were seen in 2.6% patients, much lower with the laparoscopic approach
than with the open approach. When laparoscopic approach was converted to open,
the wound infection rate became like the planned open approach. Subgroup analy-
sis in this paper revealed that the risk of subhepatic collections, retained stones,
wound infections, re-operations and mortality were lower with the laparoscopic
approach than with the open approach. However, bile leaks were higher with the
laparoscopic approach. Importantly, CBD injuries were significantly lower with
SC [0.08%] than with total cholecystectomy (0.4%) in the pooled analysis of the
literature reviewed [1].
In a matched analysis of a national database, there was no difference in the mor-
bidity, mortality or re-admission rates between LSC and laparoscopic total chole-
cystectomy though the total direct costs were higher in the LSC group [35]. In cases
of difficult gallbladder, conversion to open is always considered to be the primary
option. However, when laparoscopic surgery is converted to open, the morbidity and
mortality increase significantly [36, 37]. One of the factors may be that surgeons
trained in the last decade and current surgical trainees have had poor exposure to
open cholecystectomy due to the widespread prevalence of laparoscopic cholecys-
tectomy [38–40]. In addition, there are the benefits of laparoscopic approach over
open surgery, including lower risk of wound infection, faster recovery and less pain
[41, 42].
Leaving the gallbladder remnant open without occluding the cystic duct in any
way may be associated with significant morbidity. In one paper, patients undergo-
ing the fenestrating type of subtotal cholecystectomy stayed twice as long in the
hospital and had four times higher surgical site infections than the standard chole-
cystectomy patients [43]. Secondary interventions were required in nearly 40%
patients, usually for persistent biliary leak, in the form of ERCP and percutaneous
drainage [35].
Table 7 Complications that Haemorrhage

may be associated with Bile duct injury
subtotal cholecystectomy Spilled stones
Retained stones
Intraperitoneal collection
Wound infection
Dissemination of malignancy due to opening of the gall
bladder (if occult malignancy present)
Complications due to residual stump
Table 8 Complications Residual/recurrent stone formation

possible due to retained Stump cholecystitis
gallbladder stump and stones Choledocholithiasis
Pancreatitis
Malignancy in retained mucosa
In the hands of experienced laparoscopic surgeons, LSC gives good results. In a

series of 110 cases of LSC performed for severe acute cholecystitis over a ten year
period including 2003 laparoscopic cholecystectomies, none required conversion, the
median hospitalization was 4 days, there was zero mortality and post-operative morbid-
ity rate was 9.1%, including bile leak in 2.7% [28]. Two of the bile leaks resolved spon-
taneously while one required endoscopic biliary stent placement.
Adding intra-operative cholangiography may be helpful in delineating the anat-
omy and in determining the level of division of the gallbladder neck [23], however
similar results can be attained without the use of intra-operative cholangiography
too [44].
From the review of literature, it does seem that keeping the gallbladder remnant
open without occluding the cystic duct may be associated with significant postop-
erative biliary leak and its consequences. The popular trend seems to be towards
closing the remnant. However, a closed remnant may lead to formation of gallstones
with subsequent passing of these stones into the common bile duct [44]. This may
lead to symptomatic disease manifestation in up to 5% of the patients, [7] though
ablation of the mucosa of the remnant may lead to reduced propensity for new stone
formation [23]. Complications that may be associated with laparoscopic subtotal
cholecystectomy have been enlisted in Tables 7 and 8.
Remnant Cholecystectomy
When stones do recur in the remnant, their symptoms are often clubbed under the
umbrella tag of ‘post-cholecystectomy syndrome’. Very often, the primary surgeon
would not have mentioned that SC has been done and so the subsequent treating
physicians are not aware that the gallbladder remnant exists with its propensity to
cause post-operative problems [45, 46]. Once the remnant becomes symptomatic,
surgery is required. The median time interval between the primary procedure and
re-do procedure varies from 24 to 60 months. Due to low index of suspicion, owing
to some extent to absence of proper information regarding the primary procedure
done, the patients get investigated unnecessarily for other probable causes of their
symptoms and even undergo invasive procedures before the correct diagnosis is
reached.
Ultrasound may fail to detect the condition in up to 11% of the patients. The
condition is readily diagnosed by a CT scan or MRI/MRCP, which clearly delin-
eates the biliary anatomy as well as the size of the remnant and the presence and
number of stones in it. Re-do cholecystectomy is difficult due to the extensive
adhesions and distorted anatomy and should be attempted only by experienced
surgeons. In Concors’ series of 14 patients, 2 cases were attempted laparoscopi-
cally but both needed conversion to open while the remaining 12 were approached
through the open technique [45]. One patient [7.1%] suffered a major bile duct
injury during the process, requiring hepaticojejunostomy. In the largest series
reported till date, open approach was adopted for nearly half [48.4%] of the 93
patients, while laparoscopic approach was attempted in the remaining 51.6% of
which 20.4% required conversion to open [46]. Nearly one-fourth of the patients
had associated CBD stones and around 11% had Mirizzi syndrome, requiring
additional procedures like choledocho-duodenostomy, CBD exploration and
hepaticojejunostomy.
Though difficult, laparoscopic management of the remnant gall bladder has been
reported from high volume centers with experienced laparoscopic surgeons, with
excellent results and low conversion rates [27, 47, 48] (Fig. 8). The size of the gall-
bladder stump should be kept small during laparoscopic subtotal cholecystectomy
and can be ascertained with MRCP (Table 9).
Fig. 8 Remnant Gall

bladder (RGB) after sub
total cholecystectomy
during redo-
cholecystectomy[Image
Sharma]
Table 9 Size of Gall Should be kept small <1 cm

bladder remnant Size best ascertained by MRCP
LSC & the Risk of GB Cancer
A major concern while performing LSC is the presence of occult gallbladder cancer
[23]. Opening up the gallbladder with spillage of contents when there is an occult
malignancy in the wall of the organ is a recipe for disaster, with poor subsequent
prognosis [28, 49]. If there are any suspicious findings on pre-operative imaging to
suspect malignancy, like irregular thickening of the wall, it is better to convert to
open approach and perform a complete cholecystectomy [23, 28]. Some authorities
also recommend taking biopsies from the mucosa of the remnant for histopathologi-
cal examination to rule out the possibility of malignancy as well as dysplasia in the
remnant [24].
Conclusion
LSC is a valuable addition to the armamentarium of surgeons treating gallbladder

disease. It helps in avoiding conversion to open surgery in situations where there is
likely to be difficulty in dissection in the hepato-cystic triangle as well as in separat-
ing the gallbladder from the liver bed. It helps in preventing injuries to the biliary
ducts as well as vascular injuries and bleeding from the liver bed. In experienced
hands, it has low morbidity and excellent outcomes. Subtotal cholecystectomy
should never be attempted where there is the slightest doubt of the presence of
occult malignancy. Keeping the gallbladder remnant open without any occlusion of
the cystic duct may reduce the incidence of post-operative stone formation in the
remnant but, at the same time, may be associated with significant post-operative
morbidity due to bile leak and its consequences. Hence, closing the remnant seems
to be the prevalent choice, though this may lead to formation of stones in the rem-
nant with recurrence of symptoms in a minority of patients. Recurrent disease may
be prevented to some extent by keeping the remnant less than 1 cm in size and ablat-
ing the mucosa in it. Recurrent stones disease in the remnant requires a high index
of suspicion in the minds of the treating physician and so, it is of paramount impor-
tance that the primary surgeon mentions doing a subtotal cholecystectomy in the
operation notes of the discharge summary. CT scan or, better still, MRCP is the
investigation of choice. Treatment requires re-operation, which is a difficult under-
taking due to the presence of adhesions and distorted anatomy and should be taken
up only by surgeons experienced in hepato-biliary surgery. Laparoscopic excision
of the remnant is feasible in expert hands with good short- and long-term results.
Key Clinical Points

1. Laparoscopic cholecystectomy is a very common procedure, of which approxi-
mately 6% of the procedures are difficult and requires some modification.
2. Confusion is created by using both the terms subtotal and partial cholecystec-
tomy interchangeably, and both the terms often describe the same operation as
well as the same term is often used to describe operations with variable portions
of gallbladder left behind.
3. In Type I LSC, the mucosa on the strip of gallbladder wall left on the liver bed
may be stripped or may be destroyed using electrocautery, argon beam or radio-
frequency ablation. In Type II a remnant gallbladder stump is left insitu,
whereas Type III is a combination of both.
4. Combining both the proposed classification or types of LSC by Dr. Palanivelu
and Dr. Strasberg, Type II & Type III can be of fenestrating or reconstituting
types based upon no closure or closure of the remnant gall bladder stump.
5. Closure of the gallbladder remnant seems to cause lower incidence of bile fis-
tula. Bile leak after subtotal cholecystectomy is expected and it occurs with a
higher frequency with the fenestrating type (42%) than with the reconstituting
type (16.5%).
6. Subtotal cholecystectomy may be more approachable with laparoscopic tech-
niques rather than open due to the magnification afforded and the proper angle
of view that can be obtained with a 30-degree telescope.
7. No difference in the morbidity, mortality or re-admission rates are seen between
LSC and laparoscopic total cholecystectomy though the total direct costs are
higher in the LSC group.
8. Closed GB remnant may lead to formation of gallstones with subsequent pass-
ing of these stones into the common bile duct and its complications.
Ablation of mucosa of stump may be helpful in preventing stone formation.
9. It is of paramount importance to clearly mention the possible amount of GB
remnant left behind in the primary surgery.
10. Ultrasound may fail to detect the remnant gall bladder with stones in up to 11%
of the patients. It is readily diagnosed by a CT scan or MRI/MRCP, which
clearly delineates the biliary anatomy as well as the size of the remnant and the
presence and number of stones in it.
11. Remnant cholecystectomy by laparoscopy in symptomatic case by experienced
laparoscopic surgeons is feasible with excellent results and low conversion rates.
12. Biopsies from the mucosa of the remnant for histopathological examination
should always be done to rule out the possibility of leaving malignancy as well
as dysplasia in the remnant.
Editor’s Note1
Laparoscopic subtotal cholecystectomy has been a safe bail out alternative in

patients where the Calots triangle anatomy is unclear, posterior gall bladder wall is
adherent to the liver bed in gall bladder fossa in cirrhotics and in certain cases of
Mirizzi syndrome [1–3]. Subtotal cholecystectomy, antegrade fundus first technique
and per-operative cholangiograms have been reported to reduce incidence of con-
version and complications in difficult gall bladder [4].
echnical Modifications in Difficult Gallbladder

T
and Subtotal Cholecystectomy
ear Infrared Cholecysto-Cholangiography

N
Near infrared cholecysto-cholangiography with injection of indocyanine green into
the gallbladder is being evaluated and cited to be promising in visualization of
Hartmann’s Pouch, cystic duct, CBD and CHD in a difficult inflamed
gallbladder[5].
ltrasonic and Saline Jet Dissection

U
Use of newer energy sources like the ultrasonic dissection as also saline jet dissec-
tion may aid in dealing with adhesions/difficult tissue planes and reduce bleeding in
difficult gallbladder[6,7]. Ultrasonic scalpel dissection has also been shown to
decrease incidence of gallbladder perforation and useful in difficult gallbladder [6].
lipless Laparoscopic Cholecystectomy

C
A few authors have reported that clipless laparoscopic cholecystectomy with use of
harmonic scalpel to seal the cystic duct stump does not increase bile leak rates [8,9],
however contrary reports with increased bile leak rates with clipless surgery has
also been noted [10]. The findings of these studies become especially relevant in the
context of a difficult laparoscopic cholecystectomy where ligation of cystic duct
may not be feasible in all cases. However, most case series and retrospective reviews
report a postoperative complication of bile leak in some patients undergoing subto-
tal cholecystectomy particularly if the gallbladder remnant is left open [1–3].
Closure of the gall bladder remnant and cystic duct stump or preferably both results
in less postoperative bile leaks. Despite the above findings it needs to be emphasized
that laparoscopic subtotal cholecystectomy diminishes the chance of a biliary injury
1
in an unsafe cystohepatic triangle anatomy albeit an increased bile leak which can
often be managed with drainage and endoscopic stenting [3]. Figures 5, 6, 7 shows
subtotal cholecystectomy with suturing of gall bladder stump.
Endovesical Approach
Simply known as the inside out approach for management of difficult gallbladder
when Calots triangle dissection is unsafe, was shown to be helpful before perform-
ing a subtotal cholecystectomy [11].
ersistent/Recurrent Symptoms After Subtotal Cholecystectomy

P
and Redo Stump Excision
Some patients report recurrence of abdominal pain perceived to be due to the rem-
nant gallbladder stump or stones following subtotal cholecystectomy. Retained
stones in the gallbladder remnant can cause pancreatitis or stump cholecystitis.
MRCP has been advocated to image the size of residual stump i.e. whether only
cystic duct has been left behind or a remnant of gallbladder also exists and if there
are any retained stones. The size of the remnant of gall bladder stump in MRCP is
reported to have a significant association with long term complications [12]. CT,
PTC and Endoscopic USG have also been suggested to help in imaging retained
stump/stones. Anecdotal case series reports the use of staplers in laparoscopic sub-
total cholecystectomy increased the chance of retention of stones and slippage of
stones into CBD due to pressure of stapling process [13]. Emerging literature on
redo laparoscopic completion cholecystectomy suggests that though feasible it is
not without inherent risks of biliary tract injury and may require conversion to open
[3,14]. Figure 8 shows redo cholecystectomy.
Spyglass Cholangioscopy
Spyglass cholangioscopy is a recently evolving technique which helps visualization
of biliary tract anatomy and is considered useful particularly in altered biliary anat-
omy. The technique may aid detection and treatment of retained or recurrent stones
in the gallbladder remnant after subtotal cholecystectomy.
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Prediction and Grading Methods
of a Difficult Laparoscopic
Cholecystectomy
Nikhil Gupta, Priya Hazrah, and Gautam Anand
Introduction
Laparoscopic cholecystectomy (LC) has rapidly evolved to be the procedure of

choice for management of symptomatic gall stone disease [1]. Initially, the compli-
cation rate with LC was high but with technological advancement and increase in
the expertise, it has now reached a remarkably low level at 2.0–6.0% [2]. Conversion
rate of 7–35% has been reported in literature [3].
Definition of Difficult Gallbladder
What constitutes a difficult laparoscopic cholecystectomy is a subjective definition

with authors having described it multifariously. One of the simplest definitions of
difficult gallbladder is a procedure with increased surgical risk as compared to stan-
dard cholecystectomies [4].
A difficult gallbladder dissection may be due to:
• Congenital variants in anatomy,

• Altered pathology for example inflammations and scarring distorting local
anatomy,
• Obscured anatomy due to increased visceral fat and
• Increased risk of bleeding as seen in cirrhotics.
N. Gupta
Department of Surgery, ABVIMS and Dr RML Hospital, New Delhi, India
P. Hazrah (*) · G. Anand
Department of Surgery, Lady Hardinge Medical College, New Delhi, India
https://doi.org/10.1007/978-981-16-5473-2_4
84 N. Gupta et al.
Difficulty in LC can be measured as follows:
A. Postoperative outcome variables/ procedural modifications

B. Scoring systems grading various intraoperative findings.
efining a Difficult Gall Bladder Based on Outcome or

D
Procedural Modification
Most individual studies make their assessment of difficult LC based on outcome

variables. Some of the outcome variables used for measuring difficulty of LC are
morbidity, mortality, conversion, operative time, postoperative hospital stay, bile
leak and iatrogenic injuries. Parameters like operative time, (time taken to dissect
gallbladder from liver bed, time taken for Calots dissection, time taken to identify
cystic duct), bile or stone spillage, rupture of gallbladder and conversion to open
have been suggested as surrogate markers of operative difficulty [3, 5–9]. Others
define difficulty with need for modification of procedures like performance of sub-
total cholecystectomy, cholecystostomy, fundus first approach or necessity for intra-
operative cholangiography [6, 9–11]. The problem with outcome-variable oriented
classification is that surgeon’s skill becomes a confounding factor.
efining Difficult Gallbladder Based on Grading and Scoring

D
Systems Using Intraoperative Variables
Grading/scoring systems with intraoperative variables are more objective and have
less bias because they are largely independent of operative skills of the surgeon. The
earliest attempt to define an objective scoring system to measure intraoperative dif-
ficulty was proposed by Cuscheri et al. in 1992 [5] followed by Nassar in 1995 with
modification in 1996. The modified Nassar scale has an addition of grade 5 to the
original 4 categories (Table 1) [12], based on clinico-radiologic and operative
parameters. Randhawa et al. in their attempt to develop a preoperative predictive
system stratified difficulty based upon limited intraoperative parameters viz.: time
taken, bile spillage, injury to duct/ artery and conversion (Table 2) [7]. In a study
using the Delphi technique to define operative difficulty, an elaborate set of intraop-
erative parameters with precise grading was proposed which were broadly catego-
rized as factors related to inflammation of the gallbladder and intra-abdominal
factors unrelated to inflammation. Factors related to inflammation of the gall blad-
der was further subcategorized into: appearance around the gallbladder, appearance
of the Calot’s triangle area, appearance of the gallbladder bed, additional findings of
the gallbladder and its surroundings (Table 3) [13].
Sugrue et al. graded operative difficulty based on a few intraoperative parameters
along with BMI and time taken to identify cystic artery and duct (Table 4) [6]. The
cholecystitis severity/difficulty grading of Parkland et al. incorporates an array of
intraoperative variables as shown in Table 5) [14]. Classifications based on
Prediction and Grading Methods of a Difficult Laparoscopic Cholecystectomy 85
Table 1 Difficulty grading by operative parameters of gallbladder cystic pedicle and adhesions as
proposed by Nassar et al. [12] (Modified Nassar Scale)
Grade description
I Gallbladder—floppy, non-adherent
Cystic pedicle—thin and clear
Adhesions—simple up to the neck/Hartmann’s pouch
II Gallbladder—mucocele, packed with stones
Cystic pedicle—fat laden
Adhesions—simple up to the body
III Gallbladder—deep fossa, acute cholecystitis, contracted, fibrosis, Hartmann’s adherent to
CBD, impaction
Cystic pedicle—abnormal anatomy or cystic duct—short, dilated or obscured
Adhesions—dense up to fundus; involving hepatic flexure or duodenum
IV Gallbladder—completely obscured, empyema, gangrene, mass
Cystic pedicle—impossible to clarify
Adhesions—dense, fibrosis, wrapping the gallbladder, duodenum or hepatic flexure
difficult to separate
V Mirizzi Syndrome type 2 or higher, cholecysto-cutaneous, cholecysto-duodenal or
cholecysto-colic fistula
Please also refer to Table 9, preoperative parameters for grading severity by Nassar et al.
(Published with permission)
Table 2 Intraoperative criteria used to Easy

define difficulty of laparoscopic Time taken <60 min
cholecystectomy by Randhawa and
No bile spillage
Pujahari [7]
No injury to duct, artery
Difficult
Time taken 60–120 min
Bile/stone spillage
Injury to duct
No conversion
Very difficult
Time taken >120 min
Conversion
Please also refer to Table 10, preopera-
tive parameters for grading severity by
Randhawa and Pujahari (Published
with permission)
preoperative and intraoperative parameters to predict outcome related to mortality,

morbidity, hospitalization and conversion in the acute/non elective settings are
shown in Tables 6 and 7 [15, 16]. A recently proposed preoperative parameter-based
risk scoring system to predict Clavien Dindo grade 4, grade 5 complications has
been tabulated in Table 8 [17]. Tables 9 and 10 enlists the various preoperative grad-
ing scales based upon classified intraoperative difficulty [7, 18].
86 N. Gupta et al.
Table 3 Intraoperative findings that were considered to potentially contribute to surgical diffi-
culty score in mulitinational collaborative study on surgeons using Delphi technique (2017) [13]
A. Factors related to inflammation of the gallbladder Score
[a] Appearance around the gallbladder
1. Fibrotic adhesions around the gallbladder due to inflammation 2
2. Partial scarring adhesions around the gallbladder 2
3. Diffuse scarring adhesions around the gallbladder 4
[b] Appearance of the Calot’s triangle area
4. Sparse fibrotic change in the Calot’s triangle area 2
5. Dense fibrotic change but no scarring in the Calot’s triangle area 3
6. Partial scarring in the Calot’s triangle area 4
7. Diffuse scarring in the Calot’s triangle area 5
[c] Appearance of the gallbladder bed
8. Sparse fibrotic change in the gallbladder bed 1
9. Dense fibrotic change but no scarring in the gallbladder bed 2
10. Partial scarring in the gallbladder bed 3
11. Diffuse scarring in the gallbladder bed [includes atrophic gallbladder with no 4
lumen due to severe contraction]
[d] Additional findings of the gallbladder and its surroundings
12. Edematous change around the gallbladder/in the Calot’s triangle area/in the 1
gallbladder bed
13. Easy bleeding at dissection around the gallbladder/in the Calot’s triangle area/in the 3
gallbladder bed
14. Necrotic changes around the gallbladder/in the Calot’s triangle area/in the 4
gallbladder bed
15. Non-iatrogenic, perforated gallbladder wall and/or abscess formation towards the 3
abdominal cavity noted during adhesiolysis around the gallbladder
16. Abscess formation towards the liver parenchyma 4
17. Cholecysto-enteric fistula 5
18. Cholecysto-choledochal fistula [included in the expanded classification of Mirizzi 6
syndrome]
19. Impacted gallstone in the confluence of the cystic, common hepatic, and common 5
bile duct [included in the expanded classification of Mirizzi syndrome]
B. Intra-abdominal factors unrelated to inflammation
20. Excessive visceral fat 2
21. Inversion of the gallbladder in the gallbladder bed due to liver cirrhosis 4
22. Collateral vein formation due to liver cirrhosis 4
23. Non-inflammatory [physiological] adhesion around the gallbladder 1
24. Anomalous bile duct 4
25. Gallbladder neck mounting on the common bile duct 3
Operative difficulty might be classified as:
I. Access related
II. Dissection related i.e. dissection of calots/dissection from liver bed
III. Extraction related.
Table 4 Operative grading system for cholecystitis severity by Sugrue et al. [6]
Gallbladder appearance
Adhesions <50% of GB 1
Adhesions burying GB 3
Max score 3
Distension/contraction
Distended GB (or contracted shrivelled GB) 1
Unable to grasp with atraumatic laparoscopic forceps 1
Stone ≥1 cm impacted in Hartman’s pouch 1
Access
BMI >30 1
Adhesions from previous surgery limiting access 1
Severe sepsis/complications
Bile or pus outside GB 1
Time to identify cystic artery and duct > 90 min 1
Total max 10
Degree of difficulty
A mild < 2, B moderate 2–4, C severe 5–7, D extreme 8–10
Table 5 Parkland grading scale for severity of cholecystitis [14]

Cholecystitis Severity
Grade Description of Severity
1 Normal appearing gallbladder (“robin’s egg blue”)
No adhesions present
Completely normal gallbladder
2 Minor adhesions at neck, otherwise normal gallbladder
Adhesions restricted to the neck or lower of the gallbladder
3 Presence of ANY of the following:
Hyperemia, pericholecystic fluid, adhesions to the body, distended
gallbladder
Adhesions obscuring majority of gallbladder
Grade I-III with abnormal liver anatomy, intrahepatic gallbladder, or
impacted stone (Mirizzi)
Perforation, necrosis, inability to visualize the gallbladder due to
adhesions
Whereas access and extraction related difficulties are commonly encountered in

other laparoscopic procedures as well, dissection related challenges unique to a dif-
ficult gallbladder are being primarily emphasized in this chapter.
88 N. Gupta et al.
Table 6 Tokyo Guidelines 2018 severity grade for acute cholecystitis [15]
Grade III (severe) acute cholecystitis
“Grade III” acute cholecystitis is associated with dysfunction of any one of the following
organs/systems:
1. Cardiovascular dysfunction: Hypotension requiring treatment with dopamine ≥5 lg/kg per
min, or any dose of norepinephrine
2. Neurological dysfunction: Decreased level of consciousness
3. Respiratory dysfunction: PaO2/FiO2 ratio < 300
4. Renal dysfunction: Oliguria, creatinine >2.0 mg/dl
5. Hepatic dysfunction: PT-INR >1.5
6. Hematological dysfunction: Platelet count <100,000/mm3
Grade II (moderate) acute cholecystitis
“Grade II” acute cholecystitis is associated with any one of the following conditions:
1. Elevated WBC count (>18,000/mm3)
2. Palpable tender mass in the right upper abdominal quadrant
3. Duration of complaints >72 ha
4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic
abscess, biliary peritonitis, emphysematous
Cholecystitis)
Grade I (mild) acute cholecystitis “grade I” acute cholecystitis does not meet the criteria of
“grade III” or “grade II” acute cholecystitis. It can also be defined as acute cholecystitis in a
healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder,
making cholecystectomy a safe and low-risk operative procedure
Table 7 AAST EGS grade descriptions of acute cholecystitis severity [16]

Imaging Criteria
AAST Clinical (CT/US/HIDA Operative Pathologic
Grade Description Criteria findings) Criteria Criteria
I Acute Right upper Wall thickening; Inflammatory Acute
cholecystitis quadrant distention; changes inflammatory
(RUQ) or gallstones or localized to changes in the
epigastric sludge; GB; wall GB wall
pain; pericholecystic thickening; without
Murphy’s fluid; non- distention; necrosis or pus
sign; visualization of gallstones
leukocytosis gallbladder
(GB) on
hepatobiliary
iminodiacetic
acid (HIDA)
scan
II GB empyema or RUQ or Above, plus air Distended GB Above, plus
gangrenous epigastric in GB lumen, with pus or pus in the GB
cholecystitis or pain; wall or in the hydrops; lumen; necrosis
emphysematous Murphy’s biliary tree; necrosis or of GB wall;
cholecystitis sign; focal mucosal gangrene of intramural
leukocytosis defects without wall; not abscess;
frank perforated epithelial
perforation sloughing; no
perforation
Table 7 (continued)
Imaging Criteria
AAST Clinical (CT/US/HIDA Operative Pathologic
Grade Description Criteria findings) Criteria Criteria
III GB perforation Localized HIDA with focal Perforated GB Necrosis with
with local peritonitis in transmural wall (non- perforation of
contamination RUQ defect, iatrogenic) with the GB wall
extraluminal bile outside the (non-
fluid collection GB but limited iatrogenic)
or radiotracer to RUQ
but limited to
RUQ
IV GB perforation Localized Abscess in RUQ Pericholecystic Necrosis with
with perichole- peritonitis at outside GB; abscess; perforation of
cystic abscess ormultiple bilio-enteric bilio-enteric the GB wall
gastrointestinal locations; fistula; gallstone fistula; (non-
fistula abdominal ileus gallstone ileus iatrogenic)
distention
with
symptoms of
bowel
obstruction
V GB perforation Above, with Free intra- Above, plus Necrosis with
with generalized generalized peritoneal bile generalized perforation of
peritonitis peritonitis peritonitis the GB wall
(non-
iatrogenic)
Table 8 Scoring System to Predictor Category Points

predict Clavien Dindo grade Age (years) 18–30 0
4/5 complications post
31–40 2
cholecystectomy in non
elective setting by Burke 41–50 4
et al. [17] 51–60 6
61–70 8
71–80 10
≥ 80 12
Sepsis Yes 5
No 0
Planned open procedure Yes 5
No 0
eGFR1 <30 13
≥ 30 to <60 7
≥ 60 to <90 3
≥ 90 0
Missing 7
(continued)
90 N. Gupta et al.
Table 8 (continued) Predictor Category Points

Albumin < 2.5 8
≥ 2.5 to ≤3.1 4
> 3.1 to ≤3.7 2
> 3.7 0
Missing 0
Classification of risk of complication based on the above
scoring system is as follows:
0–22 is low risk (0.1–4.7%), 23–27 medium risk (5.5–9.9%),
28–43 high risk (11.5–59.4%) (Published with permission)
Table 9 Preoperative clinicora- Points

diological risk scoring system Age (years)
proposed by Nassar et al. based
<40 0
upon their intraoperative scoring
system post validation in a large 40+ 1
dataset (2019) [18] Gender
Female 0
Male 1
ASA classification
1 0
2 1
3 2
4–5 7
Primary diagnosis
Pancreatitis 0
Biliary colic 0
CBD stone 1
Cholecystitis 4
Thick-walled gallbladder (≥3 mm)
No 0
Yes 2
CBD dilation (>6 mm)
No 0
Yes 1
Pre-operative ERCP
No 0
Yes 1
Admission type
Elective 0
Delayed 1
Emergency 2
Table 10 Scoring system proposed to predict intraoperative difficulty based on preoperative
clinico-radiological parameters proposed by Randhawa and Pujahari [7]
Max. score
History
Age <50 yrs (0) >50 yrs (1) 1
Sex Female (0) Male (1) 1
H/o hospitalization N (0) Y (4) 4
Clinical
BMI wt (kg)/ht. (mt2) <25 (0) 25–27.5 (1) >27.5 (2) 2
Abdominal scar N (0) Infra-umbilical (1) supra-umbilical (2) 2
Palpable gallbladder N (0) Y (1) 1
Sonography
Wall thickness Thin (0) Thick >4 mm (2) 2
Pericholecystic N (0) Y (1) 1
collection
Impacted stone N (0) Y (1) 1
Maximum Score 15, Y YES, N NO (Published with permission)
Prediction of Difficult Laparoscopic Cholecystectomy
Prediction of difficult laparoscopic cholecystectomy entails issues which address:
1. Patient selection criteria in acute settings.

2. Patient selection in chronic settings.
3. Use of preoperative predictors related to difficulty as indicated by findings in
history, physical examination, biochemical parameters, radiologic studies.
4. Use of intraoperative findings that aid in grading difficulty.
5. Scoring systems as predictors of difficulty and their validation.
6. Treatment recommendations based on severity grading
Patient Selection Criteria in Acute Settings
uidelines for Patient Selection in Clinically Diagnosed Acute

G
Cholecystitis or Emergency Cholecystectomy
A crucial consideration in performing a safe laparoscopic cholecystectomy lies in

appropriate patient selection especially in the context of acute cholecystitis. Acute
cholecystitis and emergency/non elective operations have been suggested to be a
risk factor for intraoperative difficulty [18].
Age: Age is reported as an independent risk factor for grade 3 and grade 4
Clavien Dindo complications in a large volume study analyzing risk factors for
cholecystectomy in non-elective setting [17].
92 N. Gupta et al.
Duration of acute illness: Early laparoscopic cholecystectomy typically per-

formed within 72 h of onset of acute cholecystitis is a reasonably accepted protocol
in most centers. Authors evaluating early laparoscopic cholecystectomy in acute
cholecystitis i.e., typically performed within 72 h as compared with postponed lapa-
roscopic cholecystectomy performed within 6 days of onset noted a higher rate of
subtotal cholecystectomy in the latter group. Performance of surgery after 9 days
has been associated with higher rates of subtotal cholecystectomy and conversion
[19, 20].
Comorbidities: Presence of comorbidities is a decisive factor in choosing
between laparoscopic cholecystectomy and drainage (cholecystostomy) in higher
grades of acute cholecystitis as per Tokyo and AAST EGS guidelines [15, 16]. In a
study evaluating possible predictors of conversion to subtotal cholecystectomy in
acute cholecystitis, it was noted that ASA >3 was an important factor [20].
Palpable tender gallbladder mass: Palpable tender gallbladder mass, has been
denoted to be Grade 2 severity in the Tokyo classification (Table 6) [15].
Planned open surgery: A preoperative plan for open surgery has been shown to
be an independent predictor of higher risk of postoperative complications after
laparoscopic cholecystectomy [17].
Sepsis: Presence of local and generalized sepsis are proposed risk factors for
difficult cholecystectomy and post cholecystectomy complications (Tables 6, 7 and
8) [15–17].
WBC Count: An elevated WBC count >18,000 has been proposed as a criterion
to define grade II severity in acute cholecystitis grading in 2018 Tokyo Guidelines [15].
Albumin: The risk of postoperative complications after non elective cholecys-
tectomy has also been stratified based on preoperative albumin levels with lower
levels increasing the risk (Table 8) [17].
Renal function: Low estimated GFR has also been shown to adversely affect
outcome in laparoscopic cholecystectomy (Table 8) [17].
Ultrasound (USG):USG which is a very common investigation to detect gall
bladder disease has features incorporated in grading of severity of acute cholecysti-
tis, like: (1) Non visualization of the gallbladder, (2) increased wall thickness, (3)
pericholecystic fluid, (4) fluid in right upper quadrant, (5) air in biliary tree, (6)
abscess formation, (7) free intraperitoneal fluid (generalized), (8) gall stone ileus
and (9) cholecystoenteric fistula [16] (Table 7) (Figs. 1 and 2).
Grade/severity of disease: Grade 3 acute cholecystitis has been a relative con-
traindication for cholecystectomy in acute cholecystitis, a higher incidence of con-
version to open, subtotal cholecystectomy and longer postoperative stay has been
noted in these patients though a translation into higher postoperative morbidity or
mortality may not be always eminent [10, 19]. The 2018 Tokyo guidelines recom-
mends early cholecystectomy in low-risk patients with mild severity. In high-risk
patients or low risk patients with moderate and severe acute cholecystitis treatment
in higher centers and cholecystostomy/early preoperative drainage as a bailout
option is deemed more appropriate [11]. Table 6 outlines grading of severity of
Fig. 1 Abdominal
ultrasound showing
pericholecystic fluid
Fig. 2 Abdominal
ultrasound showing thick
gallbladder wall
acute cholecystitis as proposed by the 2018 Tokyo guidelines [15]. The guidelines
incorporate comorbidity, organ system involvement, features suggestive of local-
ized infection and other operative/non operative parameters. Any of the following
organ involvement is classified as grade 3: cardiovascular, respiratory, neurological,
renal, hepatic and haematological.
The other widely used classification system to stratify management of cholecys-
tectomy in the emergency setting is the AAST EGS (American Association for the
Surgery of Trauma emergency general surgery) grading which incorporates radio-
logic imaging (CT/US/HIDA), intraoperative and pathology variables (Table 7)
[16]. Table 8 enlists risk factors associated with postoperative complications after
cholecystectomy in non-elective settings [17].
Magnetic resonance Cholangiopancreatography (MRCP): MRCP findings
like thickness of GB around the neck, and disruption of common hepatic duct are
94 N. Gupta et al.
proposed as important parameters for predicting conversion or subtotal cholecystec-

tomy [20].
CT Scan: CT scan may be beneficial in detecting gall bladder wall abnormali-
ties/ perforation local sepsis and fluid/biliary collections in right upper quadrant or
generalized peritonitis and pus/ air in biliary tract (Table 7) [16].
HIDA Scan (hepatobiliary iminodiacetic acid): Non visualization of gall blad-
der or radiotracer leak in the right upper quadrant can be important contributory
findings in HIDA scan which are considered in AAST EGS classification
(Table 7) [16].
Patient Selection in Non-Acute (Chronic) Setting
Unlike acute/acute on chronic setting the chances of encountering difficulty in

chronic settings may not be obvious unless attention is paid to subtle characteristics
in history and physical examination along with radiologic findings. Prior upper
abdominal surgery and cirrhosis were the conventional relative contraindication to
laparoscopic cholecystectomy in non-acute settings. However recent studies sug-
gest that laparoscopic cholecystectomy can be safely performed in cirrhotic patients,
within Child-Pugh classes A and B, with acceptable morbidity and conversion
rate [21].
Despite adherence to the above selection criteria, the surgeon often encounters
an unanticipated difficulty during operation. The crux of the issue lies in predicting
a difficult laparoscopic cholecystectomy in patients of chronic cholecystitis without
any conventional relative contraindications to performing the procedure and rela-
tively normal findings in clinical radiologic and biochemical parameters. Therefore,
studies are evolving which throw light on the possible predictors of difficult laparo-
scopic cholecystectomy and scoring systems thereof.
ossible Preoperative Clinical Predictors/Indicators of Difficult

P
Laparoscopic Cholecystectomy in Elective Setting
There are many risk factors which make laparoscopic cholecystectomy difficult like
old age, male sex, obesity, BMI, attacks of acute cholecystitis, number of previous
attacks of acute cholecystitis, cholangitis, previous interventions like ERCP stent-
ing, fever, leukocytosis, previous abdominal surgery, clinical signs of acute chole-
cystitis, and certain ultrasonographic findings i.e. thickened gall bladder wall,
distended gallbladder, contracted gallbladder, pericholecystic fluid collection, stone
impacted at neck, fixed stones >2 cm, CBD stones and abnormal anatomy.
Challenging intraoperative pathologic encounters like dense adhesions at calot’s
triangle, fibrotic and contracted gallbladder, acutely inflammed edematous or gan-
grenous gall bladder and cholecystoenteric and cholecystocholedochal fistula etc.
are wary premonitions of a difficult laparoscopic cholecystectomy [6, 9, 12,
13, 22–24].
Patient’s history, clinical examination and pre-operative ultrasonographic evalu-

ation can guide a surgeon to some extent in predicting difficulty during surgery. The
intraoperative assessment is also important in predicting a difficult gall bladder.
Whereas preoperative parameters guide on patient selection and appropriate timing
of surgery, intraoperative parameters can guide conversion or use of alternative bail-
out procedures like subtotal cholecystectomy or drainage. Tables 9 and 10 enlists
preoperative factors as predictors of intraoperative difficulty [7, 18].
Parameters Observed in History
Age: Few studies have reported age >50 years as a significant risk factor. Conversion
rates are also higher in elderly population. It may be attributed to long duration of
symptoms and multiple attacks [18, 25, 26].
Gender: Male Sex is also considered as a risk factor for difficult cholecystec-
tomy. Incidence of conversion to open and mortality is higher in male gender than
their female counterparts. Omental and other organ adhesions are more commonly
seen in male patients. It may be due to their late presentation; they generally seek
medical help after multiple attacks of inflammation. It results in chronic changes
which makes surgery more challenging [18, 26–30].
History of hospitalization for acute attacks: Patients who require hospitaliza-
tion for acute attacks generally carry more chances of difficult laparoscopic chole-
cystectomy and conversions. They are found to be having dense adhesions at Calot’s
triangle and GB fossa. Number of previous attacks, cholangitis and ERCP stenting
has significant association with probability of difficult LC [6, 9, 22, 23]. Pain lasting
for more than 4 h has been mentioned as a predictive factor of difficult LC [31].
Diabetes Mellitus: DM has been found to be useful predictor of difficult LC in
multivariate analysis [31, 32].
Parameters Observed on Clinical Examination
BMI/Obesity: Obesity is considered as a significant risk factor for difficult LC in

many studies [7, 33]; though few surgeons have reported that there is no difference
in operative time, duration of hospitalization and complication rates [34]. Obese
patients pose challenges in achieving pneumoperitoneum, placing subcostal port,
retracting fundus of GB and fascial closure. Open trocar placement is also difficult
in these patients due to thick layer of fat and pendulous abdomen with umbilicus
almost reaching upto pubic symphysis [35]. Also visceral fat associated with obe-
sity may obscure delineation of anatomy. BMI as a surrogate marker of difficult
access was considered as a risk factor in the classification proposed by Sugrue et al.
(Table 4) [6].
Scar of previous surgery: Upper abdominal scar of previous surgery is also
considered as independent prognostic indicator of difficult LC. Omentum and other
abdominal organs get adhered to anterior abdominal wall leading to difficulty in
trocar placement and visualization of hepatobiliary structures; many surgeons avoid
96 N. Gupta et al.
laparoscopic approach in scarred abdomen due to these reasons [3, 26, 27]. Open
trocar placement at umbilicus to achieve pneumoperitoneum avoids bowel injury in
such cases and allows adhesiolysis. Surgeon should resist eliminating adhesions
excessively. Only those adhesions that prevent placement of canulas or interfere
with visualization of organ of interest should be lysed [36].
Palpable GB: It is a clinical sign seen in patients having mucocele or empyema.
It is difficult to catch hold of the fundus of GB in these cases and aspiration of the
contents is often required; it is time consuming and carries risk of spillage. Randhawa
et al. has found a significant correlation between palpable GB and difficult LC
[7, 37].
Blood parameter: In a study evaluating an array of clinical and biochemical
parameters in predicting difficulty of cholecystectomy, elevated CRP and neutrophil
lymphocyte ratio were considered as independent predictors of complicated acute
cholecystitis in multivariate analysis [38]. A higher WBC count and fibrinogen lev-
els have also been found to be predictors of difficult gallbladders [31, 39]. Bilirubin
>2 mg/dl was found to be an important risk predictor in multivariate analysis in a
study [32]. However alkaline phosphatase level or liver enzymes have not found to
be corroborative in a study [39].
ASA Class: Patients with higher ASA class implying greater comorbidities was
a risk factor for anticipated intraoperative difficulty [18]. ASA >3 has been pro-
posed as a predictor of intraoperative difficulty [20].
Parameters in Abdominal Sonography
Thick GB wall: Thickened gall bladder wall is an ultrasonographic finding of acute

cholecystitis and it is reported to be a significant factor in many studies [7, 8, 18, 27,
31, 40, 41]. James in 1990, showed that a preoperative gallbladder ultrasound evalu-
ation for symptomatic cholecystitis which documents a thick gallbladder wall
[>4 mm] with calculi, is a clinical warning for the laparoscopic surgeon of the
potential for a difficult laparoscopic cholecystectomy procedure which may require
conversion to an open cholecystectomy [41]. In gallstone disease, the most common
reason for wall thickening is acute or chronic pericholecystic inflammatory change
(Fig. 2). An acutely inflammed and edematous GB wall may rupture with spillage
of infected bile and stones can further limit visualization of the operative field,
resulting in a more difficult operation. Chronic inflammatory changes lead to adhe-
sion formations which can pose as an impediment for the detachment of the gall-
bladder from its bed [37].
Impacted stone at the neck of GB: Patients with a large impacted stone at
Hartman’s pouch have higher incidence of operative difficulty (Fig. 3). The large
impacted stone can not only predispose to inflammation in the gall bladder and its
surroundings but also make grasping difficult. Moreover, impacted stone at neck
may predispose to formation of mucocoele, empyema, Mirrizi syndrome and chole-
cystocholedochal fistula resulting in operative difficulty [8, 13, 42]. Need for
increased rate of operative cholangiography in patients with Hartmann’s pouch
stone has been noted [42].
Fig. 3 Abdominal
ultrasonography depicting
large gall bladder calculus
with posterior acoustic
shadowing:Impacted stone
at neck
Fig. 4 Abdominal
ultrasonography showing
dilated CBD
Distended GB: Various studies have shown that distension of gallbladder [trans-
verse diameter more than 5 cm] is associated with technical difficulty [43].
Small shrunken gallbladder: A small shrunken gallbladder consequent to
chronic inflammation can result in hard fibrotic adhesions in region of the cystic
artery and duct which are difficult to dissect and can make grasping difficult [31].
Gallbladder wall flow: In a study evaluating sonographic parameters as pointers
of difficulty, gallbladder wall flow emerged as a significant factor [8].
Air in gallbladder lumen, wall or biliary tree: Presence of air in gallbladder
lumen, wall or biliary tree can be resultant to cholecystoenteric fistula or emphyse-
matous cholecystitis both of which are predicaments of difficulty in AAST EGS
classification (Table 7) [16].
CBD stone and CBD diameter: Presence of CBD stones and CBD dilatation
>6 mm were found to be independent risk factors predictive of intraoperative diffi-
culty (Fig. 4) [18, 32].
98 N. Gupta et al.
Other parameters (Multiple stones/enlarged liver): Most of the studies did

not find any statistical significance between difficulty during LC and the presence of
multiple stones [37, 43]. However, gallbladder rupture in patient with multiple
stones can lead to spillage of stones, retrieving of which maybe tedious and likewise
an abnormal liver anatomy may pose a difficulty [Table 5].
Parameters in Computed Tomography Scan (CT Scan)
Certain parameters in CT-Scan have also been reported to be associated with diffi-
cult cholecystectomy viz.: irregular or absent walls, hyperdensity, pericholecystic
fluid, hydrops, wall thickening >4 mm [39].
Parameters in MRCP
Signal intensity variations in MRI have been suggested to predict gallbladder wall
fibrosis or necrosis. In a study using MRI to evaluate signal intensity in patients
with acute cholecystitis it was noted that lower signal intensities were associated
with higher rates of conversion to open, prolonged operating time and need for sub-
total cholecystectomy in patients of acute cholecystitis [44]. Obscuration near the
gallbladder neck, thickness of GB around the neck and disruption of common
hepatic duct on MRCP may also be significant predictors of conversion to open or
subtotal cholecystectomy [20] (Fig. 5).
Fig. 5 MRCP picture

showing a distended gall
bladder with calculi
impacted at its neck with
multiple small calculi in
Gall bladder. (Image
Courtesy: Dr. Munish
Guleria, Professor
Radiology, Dr. RML
Hospital)
Preoperative Interventions
ERCP: Preoperative interventions like ERCP have been found to be a significant

factor indicative of operative difficulty [18]. ERCP particularly if a prior stent has
been placed can increase inflammatory adhesions in the region of Calot’s triangle.
Percutaneous cholecystostomy: Prior percutaneous cholecystostomy has also
been proposed to increase difficulty of subsequent laparoscopic cholecystec-
tomy [32].
Intraoperative Parameters Used to Grade Difficulty in LC
The intraoperative parameters can largely be classified as
• Parameters related to disease process (generally independent of surgeon’s ability)

• Parameters that may be dependent on surgeon’s ability
Parameters Related to Disease Process
Difficulty related to grasping gallbladder: Overdistended/Shrunken gallbladder/

Stone impacted at Hartman’s Pouch/ Deep intrahepatic location: An overdistended
gallbladder which impedes grasping without decompression also a shrunken con-
tracted gallbladder both contribute to some degree of operative difficulty, besides a
large gallbladder size has also been proposed as an impediment [5, 6, 12, 14]. The
location of gallbladder deep in the gallbladder fossa has also been cited to mount
difficulty in cholecystectomy as also dissection [12–14]. Stone impacted at
Hartman’s pouch has been proposed as an independent factor predicting difficulty
[6, 14, 45]. Figures 6 and 7 shows an intraoperative picture of a difficult gallbladder
with stone impacted at the Hartman’s pouch.
Fig. 6 Intraoperative
picture of gall bladder with
calculus impacted at
Hartman’s Pouch (yellow
arrow) and adhesions in
the region of Calots
triangle. [Image Courtesy:
Dr. Deborshi Sharma]
100 N. Gupta et al.

showing frozen callots
with stone impacted at
infundibulum causing a
distended gall bladder
picture: gall bladder
obscured due to adhesions
between bowel
omentumand liver. [Image
Courtesy: Dr. Deborshi
Sharma]
Extent of adhesions: The extent of adhesions, as also the type of inflammation,

around the calots, gall bladder, CBD and adjacent organs like duodenum colon and
liver bed are important parameters that impact operative difficulty [5, 6, 12–14, 16].
Inability to visualize the gallbladder due to adhesions has been denoted with higher
grades/scores in classification systems [6, 14]. Adhesion of Hartman’s pouch with
CBD is particularly significant [12]. Contrarily adhesions were not found to be an
important factor in prognosticating difficulty grading in a recent study [43]. Figure 8
shows an intraoperative picture of adhesions between liver and bowel obscuring the
visibility of gallbladder.
Inflammation-Type of adhesion: Flimsy versus Edematous/Fibrotic: The
inflammation that pose difficulty can be edematous or fibrotic and scarring. Fibrotic
adhesions on the medial aspects especially a fibrotic Calots, evidence of local sepsis
or infection, edema in Calots triangle or gallbladder bed and easy friability or bleed-
ing are some of the important measures of operative difficulty [5, 12–14]. In an
evaluation by surgeons of various intraoperative factors perceived to pose difficulty,
diffuse scarring in the Calot’s triangle area was reported to be the amongst the stron-
gest factor contributing to surgical difficulty [13]. Figure 9 shows an inflamed
picture showing inflammed
gall bladder with adhesions
around the gallbladder.
[Image Courtesy: Dr.
Deborshi Sharma]
picture of dense adhesions
of gall bladder with colon
and duodenum. [Image
Sharma]
gallbladder with flimsy adhesions and Fig. 10 shows dense adhesions between gall-
bladder and adjacent duodenum and colon.
Empyema/necrosis/gangrene/perforation of gallbladder: Empyema, perfora-
tion, necrotic or gangrenous gallbladder has been allotted maximum grades/scores
in most scoring systems [5, 12–16].
Fistula of the gallbladder: The presence of a cholecystoenteric or cholecysto-
choledochal fistula was graded with highest points regarding difficulty in one of the
scoring systems grading intraoperative parameters [12–14, 16]. Figure 11 is an
intraoperative picture depicting a shrunken fibrotic gallbladder with cholecystoduo-
denal fistula.
Abscess formation/non iatrogenic perforation/pericholecystic collection/
peritonitis: Pus or biliary collection can be intrahepatic or extrahepatic and may be
associated with localized or generalized peritonitis. Pus or biliary collection with
localized peritonitis is classified in moderate to severe grades of difficulty in most
classification [5, 6, 12–16, 43]. Presence of generalized peritonitis is graded as cat-
egory 5 (highest category) in AAST EGS Classification (Table 7) [16].
102 N. Gupta et al.
picture of shrunken
gallbladder with
cholecystoduodenal fistula
(Yellow Arrow). [Image
Sharma]
Other non-inflammatory parameters: Excessive visceral fat, altered liver

anatomy, anatomical anomalies of gall bladder and cystic duct that is short or absent,
or obscured, presence of venous collaterals in cirrhotics are also parameters pro-
posed as impediments to easy cholecystectomy [12–14].
Parameters that May be Dependent on Surgeon’s Ability
Intraoperative parameters which have been proposed to grade difficulty but maybe
dependent on surgeon’s ability include time taken for operation, injury to biliary
duct or vessels, bile or stone spillage and conversion [5–7].
Tables 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 enumerates the various preoperative and
intraoperative parameters that can point out to a difficulty in laparoscopic
cholecystectomy.
Scoring Systems in Grading Difficulty and Their Validation
Scoring systems may incorporate the following types of variables:
(a) Preoperative Variables only

(b) Intraoperative Variables only
(c) Both preoperative and intraoperative variables
rading Systems Using Preoperative Parameters and

G
their Validation
Nassar et al. devised a preoperative risk scoring systems from extrapolation of data
from two large databases (Table 9) [18]. The preoperative scoring system was devel-
oped based on intraoperative grading system of difficult laparoscopic cholecystec-
tomy earlier proposed, as enlisted in Table 1 and validated. Increasing age, ASA
classification, male gender, diagnosis of CBD stone or cholecystitis, thick-walled

gallbladders, CBD dilation, use of pre-operative ERCP and non-elective operations
were found to be significant independent predictors of difficult cases (Table 9). The
preoperative predictive variables proposed by Randhawa include: age, gender, BMI,
history of hospitalization, presence of abdominal scar and palpable gallbladder
along with sonographic parameters of wall thickness, pericholecystic fluid and
impacted stone at neck as enumerated in Table 10 [7]. The authors used their own
grading of intraoperative difficulty as per criteria shown in Table 2 in their analysis
for derivation of the above factors. A modified Randhawa classification has been
suggested to provide better outcome prediction. In the analysis four factors viz.:
cholecystitis, ERCP, thickened wall, contracted gallbladder were indicative for
very-difficult laparoscopic cholecystectomy and 3 factors namely: obesity, biliary
inflammation or procedure, contracted gallbladder were significant predictors of
conversion [46]. Classification of risk of complication based on preoperative scor-
ing system proposed by Burke J et al. (Table 8) is as follows: 0–22 low risk
(0.1–4.7%), 23–27 medium risk (5.5–9.9%), 28–43 high risk (11.5–59.4%) [17].
rading Systems Using Primarily Intraoperative Parameters and

G
their Validation
Different scoring methodologies have been suggested from time to time using over-
lapping criteria, further adding to the controversy. One of the earliest classification
of intraoperative difficulty during cholecystectomy was proposed by Cuscheri in
1992, [5]. Nassar et al. proposed grading of operative difficulty by assessment of
gallbladder, cystic duct pedicle and adhesions, Table 1 [12, 18]. A prospective mul-
ticenter cohort CholeS study using the above grading system observed that with
increase in grades from 1 to 5, the median hospital stay increased from 0 to 4 days,
and the 30-day complication rate increased from 7.6 to 24.4% respectively the find-
ings being significant. The Nassar grading scale emerged as an independent predic-
tor of operative time, conversion to open and 30 days complication and reintervention
rates. Use of this difficulty scale helps standardization of operative findings and thus
is proposed to facilitate audit, training assessment and research across multiple
grades of surgeons [47]. In a multinational collaborative study on surgeons using
Delphi technique, a consensus was reached on multiple intraoperative parameters as
predictors of difficulty. The factors were primarily classified as those related to
inflammation in region of gallbladder, calots and gallbladder bed as well as other
non-inflammatory intraoperative variables (Table 3). Sugrue M et al. have proposed
a G10 operative scoring system to provide simple grading of operative cholecystec-
tomy and predictive need to convert to open cholecystectomy Gallbladder surgery
was considered easy if the G10 score <2, moderate (2–4), difficult (5–7) and extreme
(8–10) (Table 4). In a study comparing Parkland intraoperative grading scale and
AAST EGS scale to assess difficult LC (Table 5), authors observed that the Parkland
scale was a superior predictor of operative difficulty, conversion, complication and
104 N. Gupta et al.
operative time whereas the Parkland and AAST grades had similar predictive value
as regards rates of partial cholecystectomy, readmission, bile leak, and hospital stay
[48]. Higher the Parkland grading scale (particularly for grade 4 and above) the
greater is the chance of acute cholecystitis and gangrenous cholecystitis. A strong
correlation has been noted between Parklands intraoperative grading scale and
Tokyo classification for acute cholecystitis. Increasing Parkland grades has been
associated with increased CRP levels and higher incidence of acute and gangrenous
cholecystitis [49]. An independent validation of AAST EGS system of classification
observed good inter-rater reliability for anatomic grading. With increasing AAST
EGS grade there was increased incidence of complications, prolonged hospital stay,
higher ICU admissions and adverse events. As the above adverse events were noted
even in grade 3 patients of the classification, the authors called for a refinement of
the classification system [50]. In a comparative validation between Tokyo system
and AAST EGS classification the latter was found to outperform the former with
respect to disease severity discrimination [51]. In a multicenter validation of
Parkland scale, Tokyo guideline classification and the AAST EGS stratification sys-
tem, Parkland scale was proposed to be better than AAST EGS system and Tokyo
classification, with the latter two having similar discriminatory power [52].
Grades of Severity and Suggested Treatment
Table 11 outlines the various treatment options advised classified as per the grades
of disease in Parkland scale, Tokyo guidelines and AAST EGS classification [53].
Utility of the Scoring Systems
Scoring systems can identify patients having high risk for LC and thus help in inti-
mation of patients about the anticipated difficulty that may be encountered, the
chances of conversion and further such cases may be scheduled appropriately. These
scoring systems may aid in the decision of early conversion to open or opt to bailout
options like cholecystostomy or subtotal cholecystectomy when difficulty is encoun-
tered. The other probable use of these scoring systems is to select patients more
appropriate for trainee surgeons as opposed to more experienced surgeons.
Conclusion
Predicting a difficult laparoscopic cholecystectomy is based upon several patient

and surgeon related factors. Various predictive models/scoring systems have been
proposed to aid in preoperative and intraoperative prediction of a difficult laparo-
scopic cholecystectomy which appear promising but needs larger validation.
Conversion to OC should not be weighed as a failure of LC but a step toward con-
duct of safe cholecystectomy in difficult cases.
Table 11 Treatment options for various grades of Parkland, Tokyo and AAST EGS classifica-
tions [53]
Classification Grade Treatment recommendation
Parkland Grade 1 LC can be done with standard operative time and minimal
classification complications/conversion
Grade 2 LC can be done with standard operative time and minimal
complications/conversion
Grade 3 LC feasible but increased difficulty as compared to grade 1 and
grade 2 unpredictable operative time, complications and
conversion rates
Grade 4 LC feasible but increased difficulty as compared to grade 1,
grade 2 and grade 3 unpredictable operative time, complications
and conversion rates
Grade 5 Increased operative time high rates of complications/ conversion
Tokyo guidelines Grade 1 Low risk of complications and conversion as compared to grade
1 and 2, early cholecystectomy can be done in most cases
Grade 2 Moderate rates of complications and conversion
Early cholecystectomy challenging, drainage procedure should
be preferred as an initial option and delayed cholecystectomy
advisable
Grade 3 High complications conversion and 30-day mortality,
preoperative drainage procedure advised
AAST EGS Grade 1 LC can be performed with low risk of conversion
classification Grade 2 LC can be performed with low risk of conversion
Grade 3 LC carries risk of conversion, consider percutaneous
cholecystostomy
Grade 4 LC has high probability of conversion consider OC/percutaneous
drainage
Grade 5 LC has high probability of conversion consider OC/percutaneous
drainage
LC laparoscopic cholecystectomy, OC open cholecystectomy
Summary of different scoring systems for difficult gallbladder tabulated in this chapter
Table 1: proposed by Nassar (1995) and modified (1996)
- intraoperative factors to classify difficulty in LC [12]
Table 2: proposed by Randhawa et al. 2009
- intraoperative factors for difficulty grading in LC [7]
Table 3: a multinational collaborative study on surgeons using Delphi technique 2017
- elaborate and detailed grading of intraoperative factors [13]
Table 4: proposed by Sugrue et al. 2019
- intraoperative factors & few preoperative clinical factors [6]
Table 5: Parkland scale
- Intraoperative factors for grading difficulty of LC [14]
Table 6: 2018 Tokyo guidelines
- severity grading scale for acute cholecystitis: predominantly preoperative factors [15]
Table 7: AAST EGS grading system
- descriptions of acute cholecystitis severity grading: preoperative, intraoperative factors and
pathologic correlation [16]
Table 8: Proposed by Burke J et al. 2021
- preoperative risk scoring system in LC as predictor of complications [17]
106 N. Gupta et al.
Table 9: proposed by Nassar et al. 2019

- Preoperative factors predictive of intraoperative difficulty [18]
Table 10: proposed by Randhawa et al. 2009
- preoperative factors which predict intraoperative difficulty [7]
Table 11: Treatment strategies according to grade/severity in parkland scale, Tokyo guidelines,
AAST EGS classification (52)
Key Clinical Points

1. Difficult gallbladder has been defined as a procedure with increased surgical
risk as compared to standard cholecystectomies.
2. There is need for standardization of criteria to define operative difficulty in
laparoscopic cholecystectomy.
3. Various scoring systems have been proposed to grade severity and guide perfor-
mance of LC as also predict difficulty in acute/non elective as well as chronic/
elective settings (Tables 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11).
4. Tokyo guidelines 2018 classifies severity of acute cholecystitis based on pres-
ence or absence of organ system failure and local sepsis.
5. Tokyo guidelines recommend early cholecystectomy for low-risk patients with
mild severity in acute cholecystitis. In high-risk patients or low risk patients
with moderate and severe acute cholecystitis treatment in higher centers and
cholecystostomy with drainage is deemed appropriate.
6. The AAST EGS guidelines can help decide on performance of LC in acute/
emergency setting and is based upon clinical radiologic and intraoperative cri-
teria along with pathologic correlates.
7. Prediction of difficult laparoscopic cholecystectomy in the setting of chronic
cholecystitis requires the judicious consideration of a number of clinical, bio-
chemical, radiological and intraoperative parameters.
8. Earlier difficulty was judged based upon coarse parameters like time taken,
injury, conversion and or modification of surgery which could be biased due to
experience of operating surgeon.
9. Newer scoring systems classify operative difficulty more precisely and incorpo-
rates a larger number of variables (Tables 1, 2, 3, 4, 5, and 7).
10. Scoring systems can be used to:
(a) inform patients about the likelihood of difficulty or conversion,
(b) aid appropriate scheduling of surgery, viz.: elective vs non elective,
(c) objectivize decision on conversion and or process modification example:
cholecystostomy/subtotal cholecystectomy,
(d) help select suitable cases for trainee surgeons,
(e) facilitate precise data recording for research.
11. The Parkland scale, intraoperative scale of Nassar, Tokyo guidelines and AAST
EGS scales have been validated in large data sets. Emerging reports on valida-
tion of some of these systems are encouraging and wider application in multi-
national collaborative studies is desirable.
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Robotic Assisted
Pancreaticoduodenectomy
Brij B. Agarwal and Neeraj Dhamija
Introduction
Pancreatic cancer remains one of the deadliest malignancies even after the advance-
ment in the diagnostic, surgical and adjuvant therapy. The first attempt for mini-
mally invasive resection of the pancreatic head malignancy was made by Gagner
and Pomp [1] in the year 1994. They concluded that there is no added benefit in
performing laparoscopic pancreaticoduodenectomy [2]. Since then, there has been
a very gradual increase in number of pancreatico-duodenectomies performed by
minimally invasive route mostly due to improved optics and instruments along with
reconstruction techniques. It was after the introduction and utilisation of Robotic
platform to perform complex abdominal dissection and anastomosis; we have seen
a consistent rise in the Robotic assisted pancreaticoduodenectomy (RAPD) or com-
plete Robotic pancreaticoduodenectomy procedures (RPD).
There is a consistent increase in number of publications of both Robotic Assisted
and Total Robotic pancreaticoduodenectomy procedure over the last decade [3–5].
There are many case series evaluating the advantages of the minimally invasive
pancreaticoduodenectomy over the traditional open approach [3–8]. A recent ran-
domized controlled trial- PORTAL trial is also under way comparing Robotic pan-
creaticoduodenectomy and open procedure [9].
When the Robotic platform is used for all the sub-steps of pancreaticoduode-
nectomy procedure starting from dissection to resection and reconstruction, the
procedure is called as Total Robotic Pancreaticoduodenectomy procedure.
Whereas when the robot is used only to perform specific sub-steps like creation
of pancreatico- enteric anastomosis and bilio-enteric anastomosis after a
B. B. Agarwal (*) · N. Dhamija

Department of Laparoscopic and General Surgery, GRIPMER and Sir Ganga Ram Hospital,
New Delhi, India
https://doi.org/10.1007/978-981-16-5473-2_5
112 B. B. Agarwal and N. Dhamija
laparoscopic resection then the procedure is called as Robotic Assisted

Pancreaticoduodenectomy, and also called as robotic Hybrid pancreaticoduode-
nectomy. Irrespective of the operative platform the operative steps remain the
same with an aim of providing the patient with similar/non inferior oncological
outcome compared to open procedure [10].
Robotic surgery bridges the gap between open and minimally invasive route
by imparting seven degrees of freedom and utilization of the endo-wrist instru-
ments of the Da Vinci™ robotic system. This is advantageous while performing
complex anastomosis. A successful resection and reconstruction by minimally
invasive route will add up the advantages of early recovery and discharge from
the hospital by limiting the parietal wound morbidity. The rate of other compli-
cations like postoperative pancreatic fistula, post pancreatectomy hemorrhage
and delayed gastric emptying remains same or low as compared to the standard
open technique.
In this chapter we describe the technique of performing a Robotic Assisted
Pancreaticoduodenectomy (RAPD) procedure.
Patient Selection
In robotic pancreaticoduodenectomy procedure, the ideal favorable patient profile is:
a. Small [<2 cm] periampullary lesions and head of pancreas lesion.

b. Age of the patient <65 years
c. Acceptable co-morbidity profile
With experience more complex cases are being done by utilization of the robotic
platform stretching out the limits of above said patient profile to locally advanced
pancreatic neoplasms which require difficult dissection and vascular resection.
In high volume centers with experienced surgeons, post neoadjuvant chemother-
apy cases and those requiring vascular resections are no longer a contraindication
for RPD. Reports are available of known aberrant RHA being managed during
RPD, while definite better outcome is seen in obese patients on using the robotic
platform [8, 11–13].
echnique of Robotic Assisted

T
Pancreaticoduodenectomy [RAPD]
Patient is anesthetized and intubated by the anesthesiologist. Position of the patient

is reverse Trendelenburg with leg split or the French position. The Robotic platform
used is Da Vinci Si, docked from the head end. For the laparoscopic part of the pro-
cedure, operating surgeon stands between the legs of the patient and camera and
assistant surgeon on either side of the patient. Table 1 outlines the steps of robotic
assisted pancreaticoduodenectomy.
Robotic Assisted Pancreaticoduodenectomy 113
Table 1 Steps of Robotic Assisted Pancreatico-Duodenectomy

Steps of Robotic Assisted Pancreatico-Duodenectomy
1. Diagnostic Laparoscopy
2. Opening of Gastrocolic Omentum
3. Gastrocolic Vessels Dissection
4. Cattle-Braasch Maneuver [Mobilisation of the Right Colonic Flexure and Extended
Kocherization]
5. Hilum Exploration
6. Gastroduodenal Artery Dissection
7. Retro-Pancreatic Tunnel
8. Transection of the Stomach
9. Pancreatic Neck Transection
10. Transection of First Jejunal Loop and Ligament of Trietz
11. Cholecystectomy
12. Common Bile Duct Transection
13. Uncinate Process Dissection
14. Specimen Extraction
15. Docking of Robot for Reconstruction
16. Pancreatico-Jejunostomy
17. Hepatico-Jejunostomy
18. Undocking of Robot
19. Gastro-Jejunostomy
20. Drain Placement and Closure
Diagnostic Laparoscopy
After painting and draping, pneumoperitoneum is created with the palmer’s point
approach. Staging laparoscopy is done with 5 mm, 30-degree telescope. The pari-
etal and visceral surface of the peritoneum is inspected carefully for any nodules
with suspected metastasis. The peritoneal cavity is inspected for the presence of any
free fluid. In the presence of any nodule or free fluid the samples are taken for
assessment by frozen technique to confirm for metastatic disease which will direct
the further course of surgical management. The standard port position for Robotic
Assisted Pancreatico duodenectomy is shown in the Fig. 1.
Opening Gastrocolic Omentum
The next step is to enter the lesser sac by opening of the gastrocolic omentum. This
step is aided by using the ultrasonic shear dissection and can be easily done by dis-
secting the gastrocolic omentum at the midpoint between the greater curvature and
the colonic margin. The window thus created in the gastrocolic omentum is widened
both cranially and to the right so that the entire posterior surface of the stomach is
clearly seen. Pancreas along with the covering off the posterior peritoneal lining can
be seen at the posterior aspect of the lesser sac. The adhesions between the posterior
surface of the stomach and the pancreas are divided.
Fig. 1 Port Placement in Robotic Pancreatico duodenectomy Procedure System Used Da Vinci Si;
C = Camera Arm of Robot (2 cm above and lateral to the umbilicus on the right side); R1 = Right
Hand of Operating Surgeon- Working Arm 1 (Left Mid clavicular line 8 cm from the Camera Port);
R2 = Left Hand of Operating Surgeon- Working Arm 2 (Just Lateral to the Right mid clavicular
line, 8cm from the Camera Port); A1 = Assistant Port 10mm (1cm below and lateral to the umbili-
cus on the left side); A2 = Assistant Port 5mm (Anterior axillary line on the left side 5 cm
from the R1)
Ligation of the Gastrocolic Vessels
While dissecting the gastrocolic omentum medially towards the duodenum the gas-
trocolic vessels are encountered which should be carefully dissected and clipped
separately. This usually ensures the complete mobilisation of the whole of the
greater curvature of the stomach all along till the duodenum.
attle-Braasch Maneuver [Mobilisation of the Right Colonic

C
Flexure and Extended Kocherization]
At this point the cattle-braasch maneuver and extended kocherization is done

[Fig. 2]. This important step aids in the future dissection of the uncinate.
Fig. 2 Cattell-
BraaschManuever:
(Extended Kocher +
Incision of small bowel
mesentery to posterior
peritoneum to reflect the
ascending colon and
duodenum to the left side
of abdomen)
Hilum Exploration
Dissection of the hepatoduodenal fatty tissue is performed next starting at the lesser
curvature of the stomach. The common hepatic artery is identified, and dissection is
done along the adventitial layer of the vessel which is usually avascular. Proper
understanding of the vascular anatomy of individual case by a detailed study of the
CT angiography will help and aid in the dissection. Careful dissection will eventu-
ally dissect all the fatty tissue along with the lymph nodes which should be sent
separately in an endobag or along with the main specimen for proper histopatho-
logical examination (HPE) and oncological evaluation.
Gastroduodenal Artery [GDA]Dissection
Dissection of the lymph nodes will also make the gastroduodenal artery [GDA] vis-
ible making it easy for dissection. GDA should always be double ligated with two
clips on both proximal and distal side to safely secure this vessel [Fig. 3].
Fig. 3 Dissection and

Ligation of Gastro
Duodenal Artery
Just deep to the GDA is the portal vein which should be visible by now and on
the right side is the CBD. We should carefully dissect the gastroduodenal vein
which is usually present on the right side of GDA. When it is of a significant size,
its injury can be a source of troublesome bleeding.
Retro Pancreatic Tunnel
At the lower border of the pancreas the mesopancreatic tissue is dissected to reveal
the superior mesenteric vein (SMV). The site of SMV can be can be traced by fol-
lowing the previously ligated gastroepiploic vein which leads us to the SMV. Careful
blunt dissection is done with the help of atraumatic grasper or the suction tip.
Usually, this plane is not having any major vessels but occasionally one or more
direct venous tributaries may be seen arising from the posterior surface of the pan-
creas and draining into the SMV. These can be easily secured with either harmonic
scalpel or haemolock clips. The space behind the pancreatic neck is further dis-
sected to reach and meet the already created superior space at the level of GDA
vessel and just medial to it.
Vessel First Approach During a suspected locally advanced lesion and possible
involvement of the vital vascular structures at the posterior aspect of the pancreas a
vessel first approach is utilized for dissection. In this approach the feasibility of Step
number 7 is assessed before Step Number 3, i.e. after the dissection of the epiploic
vessels. The feasibility of the creation of the retropancreatic tunnel over the great
veins- SMV and Splenic vein confluence to form Portal veinis ascertained. This
modification of the technique is important as any abnormal adhesions between the
posterior surface of the pancreas and the great veins will unable us to progress with
the pancreatic neck transection and can result in unwanted bleeding which can be a
catastrophe. This may demand conversion of the procedure to open or abandon the
procedure for non-operability.
Transection of Stomach
Stomach is transected with the help of Endo stapler 60 mm green loads. Classical
pancreatico duodenectomy describes transection of the stomach at the junction of
middle and distal third. Usually, one to two cartridges are used for transection of
stomach. Both side of the transected stomach is then opened like a book aiding in
complete visualization of the pancreatic neck.
Pancreatic Neck Transection
A successful creation of the space will enable us for the next important step of pan-
creatic neck transection. The transection of the pancreas at the level of the neck-the
region of the pancreatic neck is identified by posteriorly running superior mesen-
teric vein and splenic vein confluence to form portal vein. The line of transection is
usually parallel to the portal vein. Ultrasonic scissors is preferably used for transec-
tion [Fig. 4]. The trick is to take small bites at minimum level of setting. Careful
dissection will help us to identify the pancreatic duct which is also transected by
cold scissors and the dissection is further continued from caudal to cranial fashion
to complete the transection of the pancreas.
Transection of the Jejunum
After pancreatic transection, the omentum and the transverse colon is flipped-up to
reveal the duodeno-jejunal junction [DJ] and the ligament of Trietz. Approximately
15 cm from the DJ, jejunum is transected with the help of a 60 mm white/blue sta-
pler. The mesentery of the transected jejunum is resected close to the jejunal wall to
reach the ligament of Trietz. Careful dissection of the ligament of Trietz makes the
DJ free and this step enables us to deliver the transected jejunum to the right side of
the abdomen through the retroperitoneal tunnel.
Fig. 4 Transection of the

Neck of the Pancreas
Cholecystectomy
The CBD and the Calot’s triangle are dissected, and the cystic artery is secured. The
cystic duct is ligated in continuity but the gall bladder is not detached immediately
from liver as it aids in the dissection of the important structures at the porta. The
CBD is looped with silastic loop for identification and future transection.
Transection of the Bile Duct
After transection of the pancreas, the specimen is attached with the help of the unci-
nate process and the bile duct. The transection of the bile duct is usually done at the
level of the cystic duct and bile duct confluence. The transected margin of the bile
duct can be sent for frozen section if the indication of the resection is a distal chol-
angiocarcinoma. The transection is usually aided by the harmonic scalpel with care
taken to remain away from the portal vein.
Transection of the Uncinate Process of the Pancreas
At this step the only structure which is holding the specimen is the uncinate process
of the pancreas. The dissection of the uncinate process begins in a caudal-to-cranial
fashion. Traction over the specimen side and counter traction by assistant surgeon
over the portal vein will expose the mesopancreatic tissue in close proximity to the
superior mesentric artery [SMA]. Careful dissection of the venous tributaries to the
portal vein travelling through the uncinate and ligation of the small arteries from
SMA to the uncinate is done with the help of Harmonic Scalpel and Haemolock
clips/Ligaclips wherever necessary [Fig. 5].
Out of all the vessels in the region of the uncinate the “First jejunal vein” is the
most notorious. It runs as a course of a ‘U’ shaped loop of vein traversing through
the uncinate and therefore you have to either dissect it completely or secure it twice
to have proper control of this vessel. This is a common source of bleeding from the
Fig. 5 Dissection of the

Uncinate process of
Pancreas
uncinate process while dissection. A step-by step approach is followed, and the ves-
sels secured to reach and meet the cranial edge of the uncinate where it joins the
already formed window of the dissected bile duct. This will complete the resection
of the specimen of Pancreatico-Duodenectomy.
Specimen Extraction
The resected specimen is placed in an Endobag and retrieved from the port-site. The
specimen can also be retrieved from Natural orifice -Vagina in consenting post-
menopausal women undergoing minimally invasive pancreaticoduodenectomy with
acceptable results.
Docking of the Robot for Reconstruction
The Robot is docked from the head end. In the robotic arm-1 a needle holder is
equipped and in the robotic arm-2 atraumatic bowel grasper is equipped. The oper-
ating surgeon sits at the robotic console and the reconstruction is started.
Reconstruction After Robotic or Robot Assisted Pancreaticoduodenectomy

Reconstruction after the resection of the pancreaticoduodenectomy involves three
technically challenging anastomosis. It consists of-
–– Pancreatico-Jejunostomy [PJ]
–– Hepatico-Jejunostomy [HJ]
–– Gastro-Jejunostomy [GJ]
To begin the reconstructive phase, the transected jejunum approximately 15 cm

from the DJ is brought to the right side through the retro-colic route by forming a
window in the mesentery of the transverse colon. A single loop reconstruction is
preferred by performing a series of reconstruction in order of a PJ, HJ & GJ.
Pancreatico-Jejunostomy [PJ]
Before we start doing the PJ, we make sure that there is adequate mobilization of
approximately 3–5 cm of the pancreas in the posterior aspect so that the posterior
surface of the pancreas is exposed. The reconstruction is done in an end-to-side
fashion where the cut end of the pancreas is anastomosed to the side of the jejunum.
Preferred technique is selective duct-to-mucosa suturing with dunking of the rest of
the pancreas. It consists of a four layered anastomosis. The technique used by the
authors is described here below:
I. The first layer consists of the interrupted 4-0 PDS (polydioxanone) sutures
from the posterior surface of the pancreas and the sero-muscular layer of the
jejunum. It is started at a distance of approximately 1 cm from the cut edge of
the pancreas at the posterior surface. It usually takes about 6–8 sutures to com-
plete this layer [Fig. 6].
II. The second layer is a selective duct-to-mucosa layer. As the duct of the pan-
creas is eccentrically located and is closer to the posterior aspect of the p ancreas,
selective sutures are taken between the posterior ductal margin and the posterior
lip mucosa of the jejunal enterotomy. About 4 interrupted sutures with 4-0 PDS
are required in this fashion. Rest of the second layer consists of the interrupted
sutures with 4-0 PDS between the full thickness of the jejunum and the pancre-
atic parenchyma at the level of the duct where at least 2–3 sutures are taken both
cranially and caudally to the duct of the pancreas. At this step a stent [silastic
feeding tube of 5 cm and 6-8Fr] can be introduced into the duct of the pancreas
and the intestinal lumen to create a stented anastomosis [Fig. 7].
III. The third layer of the PJ consists of a 6-8 interrupted 4-0 PDS sutures from the
anterior surface of the cut edge of the pancreas and the anterior lip of enterot-
omy of the jejunum. Care must be taken for not tightening the sutures too much
which can cause tear of the pancreatic parenchyma [Fig. 8].
Fig. 6 Ist Layer of

Pancreatico-Jejunostomy
Fig. 7 IInd Layer of

Fig. 8 IIIrd Layer of

Fig. 9 Hepatico-
Jejunostomy
IV. The fourth layer is between the anterior surface of the pancreatic serosa and the
sero-muscular layer of the anterior surface of the jejunum. It is done by inter-
rupted 4-0 PDS sutures.
This completes the PJ. The jejunum is then anchored near the bile duct with a 4-0
PDS suture to create a HJ at approximately 10 cm from the PJ.
Hepatico-Jejunostomy [HJ]
An enterotomy is made at the anti-mesenteric border of the jejunum for a length less
than the diameter of the bile duct. An interrupted 4-0 PDS sutures are taken starting
from the posterior layer of the bile duct followed by the anterior layer [Fig. 9]. Stent
or a T-Tube is not placed across the HJ. The jejunum is fixed to the mesenteric win-
dow at the transverse colon and the window is closed by 3-0 vicryl sutures.
Undocking of the Robot
After PJ and HJ, the robot is undocked and rest of the procedure is performed by
laparoscopic approach.
Gastro-Jejunostomy [GJ]
Approximately 30 cm from the HJ, a GJ is created. It is preferably done with the
help of a stapler using a blue reload and 60 mm cartridge. An enterotomy is created
at the antimesenteric border of the jejunum and posterior surface of the stomach. An
Endo GIA stapler is passed from the enterotomy, one limb in the stomach and
another in the jejunum to create the stapled GJ. The enterotomy site is closed with
the help of 3-0 PDS suture in a single layer continuous fashion.
After reconstruction, haemostasis is ensured and a ‘Stamm type’ of feeding jeju-
nostomy is done with a 12 Fr Ryles tube.
Abdominal Drain Placement Is Done at Three Sites
• From left side of the abdomen at the superior surface of the pancreas above the
PJ and close to the GJ.
• From right side of the abdomen near the HJ.
• A dependent drain in the pelvis from the right side of the abdomen.
The skin incisions are closed in layers after careful closure of the ports with vic-
ryl no.1 and skin with staplers. Ryles tube is generally not required and if inserted
is removed in the post-operative recovery room after full recovery from anesthesia.
Outcomes After RPD/RAPD
Miami guidelines mention about outcome improvement with minimally invasive

PD (MIPD) in centers with minimum 20 cases per year [14]. Similarly, after RAPD/
RPD statistical improvements are seen in operating time, estimated blood loss, con-
version to open, decreasing major complications and postoperative pancreatic fis-
tula occurrences after approximately performing 40 cases (Range 22–80) [15–21].
These high-volume centers have a far better 90day mortality rate compared to low
volume centers [22].
RAPD vs RPD has virtually no outcome difference in terms of harvested lymph
nodes 13.6 ± 4.0 vs 14.2 ± 5.7 (P-value 0.698), operating time 415.3 ± 89.2 vs
362.4 ± 75.6 min (P value 0.047), estimated blood loss 300 ml [75–500] vs 200 ml
[100–400] (P Value 0.439) and blood transfusion requirements (P-value 0.579) [23].
The parietal wound related morbidity is also reduced and this clubbed with an unevent-
ful recovery helps in the early initiation of the adjuvant therapy in a suitable candidate.
Complications of Pancreaticoduodenectomy
The main complications during a robotic pancreaticoduodenectomy surgery are

bleeding and it is the most common cause of conversion to the open technique.
The important postoperative complications include:
–– Postoperative pancreatic fistula [POPF]

–– Post Pancreatectomy Hemorrhage [PPH]
–– Delayed Gastric Emptying
–– Bile leak/Biliary Fistula/Stenosis
–– Anastomotic Leak
–– Intraabdominal infection
–– Re-laparotomy
Recent reports suggest that after Robotic PD, POPF incidence is only around
10% with high risk factors like soft pancreas and narrow duct ≤2 mm [23]. RPD
also shows decreased incidence of delayed gastric emptying (3%) and has better
oncologic outcomes in comparison to open PD [24].
Conclusion
Incorporation of the advantages of Robotic Assisted surgery to the complex abdom-

inal surgery can help in implementation of the ERAS protocol. This is advantageous
for rapid recovery and discharge from the hospital.
Minimally invasive pancreaticoduodenectomy adds up-to the training of the resi-
dents, who after closely watching the anatomy of the complex resection and recon-
struction can add rehearsal of the video for better understanding. Cost is an issue for
starting and implementation of the robotic pancreaticoduodenectomy program.
Key Clinical Points

1. Gradual increase noted in number of pancreatico-duodenectomies performed
by minimally invasive route is mostly due to improved optics and instruments
along with reconstruction techniques.
2. Recent meta-analyses have vouched for the safety of robotic pancreaticoduode-
nectomy with a non-inferior outcome over laparoscopic and open approaches
and proposes certain beneficial trends in intraoperative and postoperative
parameters.
3. A successful resection and reconstruction by minimally invasive route will add
up the advantages of early recovery and discharge from the hospital by limiting
the parietal wound morbidity.
4. Post neoadjuvant chemotherapy cases and those requiring vascular resections
are no longer a contraindication for RPD.
5. A definite better outcome is seen in obese patients on using the robotic platform.
6. Miami guidelines mention about outcome improvement with MIPD in centers

with minimum 20 cases per year. RAPD/RPD improvements are seen in operat-
ing time, estimated blood loss, conversion to open, decreasing major complica-
tions and postoperative pancreatic fistula occurrences after approximately
performing 40 cases.
7. RAPD vs RPD has virtually no outcome difference in terms of harvested lymph
nodes, operating time, estimated blood loss and blood transfusion requirements.
8. The main possible complication after RPD/RAPD is bleeding and it is the most
common cause of conversion to the open technique during RPD/RAPD.
9. Increased operative time was the most consistent drawback of robotic as com-
pared to open PD, whereas the prominent advantages of robotic approach were
less intraoperative blood loss, lower postoperative complications and wound
infection rate, earlier hospital discharge rates and a possible improved onco-
logical outcome reflected by increased number of harvested nodes along with a
lower margin positivity.
10. Mesopancreas/level 3 dissections in robotic pancreaticoduodenectomy had less
blood loss, no delayed gastric emptying and lower chyle leakage.
11. Robotic intracorporeal anastomotic technique has an obvious advantage over
laparoscopic approach due to better articulation and higher degree of freedom
of instrument movement.
Editor’s Note1
Pancreaticoduodenectomy was conventionally done by open approaches until lately

when rapid evolving techniques of minimally invasive surgery have been transposed
into the arena. Recent meta-analyses have vouched for the safety of robotic pancre-
aticoduodenectomy with a non-inferior outcome over laparoscopic and open
approaches and proposes certain beneficial trends in intraoperative and postopera-
tive parameters.
The various types of minimally invasive pancreatoduodenectomy reported in lit-
erature are:
I. Laparoscopic assisted
II. Totally laparoscopic
III. Total laparoscopic robotic assisted
IV. Totally robotic.
Minimally invasive versus open pancreaticoduodenectomy: Table EN1 lists

the results of various meta-analyses comparing robotic, laparoscopic and open pan-
creaticoduodenectomy published during the past 5 years.
Table EN1 Meta analyses published on outcome of robotic/minimally invasive and open pancre-
aticoduodenectomy in past 5 years
Disadvantages
robotic/
Advantages robotic/ minimally
Study, author [first], year No difference minimally invasive invasive
Perioperative and • Overall survival • Disease-free
oncological outcomes • Operative time survival
following minimally • Postoperative • Time to starting
invasive versus open complications adjuvant
pancreaticoduodenectomy • 30-day mortality chemotherapy,
for pancreatic duct • Rate of vein resection • Length of hospital
adenocarcinoma. • Number of harvested stay
Sun R 2021 [1] lymph nodes • rate of negative
• Rate of positive margins
lymph nodes.
Robotic versus open • Positive margin rate • Less blood loss Longer
pancreaticoduodenectomy: • Lymph nodes • Hospital stay operative time
a meta-analysis of harvested • Wound infection
short-term outcomes. • Postoperative
Yan Q 2020 [2] complications
• Reoperation or
readmission mortality
rate
(continued)
1
Disadvantages
robotic/
A systematic review and • Major complications • Less transfusion Operative time
network meta-analysis of • Fistula • Wound infection for total robotic
different surgical • biliary leak • Pulmonary was longer than
approaches for • mortality complication open
pancreaticoduodenectomy. • R0 resections. • Less hospital stay
Kamarajah SK 2020 [3] than open
• Lower conversion
in total robotic
than total
laparoscopic group
• Higher lymph
node yield in total
robotic
Robotic-assisted versus • Mortality morbidity • Less blood loss Longer
open • Pancreatic fistula operative time
pancreaticoduodenectomy • Delayed gastric
for patients with benign emptying hemorrhage
and malignant • Bile leak
periampullary disease: a • Retrieved lymph
systematic review and nodes
meta-analysis of short-term • Positive margin
outcomes. status.
Podda M 2020 [4]
Minimally invasive versus • Reduced blood Longer
open loss operative time
pancreatoduodenectomy- • Delayed gastric
systematic review and emptying
meta-analysis. • Decreased length
Pędziwiatr M2017 [5] of hospital stay
Systematic review and • Number of lymph • Less complication,
meta-analysis of robotic nodes harvested; • Margin positivity,
versus open • Operation time; • Wound infection,
pancreaticoduodenectomy. • Reoperation rate; • Hospital stay.
Peng L 2017 [6] • Delayed gastric
emptying,
• Bile leakage,
• Pancreatic fistula and
mortality.
Disadvantages
robotic/
Systematic review and • Postoperative • Reduced hospital
updated network meta- mortality length-of-stay,
analysis comparing open, • Postoperative • Estimated blood
laparoscopic, and robotic complications loss,
pancreaticoduodenectomy. number of retrieved • Pulmonary &
Aiolfi A 2020 [7] lymph nodes overall
• R0 resection rates. complications
• Postoperative
bleeding
• hospital
readmission.
Minimally Invasive The TLPD technique • Blood loss Operative time
Pancreaticoduodenectomy: was often the worst • Wound infection and
What is the Best “Choice”? approach especially for • Delayed gastric postoperative
A Systematic Review and overall and major emptying bleeding,
Network Meta-analysis of complications, • Length of hospital
Non-randomized postoperative bleeding stay
Comparative Studies. and biliary leak • Harvested lymph
Ricci C 2018 [8] nodes
• Postoperative
morbidity
Safety and efficacy of • Lymph node • Blood loss Operation time
robot-assisted versus open clearance • Infection rate
pancreaticoduodenectomy: • Postoperative • Reoperation rate,
a meta-analysis of multiple • Pancreatic fistula bile • Overall
worldwide centers. leakage complications
Zhang W 2020 [9] • delayed gastric • Clinical
emptying postoperative
• 90-day mortality pancreatic fistula
• Severe complications
Robotic • Less blood loss Operative time
pancreaticoduodenectomy • Less incidence of
provides better resection margin
histopathological outcomes involvement.
as compared to its open • Higher number of
counterpart: a harvested nodes
meta-analysis
Da Dong X 2021 [10]
Safety and efficacy for • Lymph node yield • Less blood loss Longer
robot-assisted versus open • Rate of pancreatic • Less wound operative time
pancreaticoduodenectomy fistula infection
and distal pancreatectomy: • Delayed gastric • Lower positive
A systematic review and emptying margin rate
meta-analysis. • Reoperation, • Lower overall
Zhao W 2018 [11] • Length of hospital complications
stay • Faster
• Mortality between postoperative
the two groups. off-bed activity
Increased operative time was the most consistent drawback of robotic as com-
pared to open pancreaticoduodenectomy, whereas the prominent advantages of
robotic approach were less intraoperative blood loss, lower postoperative complica-
tions and wound infection rate, earlier hospital discharge rates and a possible
improved oncological outcome reflected by increased number of harvested nodes
along with a lower margin positivity noted in some of the studies [1–11].
Mesopancreatic resection and approach to superior mesenteric artery: A
newly emerging concept in pancreaticoduodenectomy is the concept of mesopan-
creas [level 3] dissection a term akin to mesorectum and mesocolon in colorectal
cancers. It is a fascial fusion plane embryologically formed during development of
pancreas. It lies posterior to the pancreas and is comprised of pancreaticoduodenal
vessels, lymphatics, nerve plexus and loose areolar tissue. Approach to the area is
complex due to the complicated anatomy. Reports are emerging on mesopancreatic
resection in robotic pancreaticoduodenectomy. A study comparing meso pancreatic
resection in open and robotic pancreaticoduodenectomy concluded that mesopan-
creas/level 3 dissections in robotic pancreaticoduodenectomy had less blood loss,
no delayed gastric emptying, and lower chyle leakage. The lymph node yield was
higher for mesopancreas/level 3 dissection compared with mesopancreas levels 1
and 2 dissections in the robotic pancreaticoduodenectomy groups. Postoperative
complications and mortality were not different due to the additional mesopancreatic
excision. Complications, including postoperative pancreatic fistula, delayed gastric
emptying, postpancreatectomy hemorrhage, chyle leakage, bile leakage, or wound
infection were similar in level 2 vs level 3 dissections of robotic pancreatectomy
[12]. Various surgical approaches have been described for approaching the superior
mesenteric artery during pancreaticoduodenectomy, viz: anterior, posterior, left and
right approach.
Reconstruction after pancreaticoduodenectomy and Pancreaticoeneteric
anastomosis: The mode of reconstruction of pancreatico-enteric anastomosis has
been a context of debate with some authors preferring a pancreatico-jejunostomy
and others opting for a pancreaticogastrostomy. Occlusion of pancreatic duct with-
out anastomosis a method proposed to circumvent the formation of pancreatic fis-
tula has a high morbidity with increased incidence of diabetes noted in such patients
and thus not recommended [13]. In a recent metaanalysis comparing pancreatico-
gastrostomy with pancreatico-jejunostomy it was noted that the pancreaticogastros-
tomy group had significantly lower incidence in rates of postoperative pancreatic
fistulas, intra-abdominal abscesses and length of hospital stay. However, rates of
biliary fistula, mortality, morbidity, delayed gastric emptying, reoperation, and
bleeding was similar in the two groups [14].
One of the inherent deterrents in minimally invasive gastrointestinal/hepatopan-
creaticobiliary surgery is the construction of an intracorporeal anastomosis. Robotic
anastomotic technique has an obvious advantage over laparoscopic approach due to
better articulation and higher degree of freedom of instrument movement. Among
different meta-analysis, one such report comparing robotic laparoscopic and open
anastomosis in an array of surgical procedures concludes that robotic, laparoscopic
and open techniques of anastomosis yielded similar rates of leak and stricture forma-
tion [15]. Published meta-analysis on robotic pancreaticoduodenectomy also exhibit
a consistent equivalent or lower rate of pancreatic or biliary fistula [Table EN1].
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Laparoscopic Surgery for Rectal
Prolapse
Manash Ranjan Sahoo, Suyash Bajoria, and Ankit Sahoo
Introduction
Rectal prolapse is a disorder where the entire thickness of rectal wall protrudes out
through the anal sphincter. It is one of the earliest surgical problems recognized by
medical fraternity [1, 2]. However, many controversies still exist regarding the etiol-
ogy and management of this condition [3].
Rectal prolapse are often associated with a gamut of anatomic abnormalities like
diastasis of levator ani, abnormally deep cul-de-sac, redundant sigmoid colon, patu-
lous anal sphincter or loss of rectal sacral attachments [4]. Rectal intussusception or
solitary rectal ulcer have been hypothesized to be associated with rectal prolapse but
have not been clearly proven [5, 6].
Rectal prolapse is overall a rare occurrence, being higher in females and elderly—
women aged 50 years or above who suffer six times more than men [4]. Interestingly,
the age of incidence for the relatively fewer men with prolapse is generally below
40 years [7]. Autism and developmental delay syndromes have been reported to be
associated with rectal prolapse [8].
Patient Selection
Patients with rectal prolapse may present with issues related to the prolapse itself or
due to associated incontinence. Prolapse may be seen either with defecation or in a
more advanced form, with slight exertion such as coughing or sneezing. Early symp-
toms of prolapse include bowel dysregulation, discomfort, sensation of incomplete
evacuation and tenesmus [9]. It can be a very disabling and in its advanced stage
M. R. Sahoo (*) · S. Bajoria · A. Sahoo

Department of Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
https://doi.org/10.1007/978-981-16-5473-2_6
134 M. R. Sahoo et al.
characterized by a permanently expelled rectum that is often becomes excoriated and

ulcerated and is associated with mucous discharges or bleeding. The psychological
trauma is formidable and patients often avoid social contact because of
embarrassment.
Constipation with Rectal Prolapse
Pre-operatively rectal prolapse is associated with constipation in approximately

25–50%. Invariably it is the intussuscepting bowel in the rectum, which creates the
blockage and is magnified by pelvic floor straining or dyssynergia and colonic dys-
motility. The exact cause remains debatable.
Mobilizing the rectum posterior and laterally during rectopexy corrects the ana-
tomical position but it is often traded for a functional one i.e. post-operative consti-
pation. The mechanism behind post rectopexy constipation is a frequent subject of
debate. The redundant sigmoid colon after rectopexy can kink to produce mechani-
cal obstruction which has been stipulated as a cause while others blame postero-
lateral mobilization leading to interruption of the autonomic sympathetic innervation
as a cause of slower distal transit [10].
Patients with severe constipation co-existing with rectal prolapse require special
consideration in line of clinical practice guidelines of ASCRS (American Society of
Colon and Rectal Surgeons), as they may not be ideal candidates for certain surgical
manoeuvres which are known to exacerbate constipation after surgery [11]. Few
randomized studies have opined that by avoidance of division of lateral rectal liga-
ments one might have better results in constipated patients [12, 13]. Resection rec-
topexy reduces post-operative constipation by removing the redundant / neuropathic
hind gut [14].
Incontinence with Rectal Prolapse
Fecal incontinence with rectal prolapse has been reported in 50–75% of patients
[15]. Repeated stretch and trauma to the area and stimulation of the recto-anal
inhibitory reflex damages the anal sphincter [16]. De-nervation atrophy of the exter-
nal anal sphincter possibly because of pudendal neuropathy has also been demon-
strated [17].
Majority of the patients with a continence disturbance experience improvement
once the prolapse is corrected [18, 19]. Pre-existing faecal incontinence due to any
condition other than prolapse, should be evaluated [20]. If testing reveals decreased
pudendal nerve terminal motor latencies, this may have postoperative prognostic
significance, patients with evidence of nerve damage appear to have a higher rate of
incontinence after surgical correction of the prolapse, although more studies are
necessary to confirm the finding [21, 22].
The basic goals to correct rectal prolapse are threefold.
Laparoscopic Surgery for Rectal Prolapse 135
1. To eliminate the prolapse through either resection or restoration of normal pelvic

anatomy.
2. To correct associated functional abnormalities of constipation or incontinence.
3. To avoid the creation of new symptoms of bowel dysfunction.
To achieve this complex threefold goal, multiple minimally invasive operations

have been developed, each has its strengths and weaknesses, emphasizing the need
of careful patient selection and detailed patient counseling before choosing a surgi-
cal approach [23, 24].
Preoperative testing: Detailed patient history and physical examination should be
done before contemplating any intervention. The physical examination should focus
on the rectal prolapse, structure of anal sphincter with its function and on other
associated symptoms or underlying conditions. Complete rectal prolapse should
always be differentiated from prolapsing haemorrhoids or partial mucosal prolapse.
Full inspection of the perineum and complete ano-rectal examination is always
important which may reveal a patulous anus with diminished sphincter tone.
Proctoscopy may reveal a solitary rectal ulcer [25].
Pre-operative assessment of pre-existing constipation or incontinence is an abso-
lute necessity to plan operative intervention [26, 27]. Symptoms of anterior com-
partment prolapse, such as urinary incontinence and vaginal/ uterine prolapse have
to be checked because as many as 20–35% of these patients can have urinary incon-
tinence, while 15–30% have significant vaginal vault prolapse. Uro-dynamic and
uro-gynaecologic examination also allow for concomitant surgical intervention to
both the anterior and posterior pelvic compartments as multi-visceral prolapse
require a multidisciplinary approach [28, 29].
The role of fluoroscopy or MRI defecography, colonoscopy, barium enema, and
urodynamics has been elucidated in the recent ASCRS guidelines for rectal prolapse
surgery [30]. Fluoroscopic defecography, MRI defecography or balloon expulsion
testing may help in the diagnosis of not so obvious prolapses. Defecography may
also divulge associated anterior pelvic floor support defects such as cystocele, vagi-
nal vault prolapses and enterocoele [31].
Neoplasm though rarely, may form the lead point for a rectal prolapse. Hence all
rectal prolapse cases particularly in the older population, colonoscopy should be
performed before surgery, as it may change the operative plan. Weak recommenda-
tions exist regarding use of anal physiologic testing to evaluate and treat coexisting
functional disorders associated with rectal prolapse, such as constipation or faecal
incontinence [32].
Rectal Prolapse in Elderly
A balance should be achieved and morbidity of the available procedures should

always be considered and outcome analysis done carefully before selecting the suit-
able one [33]. The age-old theory of perineal procedures for old and frail patients
have recently been challenged [34]. Off-late laparoscopic approaches to treat rectal
prolapse in the elderly have shown improved benefits and decreased morbidity and
mortality [35, 36]. Laparoscopic surgery for rectal prolapse, has thus made surgeons
to reconsider more durable abdominal procedures in elderly patients [37, 38].
Laparoscopic surgery has proven to be safe in the elderly and is associated with
decreased ileus, less wound infections and a decreased length of post-operative stay
[39, 40]. Acceptable morbidity has been reported in elderly patients who underwent
a laparoscopic mesh rectopexy [41, 42]. Robotic rectopexy has also been shown to
be a safe and effective option in patients older than 75 years [43]. An increasing
number of elderly patients are being considered for minimally invasive approaches
with acceptable success rates [44, 45].
Laparoscopic Surgeries for Rectal Prolapse
Laparoscopic Resectional Rectopexy
Described by Frykmann and Goldberg (Frykmann-Goldberg procedure) [46, 47].
Procedure
Patient position and port placement: The patient should be placed in the dorsal
lithotomy position. Port position varies but in general camera is at the umbilicus
(Fig. 1). Site for exteriorization of bowel for resection if required should be marked
at time of surgery.
Vascular division: After trocar insertion, patient is generally placed in steep
Trendelenburg position particularly to move the small bowel out of the field.
Dissection is usually done from medial to lateral direction. The vascular division is
done above the level of superior haemorrhoidal vessels at the sacral promontory.
The superior rectal artery is spared because preserving the blood supply to upper
part of rectal stump will minimize the risk of an anastomotic leak. Care should be
taken to preserve the hypogastric nerves that course over the sacral promontory.
Important structures—ureters, gonadal vessels and iliac vessels are safeguarded
[48] (Fig. 2).
Mobilization of rectum: The dissection of the rectum is carried out exactly as in
the ‘abdominal phase of the Miles’ abdomino perineal resection technique except
preserving the blood supply to the rectum and preserving the lateral stalks intact.
The rectum is completely mobilized down to the levator muscles and the freed rec-
tum is drawn up into the abdomen, which makes the lateral stalks prominent. The
stalks are then sutured to the periosteum of the sacrum to hold the organ firmly in
this elevated position. Care must be taken not to narrow the bowel by placement of
sutures which may lead to obstruction [49] (Figs. 3 and 4).
Segmental resection of sigmoid with end-to-end anastomoses: The peri-
toneum lateral to the descending colon is incised upto the splenic flexure and
Fig. 1 Port position for

laparoscopic rectopexy
5 mm
12 mm
Camera 5 mm
port
Possible
extraction
site
Fig. 2 Redundant sigmoid

colon (Image Courtesy: Dr
Deborshi Sharma)
the entire left colon is mobilized from the retroperitoneal structures. The redun-
dant colon is resected so that anastomosis is established without tension.
Suturing of endopelvic fascia anteriorly to rectum is done to obliterate cul-de-
sac (Figs. 5–7).
a b
Fig. 3 (a) Lateral dissection and mobilization of rectum; (b) Posterior dissection down to the leva-
tor plate (Image Courtesy: Dr Deborshi Sharma)
Fig. 4 Fixation of
mesorectum to sacral
promontory in resection
rectopexy

redundant sigmoid which
requires resection
rectopexy
Descending
Colon
Redundant
Sigmoid
Rectum Colon
Fig. 6 Redundant sigmoid

colon retrieved for
resection
Fig. 7 Colorectal
anastomosis after resection
rectopexy
Advantages May reduce constipation in those who report pre-operatively [50, 51]
and prevent new onset of constipation. New prolapse recurrence rates of <2% and
complication rates of 4% are acceptable which greatly improves functional outcome
with minimal increase in morbidity [52, 53].
Disadvantages Significantly has no effect on patients presenting with fecal incon-

tinence and thus sigmoid resection should not be offered to patients with decreased
anal pressure on manometry. Sigmoid resection is usually not advocated in proce-
dures involving use of mesh.
Fig. 8 Suturing the

mesorectum to presacral
fascia in suture rectopexy
(Polypropylene or PDS 2-0
used)
Laparoscopic Non-Resectional Rectopexy
Types
1. Laparoscopic Suture rectopexy
2. Laparoscopic mesh rectopexy
a. Laparoscopic anterior mesh rectopexy (Ripstein)
b. Laparoscopic posterior mesh rectopexy (Wells)
c. Laparoscopic lateral mesh rectopexy (Orr -Loygue)
d. Laparoscopic ventral mesh rectopexy (D’Hoore)
Procedure The surgical steps are same as laparoscopic resection rectopexy, except
that sigmoid colon is not resected. Rectum is mobilized till the level of levator ani
muscles, following which rectopexy is performed with sutures or mesh [54].
Laparoscopic Suture Rectopexy: (Fig. 8)
It is the simplest laparoscopic procedure performed in modern times [55].

Mobilization is similar to other laparoscopic procedures. Following which posterior
wall of mesorectum is sutured without tension to the sacral promontory using 4–6
non-absorbable sutures. Most authors suture the fascia propria of the posterior
mesorectum to the presacral fascia while a partial thickness of the posterior rectum
can also be included [56, 57]. Another option is to suture the right and left peritoneal
flaps to the presacral fascia on the sacral promontory [58]. The exact location on the
promontory should be lateral to the hypogastric nerves and medial to the ureters on
both sides of the rectum [59–61]. This option is favored when risk of infection is
high or in situations of inadvertent rectal perforation or if concomitant sigmoid
resection and anastomosis is done.
Laparoscopic rectal mobilization only without rectopexy is a procedure described
but with a slight high recurrence rate. It is contemplated that adhesions following
any surgical dissection will provide passive fixation of mesorectum to the sacrum.
Laparoscopic Mesh Rectopexy
Use of a mesh during rectopexy is very commonly done with the idea that the for-
eign material will induce adhesion and create fibrosis more than suture rectopexy.
Meshes can be placed anteriorly, posteriorly, laterally or encircling the rectum, all
of which have their advantages and disadvantages.
Fig. 9 Mesh being placed

after mobilization of
rectum (Image Courtesy—
Dr Deborshi Sharma)
Fig. 10 Tackers fixing the

mesh to Pre sacral fascia
(Image Courtesy – Dr
Deborshi Sharma)
a b
Fig. 11 (a & b) Mesh edges sutured to peri-rectal tissue bilaterally (Image Courtesy—Dr
Deborshi Sharma)
Fig. 12 Suturing the

edges of peritoneum over
rectum to lateral
endopelvic fascia. Mesh
seen posterior to rectum is
kept away from small
intestines. (Image
Courtesy—Dr Deborshi
Sharma)
In Ripstein procedure (Anterior Sling rectopexy) after complete mobilization the

mesh is placed around the anterior rectal wall and secured with sutures to the prom-
ontory [62] while in the Well’s procedure (Posterior partial mesh rectopexy) mesh
is inserted between the sacrum and posterior rectum and fixed both to rectum and
promontory [63, 64]. Present day mesh rectopexy is fashioned after the variations /
modifications of the Well’s procedure where rectum is mobilized only posteriorly
just enough to allow safe midline suturing or tacking of a prosthetic material to the
pre-sacral fascia [65] and suturing the lateral edges of the mesh to the meso-rectum
(Figs. 9, 10, 11 and 12). The wrap is kept particularly loose avoiding obstructive
complications. Peritoneum is sutured closed after placement of the prosthetic.
In Orr-Loygue rectopexy the rectum is completely mobilized both anteriorly and
posteriorly and two mesh strips edges are sutured laterally to rectal wall and is
proximally fixed to the pre-sacral fascia at the promontory.
Disadvantages of laparoscopic rectopexy: High recurrence rates are seen in
patients operated without suture or mesh rectopexy while on contrary mesh related
complications are feasible if prosthetic is used. Aggravation of constipation is seen
with non-resectional procedures especially when both anterior and posterior mobi-
lization is done. Non-resectional procedures may be related to development of new-
onset constipation after prolapse correction.
Laparoscopic Ventral Rectopexy
Described originally in 2004, with dissection limited only to the anterior aspect of
rectum, preserving the lateral ligaments while the rectovaginal septum is dissected
up to the pelvic floor. The procedure preserves the hypogastric and parasympathetic
nerves while it obviates mobilization of mesorectum.
Indications: External rectal prolapse (age should not preclude selection), high
grade internal rectal prolapsed with significant symptoms of obstruction-defecation
or fecal incontinence that have failed conservative measures or is associated with
complex rectocoele or enterocoele.
Procedure: The patient should be placed in the dorsal lithotomy position.

Laparoscopic trocars should be placed as for laparoscopic posterior rectopexy. The
upper rectum is retracted cranially anteriorly and to the left of the patient so that the
mesorectum is displayed. The peritoneum is incised superficially and opened just to
the right of the sacral promontory. The pneumoperitoneum creates some space
which is extended and is continued caudally along the plane of the right outer bor-
der of the mesorectum down to the right side of the ‘pouch of Douglas’ keeping
away from the right ureter. Dissecting at the peritoneal reflection or at the base level
of pouch of Douglas, the peritoneal incision is continued from right to left over the
ventral aspect of the rectum.
In females, the recto-vaginal septum is incised and dissection continued caudally
in this plane. Dissection is continued as inferiorly as possible, upto the level of leva-
tor plate and laterally to cardinal ligaments and pelvic side walls. A second incision
can be made at the most cranial level of the ‘pouch of Douglas’ in the midline and
the peritoneum and underlying fibro-adipose tissue is dissected of, entitling a
pouchetomy performed and tissue removed. In symptomatic anterior compartment
prolapse, the vesico-vaginal plane is incised and the bladder is carefully mobilized
from the anterior vaginal wall.
In male’s dissection is same as described above except that, it is the plane
between Denonvilliers fascia and seminal vesicles which is incised to allow dissec-
tion upto the pelvic floor. A purely anterior rectal dissection is basically undertaken
to create a wide pocket till the level of pelvic floor.
Mesh placement: Strip of mesh approximately 3 × 20 cm often in shape of ‘L’
is introduced and positioned as far distally as possible. The shorter segment of ‘L’ is
placed to cover across on the anterior side of the rectum while the longer limb
Fig. 13 Mesh placement

in Ventral rectopexy
Fig. 14 Sagittal section of abdomen & pelvis after laparoscopic ventral rectopexy
stretched up to the sacral promontory along the right lateral aspect of rectum. The
mesh is fixed on the promontory and is sutured to the anterior borders of the rectum
in two parallel rows of interrupted non-absorbable material. The mesh is ultimately
placed obliquely angled from the midline distally to the right sacral promontory to
which it is secured. The vaginal vault (or cervix) can be fixed to the mesh without
tension by two additional sutures [66] (Fig. 13).
The mesh is covered by suturing the edges of peritoneum which obliterates the
potential space. In female, bites can be taken through different layers including the
posterior vaginal wall, peritoneum, mesh and anterior rectal wall. This reconstitutes
the recto-vaginal septum as a posterior colporrhaphy is performed and a shallow
neo-pouch of Douglas is forms. This continues caudo-cranially until at the site of
first incision over the promontory where the peritoneum is closed (Fig. 14).
Advantages: Morbidity is less along with reduced length of stay after laparoscopy
even in the elderly [67]. Ventral mobilization prevents bleeding from pre-sacral
venous plexus and long term constipation by retaining the autonomic nerve supply
to the rectum [68]. Re-inforcement of rectovaginal septum and treatment of genital
prolapse, rectocoele and enterocoele, as posterior colporrhaphy and vaginal sacro-
colpopexy may be performed at the same time [69]. Notable is the advantage of
performing anterior colporrhaphy along with vaginal sacro-colpopexy with another
mesh, placed on top of first. No mortality has been reported with this procedure and
recurrence ranges from 0 to 8%. Overall improvement of constipation is also seen
which can be due to preservation of autonomic nerves and prevention of recto-anal
intussusception.
Disadvantages: Mesh related complications are a possibility which includes risk

of pain, dyspareunia, infection, fistulization, stricturing, mesh erosion, sacral disci-
tis and technical failure due to placement of foreign material [70]. It has a protracted
learning curve and is a technically demanding procedure with lack of high-quality

evidence proving long term efficacy.
Mesh selection: The mesh used can be either biological or synthetic. The overall
consensus on ventral rectopexy is to use of titanium coated lightweight polypropyl-
ene mesh. Standard polypropylene or polyglecaprone meshes may stretch and can
result in recurrence. Polyester meshes are associated with increased risk of
complication.
Robotic Rectal Prolapse Surgery
Robotic rectal surgery has all the advantages related to access in deep pelvic
surgery.
Advantages Improved visualization deep in the pelvis, suturing capability and

ease of dissection and mesh placement are some of the advantages. Mesh suturing
to the perineal body, anterior rectum and lateral rectal attachments is technically
easier robotically [71] along with decreased blood loss and hospital stay.
Recurrence rates and conversion rates are comparable to that of laparoscopic

surgery [72]. Other general advantages of robotic surgery like 3-D visualization,
tremor filtering, motion scaling, enhanced dexterity and superior precision are seen
with robotic surgery.
Disadvantages: Higher costs involved with a longer operative time.
Controversies in Rectal Prolapse
Pre-operative Anal Physiologic Testing
Patients with rectal procidentia have specific abnormalities, detectable through

physiologic studies, which may aid early diagnosis. Studies of patients with rectal
prolapse have shown impaired sphincter function manifested by reduced resting and
voluntary anal pressures as also reduced rectal capacities [20].
Patients with rectal prolapse may present with either constipation or inconti-
nence. Transit studies may help in determining pre-operative constipation in patients
with rectal procidentia, which may influence the choice of operation [16]. Rectal
prolapse correction should be the first step in patients reporting rectal prolapse and
fecal incontinence. The extent to which routine anal physiologic testing guides the
operative decision in rectal prolapse patients, is contested.
Patients with severe constipation and/or pelvic dys-synergia or pre-existing fecal
incontinence, thought to be due to a process other than prolapse, should be assessed
with anal physiologic testing [32].
bdominal or Perineal Approach to Correction

A
of Prolapsed Rectum
Abdominal approaches used in correction of rectal prolapse are usually associated

with better functional and/or surgical outcomes [73]. However, recently this has
been called into question. Cochrane database reviews in 2000, 2008 and 2015 have
been unable to demonstrate significant differences in recurrence rates between both
the approaches [74].
The previously accepted recommendation of perineal procedures for elderly, sur-
gically unfit patients and abdominal procedures for young, healthy individuals, have
been recently debated [75, 76]. Perineal procedures can have a high mortality as
reported in a study of 1469 patients particularly in high ASA grades.
Laparoscopic surgery has been shown to be safe in elderly and is associated with
decreased ileus, decreased would infection and decreased length of stay with accept-
able morbidity [40]. Robotic abdominal prolapse surgery is safe for people above 75
years [43]. The traditional belief that perineal procedures have high recurrence rates
and those perineal procedures can only be performed on frail patients has been
questioned [77, 78]. The optimal operation for rectal prolapse still remains unclear
[79, 80].
Posterior Rectopexy or Ventral Rectopexy
Today we don’t have enough evidence to suggest or argue for posterior rectal pro-
lapse repairs in comparison to anterior rectal prolapse repairs. Retrospective com-
parison of two single center studies performed in 70 and 40 cases comparing ventral
rectopexy and posterior rectopexy have demonstrated similar recurrence rates [81].
Retrospective analyses of laparoscopic resection rectopexy (LRR) with laparo-
scopic ventral rectopexy (LVR) have shown varied results [82, 83]. Constipation
and incontinence were reduced in both cohorts but more complications were seen
after LRR than LVR [84]. Rigorous clinical trials comparing posterior and ventral
rectopexy are at present absent [85, 86].
Current Scenario
Robotic vs Laparoscopic Rectopexy Robotic procedures offer several advantages

over laparoscopic surgery. Robotic surgery has helped in overcoming numerous
limitations of conventional laparoscopy such as difficulties associated with rigid
instruments, limited freedom of wrist movement and other technical challenges
associated with operating in the deep confines of the pelvis. Disadvantages of
robotic surgery include the loss of tactile feedback, the limited range of motion of
the robotic arms, increased operative time, and higher equipment costs.
Systematic review and meta-analysis comparing the outcomes of robotic recto-

pexy (RR) versus laparoscopic rectopexy (LR) reveal similar recurrence, conver-
sion and re-operation rates. Most studies show that operative time is significantly
longer for RR but RR is associated with significantly lower blood loss, fewer post-
operative complications and has a shorter hospital course [43].
As far as cost is concerned, robotic surgery lags behind laparoscopic surgery
bearing high costs. The experience of surgical team and the learning also has a bear-
ing on the results of robotic colorectal surgeries, as they influence the operative time
and outcomes.
Ventral rectopexy might be particularly suited for robotic surgery. Robotic recto-
pexy has clear advantage in visualization of the deep pelvis and ease of suturing and
dissection along with placement if mesh in the rectovaginal septum [43, 87].
Although modern surgery is progressing towards robotic operations, the debate as
to which of two- robotic rectopexy (RR) or laparoscopic rectopexy (LR) is better,
continues.
Conclusion
Rectal prolapse might be associated with a spectrum of other diseases. Constipation

and incontinence are two pre-operative symptoms which can direct the procedure
which needs to be done. Minimal access surgery is safe in rectal prolapse in all ages
including the elderly with significant advantages in morbidity.
Key Clinical Points

1. Rectal prolapse may be associated with a spectrum of anatomic abnormalities,
including diastasis of levator ani, very deep cul-de-sac, redundant sigmoid
colon, patulous anal sphincter and loss of rectal sacral attachments.
2. Severe constipation co-existing with rectal prolapse require special consider-
ation in line with the ASCRS constipation clinical practice guidelines, as few
will not be ideal candidates for surgery as certain surgical procedures can
aggravate constipation.
3. Prolapse not clearly evident clinically should undergo fluoroscopic defecogra-
phy, MRI defecography or balloon expulsion testing for diagnosis. Defecography
may also detect associated anterior pelvic floor support defects such as cysto-
cele, vaginal vault prolapses and enterocoele.
4. The extent to which routine anal physiologic testing guides the operative deci-
sion in rectal prolapse patients, is controversial.
5. Resection rectopexy reduce constipation in those who report pre-operatively
and prevents new onset of constipation.
6. Laparoscopic suture rectopexy is simplest laparoscopic procedure to be done in
modern times.
7. Ventral mobilization in ventral rectopexy prevents bleeding from pre-sacral
venous plexus and long-term constipation by retaining the autonomic nerve
supply to the rectum.
8. Insufficient data presently exists to definitely argue between posterior and ante-
rior rectal prolapse repairs.
9. Robotic rectal prolapse surgery improves visualization in the deep pelvis and
suturing capability with ease of dissection and mesh placement.
10. Robotic rectal prolapse surgery is associated with significantly lower blood
loss, fewer postoperative complications, and a shorter hospital course.
Editor’s Note1
Rectal prolapse is highly associated with multiparity but 1/3rd are nulliparous.
Etiology is often undetermined. F:M = 10:1 and peak in 7th decade [1].
Surgery is the definitive treatment and its goals can be achieved with fixation of
the rectum to sacrum and/or resesction or plication of the redundant bowel.
Laparoscopic procedures include [2,3]:
(a) laparoscopic resectional rectopexy aka Frykmann-Goldberg procedure

(b) laparoscopic non-resectional rectopexy
I. Rectal mobilisation without rectopexy
II. Suture rectopexy
III. Mesh rectopexy - anterior(Ripstein), posterior (Well’s or LPMR), lateral
(Orr-Loygue) or placing mesh around.
Table EN 1: Comparison [1,2,3]

Laparoscopy/Robotic Perineal
Recurrence rate 2–5% 16–20%
Pelvic or perineal sepsis 2% 7%
Mortality 0.5% 0.7%
Complication Overall 12% 14%
Improvement in fecal incontinence 71% 63%
Improvement in constipation 50–60% 50–60%
NOTES and Other Endoscopic Approaches
NOTES-TEM Approach
Trans anal endoscopic microsurgery procedures (TEM) have also been investigated
as a modality to treat internal rectal prolapse termed as EndoRectal ProctoPexy
(ERPP), better known as “internal Delorme” [4,5].
It involves
a. Mucosal resection,
b. Plication of the muscle layer and
c. Resuturing of the mucosal defect under endoscopic guidance.
1
NOTES Endoscopic Rectopexy
Endoscopic assisted percutaneous rectopexy has been earlier reported in animal

models [6]. Recent report of a preliminary study on PAER procedure (Per Anal
Endoscopic Rectopexy) with anterior fixation to anterior abdominal wall and poste-
rior fixation to sacrum has been reported in 12 patients [7] (Fig. EN1).
NOTES Combined with TAMIS
A combination procedure of perineal rectsigmoidectomy and rectopexy proposed

for rectal procidentia using NOTES procedure and TAMIS platform has been
described.
The essential components of it are [8]:
a. Sacral fixation of the (Neo) rectum

b. Repair of the pelvic floor musculature
c. Resection of the ectatic rectosigmoid bowel
Fig. EN1 Schematic diagram of endoscopic rectopexy

1. Tsunoda A. Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A

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Laparoscopic Lymphadenectomy
for Colorectal Cancers: Concepts
and Current Results
Saumitra Rawat, Chelliah Selvasekar, and Saurabh Bansal
Introduction
The mainstay management for colon cancer remains surgery. The pathological find-
ings in the specimen are the most important predictor of further treatment and sur-
vival. Cancer staging depends upon the assessment of primary tumor [T], lymph
node metastasis [N], and distant metastasis [M] and these variables are most impor-
tant for pathologists and treating clinicians.
Nodal metastasis plays a crucial role in determining prognosis, management, and
survival of colorectal cancer patients and consists of an important parameter in con-
temporary prognostic staging systems particularly the widely used tumor node
metastasis [TNM] system proposed by the UICC/AJCC. The 5-year survival rates
range between 70% and 80% in node negative disease, with the corresponding val-
ues in node positive disease being 30%–60%. Adjuvant chemotherapy improves the
survival in node positive disease. Occult lymph node disease is present in 20%–30%
S. Rawat (*)
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram
Hospital, New Delhi, India
Royal College of Surgeons of England, London, UK
C. Selvasekar
Divisional Medical Director Clinical Services and Specialist Surgery, Christie NHS
Foundation Hospital, Manchester, UK
Vice Chair of Specialty Surgical Board in General Surgery, Royal College of Surgeons of
Edinburgh, Edinburgh, UK
S. Bansal
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram
https://doi.org/10.1007/978-981-16-5473-2_7
156 S. Rawat et al.
cases which is apparently present in completely excised disease [1, 2]. Adjuvant
chemotherapy is beneficial in such a subset of cases when identified. Some of the
other prognostic variables over and above TNM which might affect disease spread,
recurrence and eventually benefit from adjuvant chemotherapy in colorectal cancers
are: (a) venous invasion, (b) perineural invasion, (c) tumour perforation, (d) serosal
involvement and (e) incomplete resection [1, 2]. Incomplete resection particularly
refers to both primary tumor and nodal resection. Therefore, to obtain an accurate
staging a conscientiousness effort is required both by surgeons and patholo-
gists alike.
This chapter further discusses the nodal staging and the concept of adequate
lymphadenectomy in right and left sided colonic tumours and rectum with an
emphasis on the techniques of adequate lymphadenectomy.
Nodal Staging
American Joint Committee on Cancer [AJCC] 6th edition suggested a range of

7–14 LNs that should be obtained. The corresponding 7th and 8th editions in their
respective sections stated that it is important to obtain and examine at least 12 LNs
[3–7]. Even if less than the suggested number of LNs is identified, actual N stage
rather than Nx should be provided. The factors which highly impact LN recov-
ery include
I. Patient age
II. Gender and body habitus
III. Immune response to neo adjuvant treatment
IV. Tumor site and size
V. Length of colon resected
VI. Experience of surgeon
VII. Diligence and experience of a pathologist.
CAP [College of American pathologists] malignancy convention proposes that if

less than 12 LNs are found, the specimen should be reconsidered for examination
methods using lymph node enhancement techniques. In contrast to the sixth ver-
sion, the seventh release further partitions N1 into N1a, N1b, and N1c; and N2 into
N2a and N2b. N1c is a recently presented class in the seventh release, which is
characterized by Tumour deposits (TD’s) in subserosa, mesentery, or nonperito-
nealized pericolic or perirectal/mesorectal tissue with no local nodal metastasis.
The eighth version does not have critical changes in N staging definitions in contrast
to the seventh version. The master board endeavored to explain a few issues that
have stayed testing in past versions, like TDs and micrometastasis.
Laparoscopic Lymphadenectomy for Colorectal Cancers: Concepts and Current Results 157
Techniques of Colorectal Lymphadenectomy
Current Concepts
As mentioned, adequate lymphadenectomy remains the most important prognostic

determinant for overall and disease-free survival. In the last three decades, the con-
cept of lymphadenectomy in colorectal cancers has been revolutionized. The con-
cept came more into practice with evolving minimal access surgery and centres
across the world performing laparoscopic and robotic surgery. After two decades of
the utilization of laparoscopic approach for colorectal surgeries, many randomized
trials and systemic reviews have shown that the laparoscopic approach for colon
malignancy is related with quicker recovery and less morbidity in contrast with the
standard open methodology without influencing oncologic results [8–15].
omplete Mesocolic Excision [CME] and Central Vascular Ligation

C
[CVL] with D3 Lymphadenectomy for Right Sided Colonic Cancers
Western Concept of Right Sided Colonic Cancers Lymphadenectomy Hohen-

berger et al. promulgated the idea of complete mesocolic excision as the standard
operative procedure for colonic malignancy with an emphasis that CME with CVL
decreases local recurrence and improves survival rates particularly in stage III can-
cers [16]. Subsequent literature from different parts of the world likewise showed
comparable critical decrease in local recurrences and improvement of oncological
radicality [17–19].
The concept of complete mesocolic excision (CME) with central vascular liga-
tion (CVL), paralleling the concept of total mesorectal excision (TME) described by
Professor RJ Heald [20], entails dissection of entire mesocolon in the embryonic
planes of fusion. In the intaruterine period, the colon along with its vascular supply
and lymphatics is suspended in a dorsal mesentery, which subsequently fuses with
the retroperitoneum in the region of caecum, ascending and descending colon. Thus,
an avascular plane exists between the mesocolon and the retroperitoneum (Fig. 1).
It is important to note that the peritoneal bilayer covering the mesocolon envelopes
the entire colon and is not merely limited to the pelvis. The aim of CME with CVL
technique is to separate these two planes and excise the tumour along with the
colon, the mesocolon with its accompanying lymphatic and vascular supply in total-
ity, ensuring an intact visceral fascial layer is maintained. It can be achieved by
sharp dissection between the visceral and the parietal peritoneal layers. Appropriate
knowledge of anatomy of the mesocolon as well as adequate surgical expertise is
desirable for the purpose.
158 S. Rawat et al.
Ascending colon
Small
Bowel
Superior
Mesenteric
Anterior aspect artery
Caecum of mesocolon
Small
Posterior
Bowel
aspect
Mesentry Duodenum
of mesocolon
Toldt’s fascia
Right gonadal vessels Right ureter
Retroperitoneum Posterior Ileocolic

aspect Vessel
of mesocolon
Fig. 1 Schematic representation of right colon with its mesocolic anatomy
Fig. 2 Schematic diagram showing blood supply of right and left colon
The essence of CME-CVL or D3 lymphadenectomy is the ligation of the ileoco-

lic vein, right colic vein, Henle trunk, and middle colic vein at their point of drain-
age into the superior mesenteric vein (SMV). Corresponding with venous ligation,
the ileocolic artery, right colic artery, and middle colic artery are divided from their
origin on the superior mesenteric artery (SMA) (Fig. 2). CME-CVL is a technically
demanding procedure due to the complex anatomy of the region and explicit knowl-
edge of vascular anatomy (SMV and SMA) is vital to avoid iatrogenic complica-
tions. As regards oncological adequacy, this procedure is almost equivalent to
eastern concept of Japanese D3 lymphadenectomy.
Eastern Concept of Right Sided Colonic Cancers Lymphadenectomy The

Japanese Society for Cancer of the Colon and Rectum (JSCCR) classification
groups the nodes associated with lymphatic drainage of colon into three groups.
• The main lymph nodes are situated at the source of the main feeding artery.
• Intermediate lymph nodes lie between the initial and terminal branch of the
main artery
• Pericolic lymph nodes are stationed between the terminal branch of the main
feeding artery and the colonic wall [21, 22].
In D2 lymphadenectomy the pericolic and intermediate groups lymph nodes are

removed. D3 lymphadenectomy entails dissection of the main lymph nodes in addi-
tion to D2 lymphadenectomy. Thus, the western concept of CME-CVL is essen-
tially comparable to definition of D3 lymphadenectomy by the JSCCR. However, in
D3 dissection duodenal kocherization, and removal of the gastroepiploic and infra-
pyloric lymph nodes is not mentioned which has been described as a component of
CME with CVL [21, 22].
The JSCCR guidelines recommend D3 lymphadenectomy for advanced T cate-
gories (T3/4) or node positive (N+) disease and D2 lymphadenectomy for early
node negative cancers (T1N0). Whereas performance of either a D3 or D2 lymph-
adenectomy is suggested for T2N0 disease. Therefore, D3 lymphadenectomy is
essentially recommended for stage II or III colon cancer in tertiary care centers.
Total Mesorectal Excision [TME]
The notion of total mesorectal excision [TME] for rectal cancer has been the most
revolutionary concept that has evolved during the last three decades. Multiple stud-
ies noted a decrease in local recurrence to the tune of 6%–12%, and a 53%–87%
improvement in 5-year survival after incorporation of TME [23–25].
In TME the rectum, along with its surrounding mesorectum comprising of lym-
phovascular fatty tissue (the first area of drainage of tumour cells), is excised using
precise, sharp dissection in an avascular potential space between the visceral meso-
rectal fascia and parietal endopelvic fascia the so called “Holy plane” a term intro-
duced by Heald [26]. TME minimizes the chances of leaving behind residual tumor
and preserves nerve fibres which supply the urinary bladder, prostate, and vagina
(Fig. 3).
The essence of the TME hypothesis is that lymph nodes randomly distributed
within the mesorectum, which are not visible or palpable, are completely removed.
The size of the normal lymph nodes in mesorectum in about 80% of cases is <3 mm.
160 S. Rawat et al.
Fig. 3 Schematic diagram showing the “Holy plane of Heald”
Most lymph nodes in the mesorectum are located posteriorly, and 90% of the poste-
rior lymph nodes lie within the upper half of the upper 2/3 of the rectum [27].
Rectal cancers very rarely spread in a downward direction intramurally, but the
lymphatic spread in the mesorectum i.e. extramural spread, appears to be bidirec-
tional (both in distal and proximal directions), within the limits of fascia of meso-
rectum, emphasizing the need for a complete mesorectal excision. Whereas TME is
a beneficial procedure to extirpate lymphatic spread in high rectal carcinomas
located >5 cm above the dentate line, the same is not noted in lower rectal neo-
plasms [less than 5 cm from the dentate line] wherein around 15–20% cases there is
lateral nodal involvement which lies outside the confines of TME. A lateral node
dissection as described below may prove beneficial in such patients.
Lateral Lymph Node Dissection [LLND]
The lymphatic drainage from the rectum below the peritoneal reflection follows two
major pathways [Fig. 4]:
1. The superior rectal artery, inferior mesenteric artery, para-aortic corridor

2. Middle and inferior rectal artery, obturator, internal iliac and external iliac cor-
ridor (the lateral nodal group).
Total Mesorectal Excision [TME] involves removal of the first pathway of lymph
nodes [28]. Management of the lymph node stations in the second route of drainage
(the lateral nodes) has been a topic of interest lately [29]. It needs to be emphasized
that the internal iliac group of nodes is classified as regional disease (Stage III)
whereas the external and common iliac nodes are grouped as metastatic disease
5
4
6
Nodes along the common iliac vessels
7 Internal iliac nodes
External iliac nodes
8 9
Obturator nodes
Nodes along the inferior mesenteric artery
Peri rectal nodes
Lateral Pelvic Lymph nodes
Fig. 4 Schematic diagram showing the Lateral pelvic lymph nodes. In the diagram marked ves-
sels are 1. Inferior mesenteric artery, 2. Superior rectal artery, 3. Common Iliac artery, 4. External
Iliac artery, 5. Internal Iliac artery, 6. Obturator artery, 7. Middle rectal artery, 8. Internal pudendal
artery, 9. Inferior rectal artery. (Radjindrin A (2018) Does Lateral Pelvic Lymph node matters in
rectal cancer Glob Surg, 2018 doi: https://doi.org/10.15761/GOS.1000196)
Table 1 Differences in the understanding and management of LLNs between the East and
the West
Western concept Japanese concept
Regional Internal iliac nodes Internal, external and common iliac and
nodes obturator nodes
Metastatic Common iliac, external iliac and Not Applicable
nodes obturator nodes
Management nCRT with RT boost to involved LLN dissection
nodes
Radjindrin A (2018) Does Lateral Pelvic Lymph node matters in rectal cancer Glob Surg, 2018 doi:
https://doi.org/10.15761/GOS.1000196)
(Stage IV) in the TNM classification. Despite the classification radiation oncolo-
gists often treat external and common iliac nodes in rectal cancer with curative
intent in concordance with treatment of regional nodes [Table 1] [30]. The lateral
lymph nodes can be treated with either a radiotherapy boost or surgically by lateral
lymph node dissection [30]. The Japanese guidelines for colorectal cancer [2016]
recommends LLND for all rectal tumours situated caudal to the peritoneal reflection
[31]. According to the JSCCR, LLND decreases intrapelvic recurrence by 50% and
162 S. Rawat et al.
offers a survival advantage of 8–9% [31]. A randomized controlled trial noted no

increase in urinary dysfunction consequent to LLND though a tumor location below
peritoneal reflection was proposed as a risk factor for the complication [32]. A mul-
ticentre non inferiority trial from Japan, JCOG2012, could not conclude a non-
inferiority of TME alone over TME + LLND, however observed that the incidence
of urinary and male sexual dysfunction was not significantly higher in the LLND
group.[33] Nevertheless an increased morbidity has been observed following the
procedure [32–34]. Mesorectal nodal metastasis has been proposed to be another
important determinant of lateral lymph node metastasis [35].
Minimally Invasive LLND
In a study assessing feasibility of lateral pelvic lymph node dissection, when com-
pared with the open approach the laparoscopic approach was considered safe,
incurred a less blood loss, had lower hospital stay and had higher mean number of
harvested nodes [35]. An autonomic nerve preserving approach for laparoscopic
LLND based on vesical-hypogastric fascia and uretero-hypogastric nerve fascia has
been proposed [36]. Robotic LLND has similar short-term outcomes and lymph
node harvest, offering advantages in male narrow pelvis where manipulation of
instruments becomes difficult in laparoscopic approach [37, 38].
Sentinel Lymph Node [SLN] Resection
The concept of sentinel lymph node biopsy [SLNB], which has significantly
impacted the treatment of melanoma and breast cancer, is being investigated in
colorectal cancers to enhance nodal staging accuracy especially in T1 disease. The
sentinel lymph node is considered the lymph node[s] located the closest in the lym-
phatic mapping area. Despite a potential curative resection, 20–30% of node nega-
tive colorectal cancers develop distant metastasis presumably due to occult
undetected nodal disease [39]. It has been noted that small <5 mm nodal deposits
carry similar survival prognostication as >5 mm deposits emphasizing the impor-
tance of thorough examination of nodes [40]. Though yet controversial, micrometa-
static deposits <2 mm may also benefit from postoperative adjuvant therapy.
Identifying patients who have tumor-negative nodes but are at high risk of
regional or distant node metastasis who might benefit from adjuvant chemotherapy
is challenging. The current histopathological evaluation of lymph nodes with stan-
dard Hematoxylin–Eosin [HE] pathological techniques is inadequate as large
regions of the lymph nodes remains unexamined, with the subsequent risk of unde-
tected residual micrometastases. Therefore, SLN mapping in colon cancer can help
identify nodes that carry the higher risk of metastasis and such nodes can be sub-
jected to detailed pathologic scrutiny, including more sections, immunohistochem-
istry and molecular diagnostic techniques thereby enhancing the staging accuracy.
Modification in Techniques of Sentinel Lymph Node Mapping
In Vivo Versus Ex Vivo Technique

The mapping can be performed in vivo or ex vivo using various substances: blue
dyes, fluorescent dyes or radioactive tracers. Blue dye is the most commonly used
dye both for in vivo and ex vivo techniques. The ex vivo technique can be also used
in case the in vivo technique fails and has been noted to upstage the tumor in upto
12%. The results of the two techniques of mapping is reported to be similar. One
advantage of the ex vivo technique is that the patient is spared from adverse reac-
tions related to the dye but carries limitations due to the surgical disruption of the
native lymphatic channels [41]. In vivo analysis involves injecting 1–2 mL of blue
dye into the subserosa, around the tumor. The first blue-colored lymph node is
removed after 5–10 min and sent separately to the pathologist. In ex vivo mapping,
about 30 min after resection and before formalin fixation, 0.5–2 mL of blue dye is
injected subserosally or circumferentially around the tumor (depends on the loca-
tion of tumor i.e. above or below peritoneal reflection) and sites are massaged for
five minutes to push the tracer into the lymphatic vessels. The first blue stained
lymph node[s] is defined as the SLN [41]. Factors which influence the In vivo tech-
nique are: gender, age, BMI, tumor size, tumor location, previous abdominal sur-
gery, nodal status, grade of tumour, tracer used, technique and preoperative
chemoradiation [42].
Fluorescent Dye Technique Recently fluorescence navigation with Indocyanine

Green [ICG] has gained popularity for in vivo visualization of SLN. A near infra-red
imaging camera system is used in laparoscopic surgeries. The tracer can be injected
subserosally or submucosally around the tumor. Advantages of the technique is that
it offers real time visualization of lymph nodal compartments and aids detection of
aberrant lymphatic drainage. In a study evaluating this method, 96% identification
rate was noted. The main deterrent of this procedure is the high cost [43].
Immunohistochemistry and Molecular Methods for Detection of Metastasis in

Lymph Nodes Use of immunohistochemistry and molecular diagnostic methods
has been proposed for more accurate detection of micro metastasis in sentinel nodes.
Immunohistochemical examination is more sensitive than Hematoxylin–Eosin [HE]
whereas and molecular diagnostics (RTPCR/ one step nucleic acid amplification
test) is more specific, and more accurate than immunohistochemistry [IHC] in
detecting micrometastasis and isolated tumor cells [ITC]. The one step nucleic acid
amplification test also decreases time to adjuvant chemotherapy. Ultra-staging with
RT PCR demonstrated that node negative colon cancer patients who had recurrence
had positive SLN [42]. Focused examination of sentinel node using CK-IHC and
RT-PCR can identify micrometastases in 53% of patients whose SNs were labelled
as negative by conventional histopathological techniques [44]. Among all the tech-
niques used for the identification of the lymph nodes, the molecular one is the most
expensive, but appears to provide the most accurate up staging [44].
164 S. Rawat et al.
Laparoscopic Right Colonic Resections with CVL
Though there are numerous laparoscopic techniques described in literature. The

common approaches described are:
• Medial to lateral approach,

• Lateral to medial approach
• Caudo-cranial approach
We prefer the caudo-cranial approach [also called the initial retrocolic endo-
scopic approach IRETA APPROACH]. All procedures are done in the modified
lithotomy position under general anaesthesia, and table position modified in accor-
dance with the area to be mobilized.
Placement of Trocars Pneumoperitoneum is established with open or closed tech-

nique. A diagnostic laparoscopy is initially performed through a 10 mm/12 mm
umbilical port. Subsequently the camera port is shifted to suprapubic region to facil-
itate viewing of the retroperitoneal tunnel that will be created. Two other ports, a
5 mm working port is placed in the region of right iliac fossa and another 5 mm port
placed in the left subcostal region to retract small bowel and colon (Fig. 5). Later,
the camera port can be transferred to the umbilicus for enabling better visualization
during superior dissection along hepatic flexure and transverse colon. The proce-
dure is performed in head down, right up position.

right hemicolectomy
Mobilization of the Retro Colic Colon and Complete Mesocolic Excision

[CME] In the initial retrocolic tunnel approach (IRETA), dissection begins with
incision on the inferior border of terminal ileal mesentery (ileocolic fold) and is
continued upwards laterally to behind the caecum and cranially and anteriorly in the
avascular plane which separates the right ureter, right gonadal vessels and IVC pos-
teriorly from the small bowel mesentery and retroperitonealized right mesocolon
anteriorly (Fig. 1). It is important not to dissect free the lateral attachments of the
colon at this stage to maintain retraction and keep open the retroperitoneal tunnel by
preventing the colon from falling into the operative field. A retroperitoneal tunnel is
thus created between two layers of embryologic fusion. Superiorly the dissection
continues anterior to Gerota’s fascia laterally, and the duodenum and pancreas cra-
nially (Fig. 6).
Central Vascular Ligation (Figs. 7 and 8) Tenting the ileocolic mesentery by
lifting it up is a useful technique that helps in identifying the ileocolic vessels which
are dissected and traced to their origin from the superior mesenteric vessels and
clipped. The right colic artery is thereafter addressed. It needs to be noted that it is
inconsistently present. Further attention is directed to the middle colic vessels that
can be identified traversing the transverse mesocolon vertically up when the trans-
verse colon is lifted towards the abdominal wall. There are variations in drainage of
Fig. 6 Showing the right

retro colic dissection
creating the tunnel. The
image also shows
Duodenum (Yellow
Arrow), Right pericolic
tissue (Green arrow) and
Gerota’s fascia (Red
arrow)
Fig. 7 D3 Right
hemicolectomy dissection
166 S. Rawat et al.
Fig. 8 Right
Hemicolectomy D3
Dissection at completion
right colic and middle colic veins which may be encountered in the process. In
conventional right hemicolectomy only the right branch of middle colic artery is
ligated at its origin.
Mobilization of Transverse Colon and Hepatic Flexure After completion of

CVL the following sequence of steps is adopted (1) lesser sac entry by dividing
gastrocolic ligament along with omentectomy (2) dissection of hepatocolic liga-
ment and mobilization of hepatic flexure of colon (3) The attachments of the meso-
clon dissected from anterior surface of duodenum and pancreas (4) The ascending
colon dissected from its lateral attachments to abdominal wall and
retroperitoneum.
Resection of Specimen and Anastomosis If an extracorporeal anastomosis is

planned the bowel is delivered through a plastic sheath, by extending the umbilical
port and resection as well as anastomosis (handsewn/stapled) is performed outside
(Fig. 9). In a totally laparoscopic approach, the transection of the colon and anasto-
mosis is performed intracorporeally using Endo GIA stapler, conversion of the
10 mm port to 12 mm is needed for the purpose or initially a 12 mm umbilical port
may be inserted (Fig. 10). Side to side ileo- transverse anastomosis is preferred
anastomosis.
Advantages of Initial Retro Colic Approach
• There is minimal initial handling of colon thereby decreasing chances of tumor

dissemination and bowel injury
• Easy creation of retroperitoneal tunnel and excellent retroperitoneal view
• The lateral attachments of the colon are dissected last thereby eliminating need
for retraction of colon and preventing colon from falling into the operative field,
particularly useful for bulky disease
• Easy early access to vascular pedicles near the origin
Fig. 9 Extra corporeal

stappled anastomosis
Fig. 10 Intracorporeal
stappled ileocolic
side-to-side anastomosis
aparoscopic Left Sided Colonic Resections with Total

L
Mesorectal Excision [TME]
The approaches frequently described in literature for the left colon are:
• Medial to lateral approach

• Lateral to medial approach
All procedures are done in the modified lithotomy position under general
anaesthesia.
Placement of Trocars The surgeon and the camera assistant are stationed to the
right of the patient. A 10mm camera port is inserted at the umbilicus. The procedure
is performed with 4 or 5 ports: two 5-mm ports are introduced on either side and
168 S. Rawat et al.
Fig. 11 Port positions for

left sided colonic
resections
another 12-mm port (for stapler) is placed at 2 cm above and medial to the right
anterior superior iliac spine, additional 5-mm port can be inserted for bowel retrac-
tion (Fig. 11). At the commencement of operation, a diagnostic laparoscopy is per-
formed to assess for metastatic disease. The procedure is performed with patient
placed in Trendelenburg position and the table tilted to left up.
Pedicle Ligation: (Fig. 12) The omentum is displaced superiorly over the liver. A
useful manoevure commonly practised for retraction of the uterus anteriorly is
slinging the uterus using a percutaneous suture loop passed directly and tied above
the skin over a piece of gauze. Retraction of the sigmoid colon to the left and ante-
riorly helps in identification of the sigmoid vessels and inferior mesenteric artery.
The peritoneum is incised caudal and to the right of the vascular trunk, at the
level of sacral promontory and further dissection proceeds cranially to the origin of
the vascular trunk (Fig. 13). Care should be taken to make the tunnel anterior to the
ureter and hypogastric nerve plexuses which lie in close proximity. The superior
rectal artery is lifted cranially and all vessels are skeletonized, and ligated sepa-
rately using endoscopic clips (Fig. 14). In high ligation the inferior mesenteric
artery is ligated at its origin whereas in low ligation, inferior mesenteric artery is
ligated distal to its left colic branch (Fig. 12).
Fig. 12 Blood supply of left colon with site of doing high or low ligation of inferior mesen-
teric artery
Fig. 13 Medial to lateral

dissection from right side
(Red arrow—Pelvis
direction) showing the
tented inferior mesenteric
artery with its base (Yellow
arrow)
Total Mesorectal Excision and Rectal Mobilization The dissection for TME is
initially done posteriorly and laterally then subsequently anteriorly. The lateral peri-
toneal attachments of the rectum are incised down to the level of peritoneal reflec-
tion. The sigmoid colon is retracted ventrally to open the retrorectal space and
170 S. Rawat et al.
Fig. 14 Superior rectal

artery being dissected and
ligated. Iliac vessel is seen
to its right
Fig. 15 Dissection
showing the pelvic
parasympathetic nerves*
laterally
dissection is carried out in the avascular presacral plane between the parietal and
visceral pelvic fascia. The hypogastric autonomic nerves which lie posteriorly,
comes close to the mesorectum inferiorly and supply branches to the rectum where
they should be carefully dissected by sparing the pelvic branches. Vessels entering
the rectum can be addressed with harmonic or vessel sealing devices. Caudally the
dissection is continued to the rectosacral fascia following which the rectum curves
anteriorly to the pelvic floor (Fig. 15)
Anteriorly the peritoneum is incised to the level of rectovesical or rectovaginal

pouch. Traction counter traction remains an integral part of TME. Usually, a gauze
piece can be tied around rectum to pull the rectum out of the pelvis and provide
traction and counter traction. Dissection proceeds anterior to the Denonvillier’s fas-
cia, posterior to the seminal vesicles in male patients and in the rectovaginal septum
in females.
Fig. 16 Colo-anal
anastomosis
Division of the Rectum
After ensuring complete circumferential mobilization to the pelvic floor, the meso-
rectum is dissected to the rectal wall and the rectum is divided at least 2 cm below
the lesion using endostaplers.
Mobilisation of the Left Colon, Splenic Flexure and Anastomosis Proceeding in

medio-lateral fashion the left and sigmoid mesocolon is dissected of the retroperito-
neum and then the lateral peritoneal attachments of the colon along the white line of
Toldt is released. Mobilization upto splenic flexure may be done if necessary to
obtain an adequate length for anastomosing the proximal sigmoid to the distal rec-
tum. Specimens are usually extracted through suprapubic incision and end to end
colorectal anastomosis is performed using circular staplers (Fig. 16).
Advantages of Laparoscopic TME/CME
Laparoscopic resections for colorectal cancer offers the advantage of the improved
visibility due to magnification and angled optics as also good illumination of the
operation field and can aid in better delineation and preservation of the pelvic auto-
nomic nerves.
Lateral Lymph Node Dissection
After completion of TME and rectal transection, the lateral pelvic nodes are
addressed. They are grouped into three regions:
• common iliac region: comprising of the common iliac & external iliac nodes,
• hypogastric region: internal iliac nodes
• obturator region: obturator nodes (Fig. 4).
172 S. Rawat et al.
Fig. 17 Completed lateral

pelvic dissection
The procedure begins by dissecting fibrofatty tissue around the aortic bifurcation
at the origin of the common iliac vessels. The common iliac and external iliac nodes
are dissected, thereafter, the hypogastric group is addressed by exposing the hypo-
gastric nerve, external and internal iliac vessels, and ureter which are laid bare on
the lateral pelvic wall up to the iliac bifurcation. The dissection proceeds to address
the lymphatic tissues between the urinary bladder and the pelvic wall which are
cleared. The lymphatic tissue along internal iliac vessels cleared upto the middle
hemorrhoidal vessels. The obturator fossa is cleared of lymphoareolar tissue to lay
bare the obturator nerve and vessels (Fig. 17).
Complications
Common concerns following complete mesocolic excision have been rates of
• Bleeding or vascular injury,

• Chyle leak,
• Anastomotic leakage,
• Duodenal or gastric perforations and
• Clavien Dindo grade 3 & 4 postoperative complications.
Bleeding/Vascular Injury
A recent metanalysis reported an increased risk of vascular injury with CME as

compared to conventional colonic resection [45]. A higher intraoperative blood loss
has also been noted in CME group as compared to non-CME [46]. Other metanaly-
sis did not observe a higher blood loss or vascular injury with CME [47, 48].
Contrarily laparoscopic CME has been attributed to have less blood loss than open
CME [19, 49].
Anastomotic Leak
Anastomotic leak rates are not found to be different following CME CVL as com-
pared to conventional hemicolectomy, though delayed gastric emptying has been
noted [50, 51, 52].
Chyle Leak
One of the chief concerns in extended lymphadenectomy is the possibility of chyle

leak. Chyle leak can lead to malnutrition, electrolyte imbalance and a theoretical
risk of malignant recurrences. A recent systematic review on chyle leak/chylous
ascites following colonic surgery for malignancies found it to be a rare complication
(5.5%). Most chyle leaks are discovered during the index admission and can be
managed conservatively (diet change, total parental nutrition, drainage, somatosta-
tin analogues) and reoperation is rarely needed [53]. Tumour location in right colon,
extended lymphadenectomy and number of lymph nodes retrieved are proposed as
independent associates for chyle leak after colonic resections [53, 54].
Severe Complications and Risk Factors for Complications
Some studies have reported a higher postoperative complication rate following

complete mesocolic excision [52]. The rates of Clavien-Dindo Grade 1 complica-
tions is reported to be to the tune of 40% whereas severe grade 4 complications
reported is 2.7% after laparoscopic right CME. The cited independent risk factors in
multivariate analysis being: age ≥ 65 years, body mass index (BMI) ≥ 28 kg/m(2)
[55]. In another study on risk factors for severe complications after radical colonic
surgery it was observed that anemia, elevated body mass index, and open surgery
were important predictors in multinomial logistic regression [56].
Conclusion
Lymph node metastasis is an important prognostic factor in colorectal malignan-

cies. The western concept of complete mesocolic excision with central vasculature
ligation is similar to D3 lymphadenectomy practised in the east for colonic cancers.
Total mesorectal excision is an established standard of care for operable rectal can-
cers. Laparoscopic mesocolic excision for colonic cancer and laparoscopic total
mesorectal excision for rectal cancers can be performed safely with few postopera-
tive complications and good oncological outcome. Lateral lymph node dissection is
an important addition to TME for rectal cancers and has been shown to influence
survival. Sentinel node biopsy with fluorescent imaging appears to be promising in
early node negative colonic malignancies.
174 S. Rawat et al.
Key Clinical Points

1. In colorectal cancer, lymph node metastasis is a key factor for deciding progno-
sis, management, and survival of the patients. Lymphadnectomy remains the
mainstay of surgical management for colorectal cancers to improve the progno-
sis and outcomes.
2. Laparoscopic CME with CVL is established western practice in management of
colonic cancers.
3. The aim of CME with CVL technique is to dissect the embryonic fusion planes
and excise in totality the tumour along with its lymphovascular contents
enclosed in the mesocolon as a single entity.
4. D2 lymphadenectomy entails removal of the pericolic lymph nodes and inter-
mediate lymph group of nodes, whereas D3 lymphadenectomy involve dissec-
tion of the main lymph nodes in addition to D2
5. Western CME-CVL is comparable to Eastern D3 lymphadenectomy.
6. Laparoscopic total mesorectal excision remains the standard of care for rectal
cancers and allows better preservation of nerves and vessels ensuring complete
removal of lymph nodes.
7. The size of the normal mesorectum lymph nodes in about 80% of cases is
<3 mm. Most mesorectum lymph nodes are located posteriorly, and 90% of the
posterior lymph nodes lie within the upper half of the upper 2/3 of the rectum.
Metastasis in mesorectal node is bidirectional i.e. both superiorly and inferiorly
therefore necessitating complete mesorectal excision.
8. Lateral lymph node resection is advised in mid and lower rectal cancer to
improve the prognosis by reducing local recurrence but is still not the standard
of care across all centres.
9. Laparoscopic sentinel lymph node biopsy can be used to detect micrometastasis
and improve the staging in T1/T2 disease of colon cancer. Standardized use of
sentinel lymph node removal still remains controversial as expensive instru-
mentation is required.
10. Flourescence imaging and molecular staging are the two new methods to
enhance detection of tumor deposits in sentinel lymph nodes.
Editor’s Note1
Anatomy
One of the crucial steps in laparoscopic total mesocolic excision is an understanding

of the embryological fusion planes and vascular anatomy of the mesocolon. The
vascular anatomy is particularly pertinent for right colectomy as several varia-
tions exist.
ariations in Blood Supply and Venous Drainage of Right Colon

V
as Pertinent to Laparoscopic Right Hemicolectomy
In a study evaluating variations in colonic blood supply from superior mesenteric

artery it was noted that the middle colic artery and ileocolic artery were consistently
present in most patients. Whereas the right colic artery was present in 12.2% to
55.0% cases only. The right colic artery has been noted to variably originate from
superior mesenteric, ileocolic, middle colic and right branch of middle colic in vari-
ous studies. It is important to note that the ileocolic artery can cross the superior
mesenteric vein anteriorly or posteriorly. On the other hand, the right colic artery
usually crosses the superior mesenteric vein anteriorly. Similarly, variations have
been noted in the venous system. The ileocolic vein consistently drains into the supe-
rior mesenteric vein and is thus considered an important anatomical marker in lapa-
roscopic right hemicolectomy. Of particular note is the “Trunk of Henle” which can
present as a GTH (gastrocolic Trunk of Henle). GPCT (Gastropancreaticocolic
trunk) or GPT (Gastro pancreatic Trunk), the latter being rare. Right colic veins
rarely drain into superior mesenteric vein in only 19% whereas the middle colic veins
drain into the superior mesenteric vein in 84% cases in the rest of the cases these
veins drain into the trunk of Henle. The superior right colic vein is an inconsistent
vein formed from tributaries of hepatic flexure and is also known as accessory right
colic vein considered to be an important source of bleeding due to avulsion [1].
1
176 S. Rawat et al.
Fig. EN1 Laparoscopic
right hemicolectomy image
showing the dissection in
Ileocolic plane (Yellow
arrow: Caecum and
proximal right colon, Red
arrow: Ileocolic vessels)
mryological Fusion Planes Encountered in Laparoscopic

E
Right Hemicolectomy
Four critical view planes have been proposed in the open book model for standard-
ization of CME in right hemicolectomy. They are essentially derived from the
embryological fusion planes of colon and mesocolon and are: (a) retroperitoneal
plane, (b) ileocolic plane (c) transverse mesocolic plane and (d) mesogastric plane [2].
etaanalyses on Mesocolic Excision Versus Non

M
Mesocolic Excision
Table EN1 tabulates the crux of the results of various meta-analysis comparing
mesocolic excision versus non mesocolic excision. An advantage regarding onco-
logical outcome parameters viz: recurrences, diseases free and overall survival has
been consistently reported in latest studies. Surrogate pathological parameters of a
better oncological resection such as number of lymphnodes retrieved, length of
bowel excised, area of the mesocolon in specimen, distance to high tie have all been
reported to be higher in the CME group [3–12].
Table EN1 Meta-analysis showing results complete mesocolic excision versus conventional exci-
sion in colectomy for colonic cancers
Study Result
Comparing complete mesocolic CME/D3 lymphadenectomy group had better
excision versus conventional oncological outcome as cited below:
colectomy for colon cancer: A • 5-year Overall survival
systematic review and meta- OR = 1.29; 95% CI 1.02 to 1.64, p = 0.03
analysis [3] • 5-year Disease-free survival
OR = 1.61; 95% CI 1.14 to 2.28; p = 0.007.
No significant differences in morbidity and mortality
Complete mesocolic excision CME group was associated with significantly better
versus conventional oncological outcome as follows:
hemicolectomy in patients with • Number of lymph nodes harvested;
right colon cancer: a systematic (MD 9.17, CI 4.67–13.68, p < 0.001).
review and meta-analysis [4]. OS- 3-year;
(OR 1.57, 95% CI 1.17–2.11, p = 0.003),
• OS-5-year;
(OR 1.41, 95% CI 1.06–1.89, p = 0.02),
• DFS-5-year
(OR 1.99, 95% CI 1.29–3.07, p = 0.002).
No difference in:
• complications
• stage III colon cancer no significant benefit of CME on
survival
Oncological reasons for CME group was associated with a significantly better
performing a complete oncological outcome as regards:
mesocolic excision: a systematic • Higher number of lymph nodes retrieved
review and meta-analysis [5] • Better pooled 5-year overall survival
• Lower rates of local recurrence
• Lower rates of distant recurrence
Disadvantage of CME:
• Higher incidence of vascular injury
odds ratio 3, P < 0.001.
Complete mesocolic excision CME/ D3 lymphadenectomy had superior oncological
versus conventional surgery for outcome with respect to:
colon cancer: A systematic • OS -3 year
review and meta-analysis [6] RR 0.69 (95% CI 0.51–0.93, P = 0.016
• OS - 5 year
RR 0.78 (95% CI 0.64–0.95, P = 0.011
• DFS - 5 year
RR 0.67, 95% CI 0.52–0.86, P < 0.001
No statistically significant differences in:
• complications
• anastomotic leak
(continued)
178 S. Rawat et al.
Study Result
Complete Mesocolic Excision Better oncological outcome and pathological parameters
and D3 Lymphadenectomy in CME group as follows:
versus Conventional Colectomy • Higher number of retrieved lymph nodes
for Colon Cancer: A Systematic • Greater distance to high tie
Review and Meta-Analysis [7] • Resected length of bowel
• Larger area of resected mesentry
• 3-year OS
(RR 1.09, 95% CI 1.04–1.15)
• 5-year OS
(RR 1.05, 95% CI 1.02–1.08)
• 3-year DFS
(RR 1.10, 95% CI 1.04–1.17, i2 = 22%),
• Decreased local recurrence
(RR 0.35, 95% CI 0.24–0.51, i2 = 51%)
• Fewer distant recurrences
(RR 0.71, 95% CI 0.60–0.85, i2 = 34%).
Disadvantage CME group:
• Higher postoperative complications
(relative risk [RR] 1.13, 95% confidence interval [CI]
1.04–1.2)
No differences were observed in:
• Anastomotic leak rates
• Perioperative mortality.
Right hemicolectomy with Superior oncological outcome with CME in the
complete mesocolic excision is following aspects:
safe, leads to an increased • Higher number of lymph nodes retrieved
lymph node yield and to (MD 7.05, 95% CI 4.06–10.04).
increased survival: results of a • Improved 3-year overall survival
systematic review and meta- (RR 0.42, 95% CI 0.27–0.66)
analysis [8]. • Better 5-year disease-free survival
(RR 0.36, 95% CI 0.17–0.560.
No difference in:
• anastomotic leak rates
• blood loss
• postoperative complications
• serious postoperative complications -Clavien-Dindo grade
III-IV
• reoperation rate
Traditional surgery better as regards to:
• less operating time
(MD 16.43, 95% CI 4.27–28.60)
Study Result
Right-side colectomy with Better oncological outcome and pathological parameters
complete mesocolic excision vs in CME group as regards:
conventional right-side • 5-year DFS
colectomy in the treatment of 1.88 (95% CI 1.02–3.45)
colon cancer: a systematic • 5-year OS
review and meta-analysis [9]. 2.77 (95% CI 1.33–5.74)
• Higher number of retrieved lymph nodes
(MD 7.08 lymph nodes 95% CI 4.90–9.27).
No significant difference with respect to:
• morbidity
• mortality
• blood loss
• hospital stay
Advantage conventional surgery:
• longer duration of surgery with CME
(MD 33.69 min, 95% CI 12.79–54.59)
D3-lymphadenectomy enhances Better oncological outcome and pathological parameters
oncological clearance in patients with CME + D3 as noted below:
with right colon cancer. Results • tumour to vascular tie distance greater,
of a meta-analysis [10]. • greater length of colonic resection,
• wider mesentery resection
• greater number of retrieved lymph nodes.
• decrease risk of local recurrence
(HR:0.17)
• better 3-year OS
(HR:0.53)
• better 5-year OS
(HR:0.57)
No differences noted in:
• morbidity related variables
Laparoscopic Complete CME scored better as regards:
Mesocolic Excision Versus • less blood loss
Noncomplete Mesocolic (P < 0.001, (WMD) = −12.01, 95% (CI): −13.56 to
Excision: A Systematic Review −10.45),
and Meta-analysis [11]. • more harvested lymph nodes
(P < 0.001, WMD = 6.50, 95% CI: 3.57–9.42),
• longer resected colon length
(P = 0.004, WMD = 3.57, 95% CI: 1.12–6.03),
• greater distance from tumor to high tie
(P < 0.001, WMD = 1.36, 95% CI: 0.87–1.85),
• greater distance from nearest bowel wall to high tie
(P < 0.001, WMD = 1.36, 95% CI: 0.87–1.85).
No differences were observed in terms of:
• operative time,
• complications,
• wound infection,
• ileus,
• Proximal resected margin
• Distal resection margin
• Disease-free survival
(continued)
180 S. Rawat et al.
Study Result
Safety, quality and effect of Advantage of CME in oncological outcome and
complete mesocolic excision vs pathological parameters:
non-complete mesocolic • longer length of resected colon
excision in patients with colon (WMD 47.06, 95% CI: 10.49–83.62),
cancer: a systemic review and • greater tumor to the high tie distance
meta-analysis [12] (WMD 17.51, 95% CI: 15.16–19.87),
• larger area of resected mesentery
(WMD 36.09, 95% CI: 18.06–54.13)
• more harvested lymph nodes
(WMD 6.13, 95% CI: 1.97–10.28).
• better 5-year survival
(HR) 0.33, 95% CI: 0.13–0.81],
• improved 3-year survival
(HR 0.58, 95% CI: 0.39-0.86)
• better 3-year survival for Stage III disease
(HR 0.69, 95% CI: 0.60–0.80)
Disadvantage CME:
• more intra-operative blood loss
[weighted mean difference (WMD) 79.87, 95% CI:
65.88–93.86],
• higher surgical complications
(relative risk 1.23, 95% CI: 1.08–1.40)
CME complete mesocolic excision, OR odds ratio, HR hazard ratio, WMD weighted mean differ-
ence, CI confidence interval, OS overall survival, DFS disease free survival, RR risk ratio, MD
mean difference
Meta Analyses on Laparoscopic and Open Mesocolic Excision
Table EN2 enlists the results of metanalysis comparing laparoscopic and open
mesocolic excision. A better postoperative recovery, lower blood loss, less require-
ment for blood transfusion, lower overall postoperative complications, less wound
infections, early recovery of gastrointestinal function and shorter hospital stay are
some of the reported benefits of laparoscopic over open CME for colonic cancers
[13–16].
eta Analyses on Lateral Lymph Node Dissection

M
in Rectal Cancers
The results of metanalyses pertaining to lateral lymph node dissection is shown in

Table EN3. Most metaanalyses project a higher incidence of urinary dysfunction
and male sexual dysfunction associated with lateral lymphnode dissection. Though
there is no major survival benefit overall it may be helpful in patients with clinically
positive lateral lymph node that persist after preoperative chemoradiotherapy or
those who do not receive neoadjuvant chemoradiotherapy [17–21].
Table EN2 Metaanalyses comparing laparoscopic and open mesocolic excision

Study Result
Laparoscopic versus OCME vs LCME
open complete shorter operative time in the OCME.
mesocolic excision: a LCME advantageous with respect to:
systematic review by • less blood loss,
updated meta-analysis • lower wound infections,
[13] • earlier time to flatus,
• shorter time to oral feeding,
• decreased length of hospital stay
LCME had better oncological outcome and survival benefits:
• 1-year OS
(HR = 0.37 (0.22, 0.65); p = 0.004),
• 3-year OS
(HR = 0.48 (0.31, 0.74); p = 0.008),
• 5-year OS
(HR = 0.64 (0.45, 0.93); p = 0.02),
• 3 year DFS
(HR = 0.63 (0.42, 0.97), p = 0.03)
• 5-year DFS
(HR = 0.68 (0.56, 0.83), p = 0.001)
Laparoscopic vs open LCME vs OCME
complete mesocolic LCME better regarding following parameters
excision with central • 3 year overall survival
vascular ligation for (OR = 2.02, 95%CI: 1.31 to 3.12, P = 0.001),
colon cancer: A • 3 year disease-free survival
systematic review and (OR = 1.45, 95% CI: 1.00 to 2.10, P = 0.05)
meta-analysis [14] • area of the resected mesocolon
(MD = 11.75 cm2, 95%ci: 9.50 to 13.99, p < 0.001).
• decreased blood transfusion rate
(or = 0.45, 95%ci: 0.27 to 0.75, p = 0.002),
• earlier recovery of gastrointestinal function,
• less complication rate.
No differences regarding:
• harvested lymphnodes
• distance from tumor to high tie
Open compared with LCME advantageous compared to OCME as regards:
laparoscopic • shorter hospital stay
complete mesocolic [WMD = 2.29 (95% CI: −0.39 to 4.98); P = 0.09]
excision with central • lower rate of wound-infection
lymphadenectomy for [OR = 2.87 (95% CI: 1.38–5.98); P = 0.005]
colon cancer: a LCME disadvantage:
systematic review and • longer operative time
meta-analysis [15] [weighted mean difference (WMD) = –30.88 (95% CI: –62.38 to
0.61); P = 0.05]
No statistically significant difference was found in:
• short-term mortality
• anastomotic leakage,
• ileus
• deep-seated infection/abscess
• overall survival
• disease-free survival,
• local recurrence
• distant metastases
(continued)
182 S. Rawat et al.
Study Result
Comparing the safety, LC had was superior to OC in terms of:
efficacy, and • less postoperative complications
oncological outcomes (OR 0.64, p = 0.0003),
of laparoscopic and • reduced blood loss
open colectomy in (WMD –86.84, p < 0.00001),
transverse colon • earlier time to first flatus passage
cancer: a meta- (WMD – 0.94, p < 0.00001)
analysis [16] • early onset of oral diet
(WMD – 1.25, p < 0.00001),
• length of stay
(WMD – 2.39, p < 0.00001).
• lower recurrence rate
OC was advantageous in the following aspect:
• lower operation time
(p < 0.00001).
• higher rate of complete mesocolic excision
(p = 0.001).
LC vs OC equivalent in terms of postoperative survival outcomes.
LCME laparoscopic complete mesocolic excision, OCME open complete mesocolic excision, OR
odds ratio, HR hazard ratio, WMD weighted mean difference, CI confidence interval, OS overall
survival, DFS disease free survival, RR risk ratio, MD mean difference, LC laparoscopic colec-
tomy, OC open colectomy
Table EN3 Metaanalyses on lateral lymph node dissection in rectal cancers

Study Result
Lateral lymph node TME with LLND was associated with:
dissection reduces local • longer operation time
recurrence of locally (WMD 90.73 min, P < 0.001).
advanced lower rectal • greater intraoperative blood loss
cancer in the absence of (WMD 303.20 ml, P < 0.001).
preoperative neoadjuvant • higher postoperative complications
chemoradiotherapy: a (RR = 1.35, P = 0.02).
systematic review and No difference in:
meta-analysis [17] • Urinary dysfunction
• Sexual dysfunction
• Postoperative mortality
• DFS
• Total recurrence
• Lateral recurrence
• Distal recurrence
TME with LLND had benefits regarding:
reduced local recurrence in patients who did not receive nCRT
(RR 0.71, P = 0.004) not significant when combined with nCRT.
Study Result
Meta-analysis of No difference between groups in the following aspects:
survival and functional • overall survival
outcomes after total • 5-year overall survival
mesorectal excision with • disease-free survival
or without lateral pelvic • 5-year disease-free survival
lymph node dissection in • local recurrence
rectal cancer surgery • distant recurrence
[18] • total recurrence
Total mesorectal excision with lateral pelvic lymph node
dissection resulted in
• longer operative time
(MD: 116.02, 95% CI 89.20–142.83, P < 0.00001, I2 = 68%)
• higher complications
(odds ratio: 1.59, 95% CI 1.14–2.24, P = 0.007, I2 = 0%)
• urinary dysfunction
(odds ratio: 6.66, 95% CI 3.31–13.39, P < 0.00001, I2 = 23%)
• sexual dysfunction
(odds ratio: 9.67, 95% CI 2.38–39.26, P = 0.002; I2 = 51%)
Total mesorectal TME + LLND group fared worse as regards:
excision plus lateral • more complications (OR = 1.48, 95% CI [1.07, 2.03], P = 0.02)
lymph node dissection No significant difference was observed in
vs TME on rectal cancer • overall survival
patients: a meta-analysis • disease-free survival
[19] • local recurrence
• urinary dysfunction
What is the role of LLND after nCRT associated with:
lateral lymph node • lower LLR (P = 0.02).
dissection in rectal LLND disadvantageous due to:
cancer patients with • longer operative time (P < 0.01)
clinically suspected • increased risk of urinary dysfunction (P < 0.01).
lateral lymph node
metastasis after
preoperative
chemoradiotherapy? A
meta-analysis and
systematic review [20].
The efficacy and safety No difference in
of lateral lymph node • 5-year disease-free survival rate
dissection for patients • local recurrences
with rectal cancer: A LLND associated with more:
systematic review and • urinary dysfunction
meta-analysis [21] (OR = 2.14, 95%CI = 1.21–3.79, P = 0.009)
• male sexual dysfunction
(OR = 4.19, 95%CI = 1.55–11.33, P = 0.005)
TME total mesorectal excision, LLND lateral lymphnode dissection, nCRT neoadjuvant chemora-
diotherapy, LLNM lateral lymph node metastasis, LLR lateral lymphnode recurrence, OR odds
ratio, HR hazard ratio, WMD weighted mean difference, CI confidence interval, OS overall sur-
vival, DFS disease free survival, RR risk ratio, MD mean difference
184 S. Rawat et al.
etaanalyses on Sentinel Lymph Node Biopsy

M
in Colorectal Cancers
Table EN4 depicts the results of recent metaanalyses on sentinel node biopsy in
colorectal cancers. A high identification rate sensitivity and diagnostic accuracy has
been observed especially for early stage lesions. Colonic cancers, use of laparo-
scopic procedures and indocyanine green for performance of sentinel node biopsy
has been noted to have a better yield [22–24].
Table EN4 Results of sentinel lymph node biopsy in colorectal cancers

Study Result
In vivo sentinel lymph node identification using fluorescent tracer T3-T4 vs T1-T2
imaging in colon cancer: A systematic review and meta-analysis [22]. tumours
• Detection rate of
90% vs 91%,
• Accuracy rate of
77% vs 98%,
• Sensitivity of 30%
vs 80%.
Sentinel lymph node mapping for metastasis detection in colorectal • Pooled SLN
cancer: a systematic review and meta-analysis [23]. detection rate
93% (95% CI,
0.91–0.94),
• Overall sensitivity
0.72 (95% CI,
0.67–0.77)
Performance of Indocyanine green for sentinel lymph node mapping Pooled detection rate
and lymph node metastasis in colorectal cancer: a diagnostic test 91% (80%–98%).
accuracy meta-analysis [24]
SLN sentinel lymph node, CI confidence interval
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Ergonomics in Laparoscopic Surgery:
An Appraisal of Evidence
Priya Hazrah, Deborshi Sharma, Gautam Anand,

and Kayenaat Puran Singh Jassi
Introduction
Ergonomics literally stands for work rules. Ergonomics deals with the fit between
people their work environment and tools. The international society of ergonomics
defines ergonomics as: the scientific discipline concerned with the understanding of
interactions among humans and other elements of a system and the profession that
applies theory, principles, data and methods to design in order to optimize human
well-being and overall system performance. Whereas ergonomic analyses have
appraised its applications in other non-medical arenas, in the field of medical sci-
ence it has been a largely neglected issue. A recent interest has blossomed with
respect to ergonomics in the surgical field particularly after the advent of laparo-
scopic surgery. Ergonomic adjustments can help in decreasing fatigue and injuries
to doctors making surgery safer besides improving efficiency and thus patient
related outcome. This article reviews the available literature on ergonomical prin-
ciples that are commonly encountered in the practice of laparoscopic surgery, the
doctor and patient related consequences of working in ergonomically inefficient
situations and critical ergonomic adjustments in instrument design and operation
theatre methods recommended to correct these ergonomic inaccuracies.
Literature Related to Ergonomics
Literature pertaining to ergonomics in laparoscopic surgery is sparse. Evidence is

based upon respondent surveys, comparative cohorts of ergonomically trained and
not trained surgeons, experimental studies in skills laboratory or artificially
P. Hazrah (*) · D. Sharma · G. Anand · K. P. S. Jassi

https://doi.org/10.1007/978-981-16-5473-2_8
194 P. Hazrah et al.
simulated situations and is conspicuous by the absence of well-designed random-

ized clinical trials addressing the issue. The low interest in ergonomics in the medi-
cal field can be related to many factors, predominant of which might be a reluctance
to analyse work- and work-related criticism and underestimation of the importance
of the issue. Complaining of fatigue and stress related to surgical procedures were
till lately considered an inelegant mannerism and attributed to surgeon inefficiency
and thus such reports and analysis were criticized or discouraged. These issues are
further compounded by the difficulty in assessing the outcome measures of assess-
ment which are often inconsistent and ill-defined and are affected by a multiplicity
of interactive phenomenon. An example is workload assessment, which can depend
on multifarious components like physical, mental, temporal demands, task com-
plexity, situational stress and distractions.
octor and Patient Related Consequences of Improper

D
Ergonomics in Laparoscopic Surgery
Improper ergonomics in the operation theatre can lead to: unintentional injuries,
increased operative time, errors and increased morbidity. It has been reported that
poor design of surgical equipments lead to unintentional patient related injuries
thus necessitating the need for standardization of instruments by regulatory author-
ities [1]. From the perspective of the surgeon posture related strains, nerve injuries,
fatigue, decreased efficiency, increased psychological and mental stress can all
result from incorrect ergonomics. In a survey of 260 respondents of gynaecological
oncologist performing minimally invasive surgery, physical discomfort related to
MIS was reported in 88% with complaints of persistent pain in 52%. To decrease
pain, surgeons changed positions 78% of the times, limited the number of cases per
day in 14%, spread cases throughout the week in 6%, limited the total number of
cases in 3%. Of the group 29% had received treatment for pain symptoms in the
form of physical therapy (59%), medical management (28%), surgery (13%), and
time off from work (1%) [2]. The dominant upper extremity has been reported to
be the primary site of discomfort in 73% of respondents in a survey on surgeons
performing laparoscopic cholecystectomy [3]. In another respondent based study
evaluating laparoscopic graspers, 98 completed the questionnaire (response rate
35%), 77% reported physical complaints directly attributable to the use of laparo-
scopic instruments [4]. Though the increased physical workload is eminent in lapa-
roscopic surgery, studies have suggested an increased mental workload also
reflected as increased number of errors in laparoscopic surgery [5]. Thus improper
ergonomics can have important bearing on work efficiency and output with resul-
tant economic implications. Poor table height adjustment, bad monitor positioning
and suboptimal design of instrument handles were reported as important causes of
complications [3].
Ergonomics in Laparoscopic Surgery: An Appraisal of Evidence 195
hy and How Ergonomics of Laparoscopic Surgery is Different

W
from that of Open Surgery
The issue of ergonomics has gained an interest lately after the advent of laparo-
scopic surgery. Whereas an increased awareness and a rational approach to address
problems may be the reason for the upsurge in interest related to the subject, need-
less to say the effects have been multiplicated due to the decreased ergonomic ceil-
ing, resultant to increased physical and mental demands as also task complexity.
Performance of laparoscopic surgery is more stressful than open surgery [6]. The
important arenas in laparoscopic surgery which differs from open surgery and needs
consideration are: (1) Laparoscopic vision (2) Altered body postures (3) Longer
operative times (4) Workplace layout i.e. table height, monitor and foot pedal direc-
tions (5) Design and function of laparoscopic surgical equipments (6) Mental work-
load due to requirement of enhanced skills [7, 8].
(a) The Laparoscopic Vision and eye strain: The essential feature of laparoscopic
vision is that it is an indirect view: (1) depends on image transmission, clarity,
focussing, zooming, colour alteration and the efficient assistance of the camera
holding person. (2) the field of view is restricted to the area under vision as
degree of freedom of camera movement is limited (3) view is not under control
of the surgeon (4) the vision is two dimensional posing difficulty in depth per-
ception and spatial resolution. Resultant to these factors there is increased
demand for visual workload and consequential fatigue [9, 10]. Eye strain was
reported as a prominent ergonomic problem especially amongst junior surgeons
involved in laparoscopic surgery [11]
(b) Body Posture Related Problems: back pain, neck pain, shoulder/arm mus-
cle strain and pains/paresthesia in hand and fingers: Uncommon body pos-
tures excessive muscular load due to fatigue and pressure points causing nerve
injuries are the primary ergonomic concerns [9]. Back pain, neck pain fatigue
irritability and hand discomfort are some of the commonly reported symp-
toms [12].
Back pain and neck pain: Back pain is reported to be 15% more common in
laparoscopy and has been attributed to be due to a number of factors: (a) awk-
ward body posture due to far apart port positions, (b) need to look in one direc-
tion whereas instruments and foot pedals are often improperly positioned in a
different direction (c) increased neck rotation duration due to incorrect align-
ment of monitor and work axis [13] Surgeons exhibit decreased mobility of the
head and back and less anteroposterior weight shifting during laparoscopic
manipulations despite a more upright posture. This more restricted posture dur-
ing laparoscopic surgery may induce fatigue by limiting the natural changes in
body posture that occur during open surgery having an important bearing on
outcome [14]. Increased physical and mental workload both at baseline and
thereafter in the operation theatre can lead to fatigue and facilitate error in sur-
gical operations.
Shoulder and arm muscle strains: The other posture related problems in lapa-
roscopic surgery are shoulder strains and arm muscle strains due to high level
of operating table compounded with pneumo-peritoneum and long working
instruments. Higher upper extremity muscle strength is required in performing
complex manipulative tasks of laparoscopic surgery [15]. Laparoscopic surgery
requires more skills due to altered instrument designs and increased force due
to use of small muscles. Additionally longer operating times especially initially
in learning curve is needed as also increased concentration. Difference in load-
ing between dominant and non dominant shoulders increased use of power
morcellation repeated insertion and removals of laparoscopic instruments
through trocars wherein strain occurs at the shoulder have been identified as
predominant factors which pose risk to surgeons. An advantage of height of
surgeon in this regard has been observed with increase in height resulting in
decrease in time spent in extreme body posture [13]. Extreme displacements of
the arm both vertical and horizontal due to insertion of instruments through
fixed trocars resulted in increased workload especially on upper arm and foream
muscles [16]. Thus mini breaks have been advised for posture readjust-
ments [17].
Wrist pain/hand pain/laparoscopic thumb/finger numbness: An extended
wrist posture is often used for performing most laparoscopic tasks [18]. The
“laparoscopic surgeons thumb” has been reported as a damage to the lateral
digital nerve of the thumb which is a superficial branch of the radial nerve in the
region [19, 20]. Increased paresthesia of fingers has been reported particularly
more amongst junior surgeons in laparoscopic surgery [11]. The use of a ringed
silicon rubber attachment has been proposed to prevent laparoscopic thumb
[21] A questionnaire based survey with The SAGES Task Force on Ergonomics,
respondents reported 8% to 12% frequent pain in the neck and upper extremi-
ties associated with laparoscopic surgery. The peak and total muscle effort of
forearm and thumb muscles were significantly greater when the grasping task
was performed using the laparoscopic instrument as compared with open hemo-
stat [22].
ritical Adjustments for Improving Ergonomics

C
in Laparoscopic Surgery
The critical adjustments to be made in laparoscopic surgery to improve the ergo-

nomics of the procedure essentially comprise of modifications in the following
aspects:
1. Work place lay out

2. Tool (instrument) design and use
3. Work environment modification
4. Training of staff.
1. Work Place Layout
In a transition from open to laparoscopic surgery the laparoscopic equipment and

instrumentation have been adopted into an operation theatre suite ideally designed
for open surgery. Operating room crowding is significantly more in laparoscopic
surgery when compared with open surgery which calls for specially designed suite
[23]. However there are a number of inherent differences between open and laparo-
scopic surgery and operation theatres exclusively designed for performance of lapa-
roscopic surgery merit consideration. In a study evaluating the physical strain on
surgeons performing laparoscopic cholecystectomy in modern as compared to stan-
dard OR (operating room) the former was found to be ergonomically beneficial
[24]. In a prospective case-controlled study ten experienced surgeons performed
surgery in two different ORs: a standard room and a modern room. The surgeons
were asked to fill out questionnaires concerning physical and psychological wellbe-
ing before and after surgery and had their heart rate variability registered during
surgery. Physical strain experienced by the surgeon was less when performing lapa-
roscopic cholecystectomy in a modern OR compared with a standard room [24].
A number of critical adjustments in work place layout need to be undertaken for
improving the ergonomics of laparoscopic surgery (a) Operating table level (b)
Monitor level (c) Foot Pedals (d) Positioning of operating surgeon and assistant.
T Table Height: The height of the operating table has an important bearing on
O
shoulder and hand muscle strain. Most operating tables are constructed keeping in
view of open surgical procedures. The important difference between open and lapa-
roscopic surgery is that the effective working height increases in laparoscopic sur-
gery due to pneumo-peritoneum which distends the abdominal wall. Added to this
issue is the long laparoscopic working instrument, wherein a considerable portion
of the instrument protrudes out of the patients abdominal wall which necessitate
increased shoulder elevation, shoulder abduction and elbow flexion thereby causing
strain. In laparoscopic surgery task performance has been found to be best at the
height of operating table wherein the abdominal wall of the patient corresponds to
the thigh height of the operating surgeon which depends on the instrument handle
type (shank, pistol axial and rod type) as also the angle of insertion of the instrument
[25]. Thus substantial lowering of table, to a height of 30-60cmcm from the floor
has been suggested to facilitate ergonomic working. A concern regarding efficient
floor cleaning and hygiene issue has been raised as in open surgery the table height
is usually at the level of belt height however no substantial evidence against it has
been documented [25]. It has been said that the ideal operating table level should be
such that: (1) the angle between lower & upper arm should be between 90° and
120°. (2) after the insertion of instruments they should be roughly at, or slightly
below the level of the surgeon’s elbows (Fig. 1a, b) [17, 26, 27]. In a study on hand
assisted laparoscopy the optimal table height proposed is such that the extracorpo-
real instrument handle is at elbow level or 5 cm above [28]. The use of arm support
has been also been suggested [29]. Women surgeon experience greater difficulty in
laparoscopic surgery and adjustment in OT table height is often required [30].
a b
Fig. 1 (a) Instrument handles at or below the level of elbow keeps the shoulder relaxed and indi-
cates correct table height. (b) Incorrect table height and long external length of instruments leads
to forearm being flexed
onitor Position: Eye-hand-target axis misalignment occurs because of limited

M
freedom in monitor positioning and is an important ergonomic drawback during
minimally invasive surgery [31]. A simulated laparoscopic suturing in which EMG
data was compared in 18 surgeons performing the procedure with monitor positions
at: eye level, at the height of the operating field and 45° to the right, the frontal eye
level was found to be the most preferable. It has been suggested that two monitors
should be placed to ease visualization of the operating surgeon and a contralateral
positioned assistant [17, 25]. Ideally the monitor should be placed straight in front
of each person, aligned with motor axis of forearm instruments in the horizontal
plane and in the sagittal plane at 15–40° below eye level. An important limitation in
minimally invasive surgery is misalignment in the eye-hand-target axis due to moni-
tor positioning which can limit freedom of movement [31] (Fig. 2). The other
advanced adjustments that can be implemented for ergonomic improvement are:
mirror image correction for assistants in case of reverse alignment, head mounted
camera, flat display screens and video display on flexible booms [17, 31, 32]. The
important characteristics which influence the display characteristics are: contrast,
detail, brightness, lighting uniformity, focussing uniformity, sharpness and colour.
Rated scales are often implemented for assessing the perceptual quality for exam-
ple: MVCS The Maryland Visual Comfort Scale [33].
Foot Pedals/Hand Control for Electrosurgical Equipment’s/Cordless

Device: Laparoscopic surgery involves the application of various foot pedal con-
trolled electrosurgical equipments. Attention should also be metted to the proper posi-
tioning of these foot pedals to avoid body rotation related strains. Foot pedals should
be placed close to the foot, aligned in the same direction as the instruments i.e. towards
the target quadrant of surgery as also the principal laparoscopic monitor.
A built-in foot rest can help provide the necessary foot support for prolonged
usage. Often two pedals (for different devices) are used and the surgeon must be
careful not to confuse them in the darkness [17].
Fig. 2 Monitor position

below eye level and in
front
Alternatively ESU operated by hand controls may be preferable to foot controls.

Proximity of hand controls to the equipment handle is also important to ease its
usage [34].The use of cordless laparoscopic ultrasonic device has been suggested by
some authors [35].
Positioning of Assistants: The position of assistant varies according to individual

operations, also the surgeon’s choice. Whereas surgeons often believe that the posi-
tion of assistant does not have an important bearing some authors report observa-
tions to the contrary. In an analysis of hand technique and standing position during
laparoscopic cholecystectomy it was observed that the position of assistants may
have a detrimental effect on muscle work and pose physical injury to the surgeons.
In the study virtual reality simulated generated performance was analysed. Physical
ergonomics was assessed using “Rapid Upper Limb Assessment” (RULA), Mental
workload was assessed with the National Aeronautics and Space Administration-
Task Load Index (NASA-TLX).A high physical demand, effort, and frustration
(p < 0.05) was recorded in the side standing as compared to the in between standing
position of the operating surgeon. It was further noted that in the side standing posi-
tion more effort was needed in the two handed as compared to one-handed manoeu-
vring (p < 0.05) [36]. However, another study using electromagnetic motion tracking
sensor did not find any difference between the French and American position while
performing laparoscopic cholecystectomy in modern minimal invasive surgical
suite but noted a trend towards increased flexion of thoracolumbar spine in the
French position [37].
Use of External Support System: Exosuits to help in external support has been

shown to be decrease pain and fatigue without significant interference in dexterity
of performance [38].
. Tool (instrument) design and use: Ergonomic Deficiency

2
in Design and Function of Laparoscopic Tools
With evolution of laparoscopic surgery a renaissance has been witnessed in the

design of surgical equipments. Laparoscopic instruments suffer from ergonomically
inadequate handle designs and inefficient handle to tip force transmission, which
lead to surgeon fatigue, discomfort, and hand paresthesias [39, 40]. In a survey
investigating the standard of laparoscopic instruments according to ergonomic
design criteria it was observed that the handle of the instrument causing greatest
discomfort met only few ergonomic criteria [40]. When compared to open surgery
there are a number of drawbacks in laparoscopic instruments. The important
issues being
(a) Lack of haptic feedback: Laparoscopic surgery has the inherent disadvantage of
lack of haptic feedback (tactile as well as force sensation) which necessitates
more concentration and greater skill
(b) Use of long instruments: the long instruments designed to be manoeuvrable
into the depth of the abdominal cavity from exterior have an inefficient force
transmission mechanism and form a large external arc thus more force is
required which can result in fatigue of wrist and forearm muscle.
(c) Limited degree of freedom of movement of laparoscopic instrument [9].
(d) Inefficient instrument designs particularly handle designs [40].
(a) Laparoscopic Grasping and Lack of Haptic Feedback: Determinants of lapa-

roscopic pinch force depends on surgeons experience, tissue type and visual feed-
back [41]. Visual feedback and haptic feedback are the two important sensory
feedback mechanisms utilized by surgeons during performance of surgical opera-
tions. On comparing visual and tactile feed back in laparoscopic grasping, it was
observed that the reaction time to tissue slippage was faster with tactile feedback
thereby emphasizing the importance of tactile over visual feedback [42]. Novices
generally tend to hold tissues with excessive grasp force and alterations in this
regard have been suggested [43]. A relation with angle of the grasper with the tissue
has been suggested and increasing grasp force observed with increase of angle [44].
Laparoscopic instruments have diminished haptic feedback which is an important
drawback. The diminished haptic feedback and increased pinch force at the tip of
the grasper leads to tissue damage in laparoscopic grasping due to use of excessive
grasp force applied especially by novices which leads to tissue slippage as com-
pared with barehanded grasping in open (safe grasp) [42]. Regardless of the level of
experience, a need for augmented tactile feedback when learning laparoscopic grasp
control has been envisaged [45].
(b) Laparoscopic Instruments and Inefficient Force Transmission: In an EMG

study it was observed that a six-fold less efficient force transmission from handle to
tip was noted with highest workload noted in forearm & thumb muscle during
grasping, particularly prevalent in junior surgeons with <2 years experience in the
technique [46]. In another study comparing pinch force required to grasp objects
with laparoscopic instruments, tweezers used in open surgery and bare hand, it was
observed that using a lap grasper, 14.5 times many practice trials were required,
whereas with tweezers it was 4.5 times more as compared to bare hand. This diffi-
culty was particularly evident in the grasping of stiff objects and in 84% times the
laparoscopic instruments slipped while holding stiff objects [42].
(c) Limited Degree of Freedom in Laparoscopy: Laparoscopic instruments are

manoeuvred through fixed ports, the movement is about a fulcrum in the body wall
thus the degrees of freedom are limited and more dexterity of hand muscle will be
required with resultant muscle fatigue.
( d) Inefficient Instrument Designs Particularly Handle Designs: The other limi-

tations pertain to the design of laparoscopic instruments precisely the handle designs
and sizes which can lead to need for excessive grasp force with odd flexion or
hyperextension deformities and resultant nerve injuries and paraesthesias.
The Critical Adjustments in Tool Design and Use
The critical adjustments in laparoscopic instrumentation include:
i) Design of laparoscopic instruments: precisely innovations in the handle designs,

haptic enhancement, hand size considerations
ii) Instrument use: port positioning and instrument angulation.
iii) Camera ergonomics
i) Design of Laparoscopic Instruments: Precisely Innovations in the Handle

Designs, Haptic enhancement, Hand size considerations:
Handles of Laparoscopic Instruments:

The common handle designs of instruments can be classified based upon the grip
position and angulation or alignment of the shaft of the instrument with grasping
unit or handle. Depending upon the type of grip or handle, the instruments can be
classified as (1) Ring and Shank handles or finger grip type (2) Palm grip handles
often synonymous addressed as pistol grip handles (3) Wire bend handles (4) Rod
Handle (Figs. 3, 4, and 5).
The handles can be held with finger grip or palm grip. The ring and shank handles
and the pistol handle are the two common types of handles seen in most laparoscopic
instruments. The typical example of a rod handle is the laparoscopic hook. The ring
shank handles have the advantages of facilitating one handed manipulation during
dissection and cutting, directing, they are often reusable, sterilizable, interchange-
able and can be used by both right and left hands. The pistol handles on the other
hand are usually disposable and allow the integration of several functions [47]. The
instruments can have a locking rachet or maybe of the non-locking type. (Fig. 6).
Fig. 3 Ring Shank Handle

at angle with shaft
Fig. 4 Palm grip handle

partly Inline with shaft
useful where rotatory
movements at wrist is
needed like suturing
Additionally, the angle of handle with shaft can be inline or angulated configura-
tion. In contrast with open surgery where most instruments are designed primarily
in an in-line configuration, laparoscopic instruments are generally angulated at shaft
and handle junction as the direction of insertion into the abdominal cavity and direc-
tion of target in abdominal cavity differs.The ring and shank are usually placed in at
an angulation to the shaft whereas the pistol grip handle can be in both co axial or
angulated configurations. A point to be noted here is that the use of term pistol grip
has been varyingly used to denote a palm grip as well as an angulated handle shaft
configuration and similarly ring handle is often used to imply an angulated handle
shaft configuration. The ideal laparoscopic instrument should enable the surgeon to
keep both wrists in a neutral (unbent) position, permit the surgeon to keep both arms
at the sides of their body, avoid pressure points on the hands, allow the surgeon to
apply force with a power grip (hammer or gunstyle) hand position and facilitate fine
manipulation with a precision grip (pencil or forceps style) hand position [17].
Fig. 5 Rod Handle as seen

in hook
Fig. 6 Instruments with a

rachet or locking
mechanism
Handle Shaft Configuration Inline Versus Angulated Configurations: The in-

line handle configuration has been proposed to be advantageous over the pistol
(angulated) configuration when grasping at 90° to the surgeon [39]. In a study on the
optimal handle shaft angle for laparoscopic bowel suturing a 40° angle was found to
be optimal as opposed to zero and 80° configuration [48]. Contrarily studies have
suggested the axial handle to be equal or superior to the ring handle in most
laparoscopic tasks [49]. A survey on comfort intuitiveness precision and stability of

seven types of instrument handles which included those designed for laparoscopic
as well as robotic surgery, three handles—the laparosopic needle holder, da Vinci
wrist and joy stick like handle scored the most for all the above criteria [50].
Laparoscopic Grasping: Choosing the Right Type of Handle—Precision

Grasping Versus Power Grasping: Data recommending the use of one handle
over the other type is lacking nevertheless some recommendations have been made.
While choosing an instrument the important factors to be considered are: (1) the
type of surgical procedure (2) the time duration.
Human grasping activities has been classified broadly into two types (1) preci-
sion grip (2) power grip [51]. In precision grip the position of thumb is abducted
while in power grip the position of the thumb is adducted. In power grip the force is
generated between the thumb along with thenar eminence against the rest of the
fingers (Fig. 7) whereas in precision grip it is between thumb and fingers.
The precision grip is interchangeably referred to as pinch grip or finger grip in
studies, on the other hand the power grip is often mentioned as pistol grip or
palm grip.
Precision Grasping for Fine Dissection (Fig. 8): The precision grip handles and
finger grip and are advantageous when work with precision like fine grasping or
dissecting is intended [29, 52].
Fig. 7 Power grip with

smooth handles for heavy
instruments like stapling,
note here grip is between
thenar eminence and rest
of the fingers
Fig. 8 Precision grip/

finger grip/pinch grip
where meticulous work is
needed like dissection,
note here force is exerted
between thumb and other
fingers
Grasping Tissues for Prolonged Period: While grasping tissue for prolonged time
periods an instrument with a palm grip and locking mechanism is to be preferred
Instrument that incorporates a locking or ratchet mechanism will maintain the force.
“Palming” an instrument (removing the thumb from the ring and placing the palm
against the handle) can reduce the amount of wrist flexion and increase the sur-
geon’s power (Fig. 9) [17].
In a study evaluating pistol grip with pinch grip survey feedback indicated that a
significantly greater number of participants felt that using the pistol grip they expe-
rienced a greater degree of freedom and lesser discomfort nevertheless the authors
refrained from making any substantial conclusions based upon the study [53].
Heavy Grasping as in Stapling/Power Grip: In a study using muscle EMG analy-

sis comparing palm and finger grips it was observed that palm grip is more powerful
than the finger grip when grasping with laparoscopic instruments, particularly at
angles perpendicular to the surgeon’s sagittal plane [54]. Thus power grip handles
with large smooth surface and pistol type handle shaft alignment should be pre-
ferred while using heavy instruments like staplers [17]. Further the necessity for an
optimal diameter of the instrument handle dependent on hand size is emphasized for
best result a detrimental effect is observed in both extremes viz: small hand size as
well as long fingers [55, 56].
Innovations in Laparoscopic Graspers: The proposed ergonomic considerations

for laparoscopic instrument handles are: Thumb use for rotation of the knob, increas-
ing the contact area, littleforce for opening/closing of the instrument, easy clamping
with one hand use, moulded rubber grips [47]. Recent innovations include, adjust-
able handle shaft angles, rotatory handles, self-righting instruments and provision of
power grasping in procedures that require heavy sustained grasp like stapling.
Fig. 9 Palming a ringed

instrument when prolonged
grasping is required note
here the thumb is released
from the ring and the
ringed instrument is held
with the palm
Use of a Rotational Handle Piece: The earliest report of the ergonomic benefits of

a rotational handle was reported way back in 1993 when a more relaxed hand posi-
tion and smooth manipulations were observed [57]. In explorative and experimental
studies using a rotational handle piece for precision movements it was observed that
rotational hand piece had a better ergonomic position for the wrist and was best
suited for low table heights [29, 58]. A number of ergonomic handles have been
studied to improve efficiency reduce rotational stress and pressure points in the
hands and wrist.
Other innovations: Lately the incorporation of a hand held robotic device is being

studied for ergonomic benefits and a relative advantage over conventional laparo-
scopic instruments has been noted especially in performing complex task like sutur-
ing by the novice surgeons [59]. The use of rounded jaws of laparoscopic grasper
has been proposed to diminish grasp force [60]. An added haptic feedback method
incorporated in graspers has been related to be useful especially in feeling for tissue
consistencies pressure of grasping and arterial pulsation in a study [4]. Innovations
incorporating use of tactile sensing function display in grasping instruments has
been suggested [61, 62].
Laparoscopic Suturing Choosing the Right Type of Instrument: Laparoscopic

suturing has a number of ergonomic disadvantages as compared to open suturing due
to two dimensional vision, working through long instruments in limited space, lack
of touch and need for good coordination between right and left hands. Moreover the
formation of loops for knotting and preventing its escape from the instrument is chal-
lenging [63]. Laparoscopic suturing is generally best performed with an instrument
having the following characteristics: Coaxial in-line alignment which facilitates rota-
tion of the instrument with simple wrist motions. Precision grasp and locking mecha-
nism to hold the needle, thus obviating the need for the constant application of force
by the surgeon [17]. The ideal ergonomic characteristics of needle holders suggested
is: Grip opening 65–90 mm, Ring Dimension: length 30 mm, width 24 mm, Angle
between grip and tube 14° to 24°, Presence of spring, Opening and closure by flexors
and extensors of the fingers The two innovative ergonomic handles and needle hold-
ers described are the Cuschieri Ball Handle and the Cuschieri Pencil Handle [47]. In
a crossover trial using laparoscopic simulator studying laparoscopic suturing, the
authors found that the pistol grip handle led to more tissue damage and non goal
directed actions as compared with in line needle holder [64]. The pistol type align-
ment causes lesser ulnar deviation as compared to co axial alignment however the
former alignment may be disadvantageous in many surgical attributes precisely in
laparoscopic suturing where an unrestricted rotation at the wrist is desirable but
restricted with the sharply angulated pistol type alignment due to limitations caused
by hyperextension at the wrist [17]. However other authors have found pistol grip
needle drivers to be beneficial [52]. The other point of consideration for an efficient
laparoscopic suturing is needle insertion angle best within a range of 80° to 100° and
grip placed at proximal and middle third shaft of needle [65].
Hand Size: Most laparoscopic instruments are designed for a hand size of 6.5 or
more therefore surgeons with smaller hand sizes are at an inherent ergonomical
disadvantage in use of laparoscopic ring instruments as also in the use of staplers.
Contrarily in larger hand sizes also there is difficulty in handling smaller instru-
ments where power grip is desirable [55, 56, 66]. Designing equipment with provi-
sion for varying hand sizes is thus desirable. In another anonymous survey a similar
observation was noted. In the survey women reported the following devices more
awkward than their male counterparts: laparoscopic stapler, laparoscopic Harmonic
scalpel, and the laparoscopic LigaSure [67].
Need for Standardization: In order to standardize designing of laparoscopic

instruments some authors have proposed a framework for research on laparoscopic
instrument handles [68].
ii) Instrument Use Port Positioning and Instrument Angulation:

The important ergonomic considerations in port positioning and instrument use are
principles incorporating: triangulation, avoiding reverse alignment, avoiding cross-
ing of equipment and limiting scissoring effect.
The Ratio Between Internal and External Length of the Instrument and Haptic
Perception: The ideal length of the instrument that has to be inserted into the
abdominal cavity has an important bearing on haptic perception. In a study evaluat-
ing the impact of differential length ratios (intraabdominal/external length) of lapa-
roscopic instrument on haptic functions, it was observed that a non symmetrical
bias in tissue stiffness was observed in tangential probing as opposed to radial prob-
ing especially in novices due to the fulcrum effect but the same was not observed in
experts handling [69]. The best ergonomics are thus achieved when ratio of intrab-
dominal length equals external length and is 1 [70].
Insertion Angles: Insertion angles of laparoscopic instruments have important

bearing on the ergonomics. The important angles which need attention are:
(a) Manipulation angle (b) Elevation angle (c) Optical Axis target view angle (d)
Azimuth angle.
Manipulation angle: angle between two working instruments (Fig. 10).
Azimuth angle: angle between one side instrument & telescope considered as a
horizontal projection (Fig. 11).
Elevation angle: angle between the instrument and patients body (Fig. 12).
There is a direct correlation between manipulation & elevation angles. If manipula-

tion angle is of 60°, optimal elevation angle which yields the shortest execution time
and optimal quality performance is 60°. Wide manipulation angles leads to higher
elevation angles for optimal performance and task efficiency. Manipulation angle
should range between 45° and 75°. The ideal angle should be 60°. Manipulation
angles <45° or >75°—increased difficulty and degraded performance.
Equal azimuth angles improve task efficiency. The secondary or operating ports
for assisting instruments should be placed after the insertion of the telescope.
Shaft sign: When the Azimuth angle is small the axis of the scope is circumjacent
to the axis of the instrument and can lead to obstructed visualization due to the
intervening shaft of the instrument known as the shaft sign.
Optical Axis Target View Angle and Optical Axis and Instrument Axis
Alignment: The optical axis target view angle is the angle formed between the
scope axis and target operation area for example the inferior liver surface in
Fig. 10 Manipulation
angle: angle between two
working instruments, ideal
45–75 degree
Fig. 11 Azimuth angle
Fig. 12 Elevation angle:

angle between the
instrument and
patients body
cholecystectomy. It varies with the degree of the scope viz 0 degree scope/30 degree
scope and angulation of insertion. The 90° optical axis target view angle is said to
have the best accuracy i.e. optical axis is at 90° to surface of the target to be viewed
[71]. The various types of optical axis alignment with instrument manipulation are
broadly:
(1) In-optical axis manipulation (one instrument on either side of the laparoscope)
(Fig. 13).
(2) Off-optical axis manipulation-dominant type i.e. both instruments on one side
of the laparoscope to the dominant hand of the surgeon,
(3) Off-optical axis manipulation—non dominant type i.e. both instruments on one
side of the laparoscope on the nondominant side) (Fig. 14).
Fig. 13 Concepts
demonstrated are:
triangulation of
instruments/in optical axis
alignment (camera
between two working
ports)
Fig. 14 Off optical axis

parallel instrumentation
(instruments on one side of
telescope) helpful in
certain surgeries example
hernia repair
The ideal position is an in optical alignment or coaxial alignment between of the

visual axis and instrument axis. Off-optical axis non dominant placement is a rea-
sonably good alternative in certain surgeries like hernia repair. As the optical axis
and instrument axis increases from 0° to 180° there is marked degradation in perfor-
mance. Reverse alignment should be avoided as far as possible for the operating
surgeon: this occurs due to camera direction in opposition to working ports—leads
to task performance degradation [72]. In summary extreme horizontal or vertical
displacement of instrument insertion should be avoided [6].
Use of articulating instruments: Laparoscopic instruments with articulating end-

pieces compromises of a new generation of instruments which improve the degree
of freedom due to their flexibility but the complexity of the instrument may cause
difficulty in handling especially in novices [73].
iii) Camera Ergonomics
The laparoscopic vision is essentially a 2D vision so depth perception and spatial
orientation is altered. Often hand-eye coordination is disrupted by the incongruent
mapping between the orientation of the endoscopic view and the actual operative
field thereby resulting in higher mental and physical load. Any alteration in camera
axis i.e.rotational distortion can significantly decrease performance. Performance is
best when the endoscopic image is perfectly aligned with the actual task space (0°
image rotation), but degraded progressively as a function of deviation from perfect
alignment [74].
The distance of the camera from the target also affects performance, the greater
the distance worse the performance. The recent innovations that are being investi-
gated to overcome these draw backs are: multiple 2D cameras, shadow introduction,
use of a 3D camera, automatic image realignment system, left to right mirror image
correction, inverted mirror image projection head mounted cameras and autostereo-
scopic monitors [75–78]. The 3D stereoscopic vision has been noted to produce less
visual fatigue and cognitive workload in training curriculum of novices [79].
However though some benefit is seen in novices but no difference was noted in
experts using 3D vs 2D vision [59]. The 2D laparoscopic image is noted to produce
more eye strains however refocussing problems is also an observed drawback of the
3D vision in laparoscopy [80]. The direction of view of the endoscope describes the
angle between the centre of the visual field (optical axis) and the physical axis of the
endoscope. Optical axis to target view angle is the angle between the optical axis of
the endoscope and the plane of the target. The best task performance during endo-
scopic work is obtained with an optical axis to target view angle of 90° [81].
3. Work Environment Modification
Environment chaos and auditory chaos and distractions affects surgical motor per-
formance and learning and increase surgeons psychological burden in simulated
laparoscopic tasks [82]. Decreasing mental distractions by work environment
modification can improve mental performance. Classical music has been shown to
consolidate memory [83].
A systematic review of music on simulated surgery performance has failed to
demonstrate significant benefit, however in laparoscopic surgery it has been sug-
gested to improve performance related to efficient transferring of instrument and
decreased mental workload [84, 85].
4. Training of Staff
runk Muscle Training, Posture Fatigue, and Performance

T
in Laparoscopic Surgery
In comparison of thirty-one participants in training group, (6-week, 18-session

trunk i.e. abdominal and back muscle endurance training program) versus control
group (no increased endurance training session), the training group had decreased
errors in performing laparoscopic surgery [86].
Importance of training OT personnel (nursing staff and surgeon): Some studies

have suggested that the use of video game training can improve skill performance
of laparoscopic tasks, however a systematic review has failed to find any significant
difference [87].
Ergonomics: Laparoscopy Versus NOTES/SILS/Robotics
Higher ergonomic risks and muscular exertion was noted in a NOTES as compared
with conventional laparoscopy [88, 89]. SILS also requires greater skills and has
more ergonomic constraints. The difference in ergonomics between conventional
laparoscopic surgery, NOTES, robotic and SILS is beyond the scope of discussion
in the current topic.
Conclusion
Laparoscopic surgery inadvertently leads to certain ergonomic constraints related to

body posture, prolonged time duration, limited vision, lack of haptic feedback and
inconvenience caused by long instruments with limited freedom of movement and
ineffective force transmission. If ergonomic problems are not corrected laparo-
scopic surgery can lead to fatigue, muscle strains, paresthesias, visual strains and
fatigue in the surgeon and assistants and thus hamper performance. Certain critical
adjustments in work place layout related to OT table height, monitor position, cor-
rect placement of foot pedals and efficient design and choice of instruments and
equipments as also insertion angles can significantly decrease the physical and
mental strain of the operating team. With increasing experience, proper training and
right choice of equipments one can circumvent the ergonomic constraints of laparo-
scopic surgery.
Key Clinical Points
1. Improper ergonomics in the operation theatre can lead to unintentional injuries,

increased operative time, errors and increased morbidity
2. The important arenas in laparoscopic surgery which differs from open surgery
and needs consideration are: (1) Laparoscopic vision (2) Altered body postures
(3) Longer operative times (4) Workplace layout (5) Design and function of
laparoscopic surgical equipments (6) Mental workload due to requirement of
enhanced skills.
3. A number of critical adjustments in work place layout need to be undertaken for
improving the ergonomics of laparoscopic surgery (1) Operating table level (2)
Monitor level (3) Foot Pedals (4) Positioning of operating surgeon and assistant.
4. It has been said that the ideal operating table level should be such that: (1) the
angle between lower & upper arm should be between 90° and 120°. (2) after the
insertion of instruments they should be roughly at, or slightly below the level of
the surgeon’s elbows.
5. Ideally the monitor should be placed straight in front of each person, aligned
with motor axis of forearm instruments in the horizontal plane and in the sagit-
tal plane at 15–40 degree below eye level.
6. The other advanced adjustments that can be implemented for ergonomic
improvement are: dual display, mirror image correction for assistants in case of
reverse alignment, head mounted camera, flat display screens and video display
on flexible booms.
7. Foot pedals should be placed close to the foot, aligned in the same direction as
the instruments i.e. towards the target quadrant of surgery as also the principal
laparoscopic monitor.
8. Laparoscopic instruments suffer from ergonomically inadequate handle designs
and inefficient handle to tip force transmission, which lead to surgeon fatigue,
discomfort, and hand paresthesias.
9. When compared to open surgery there are a number of drawbacks in laparo-
scopic instruments. The important issues being (1) Lack of haptic feedback (2)
Use of long instruments which result in an inefficient force transmission mech-
anism and form a large external arc thus more force is required which can result
in fatigue of wrist and forearm muscles (3) Limited degree of freedom of move-
ment of laparoscopic instrument and fulcrum effect (4) Inefficient instrument
designs particularly handle designs.
10. The critical adjustments in laparoscopic instrumentation include: (1) design of
laparoscopic instruments precisely innovations in the handle designs, haptic
enhancement, hand size considerations (2) instrument use: port positioning and
instrument angulation. (3) camera ergonomics.
11. Insertion angles of laparoscopic instruments have important bearing on the

ergonomics. The important angles which need attention are: (1) Manipulation
angle (2) Elevation angle (3) Optical Axis target view angle (4) Azimuth angle.
12. The various types of optical axis alignment with instrument manipulation are
broadly: (1) In-optical axis manipulation (one instrument on either side of the
laparoscope) (2) Off-optical axis manipulation-dominant type i.e. both instru-
ments on one side of the laparoscope to the dominant hand of the surgeon, (3)
Off-optical axis manipulation—non dominant type i.e. both instruments on one
side of the laparoscope on the nondominant side.
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Surgical Meshes Used in Laparoscopic
Procedures
Anubhav Vindal, Yashika Gupta,
and Piyush Kumar Agrawal
Introduction
The term ‘mesh’ refers to prosthetic material, either a net or a flat sheet, which is
used to strengthen a hernia repair. The logic behind use of mesh is that it reinforces
the native tissue with formation of scar tissue by inducing fibrosis [1].
Mesh can be used:
• To bridge a defect: the mesh is simply fixed over the defect as a tension-free patch;
• To plug a defect: a plug of mesh is pushed into the defect;
• To augment a repair: the defect is closed with sutures and the mesh added for
reinforcement [2].
In this chapter we discuss the various types of meshes used in laparoscopic sur-
gery, their indications, advantages and disadvantages.
History
In 1890, Theodor Billroth suggested that the ideal way to repair hernias is to use a
prosthetic material to close the hernia defect [3]. Phelps in 1894 used silver wire
braided meshes for repair of hernia. Later, in 1900, Goepel, Perry and Witzel also
used these silver wire meshes for hernia repair [4–7]. The stiffness due to the metal
used in the prosthesis prompted a modification of the meshes, and these were
replaced with braided meshes made from stainless steel [8–10].
A. Vindal (*) · Y. Gupta · P. K. Agrawal

Department of Surgery, Minimal Access Surgery, Maulana Azad Medical College &
Associated Lok Nayak Hospital, University of Delhi, New Delhi, India
https://doi.org/10.1007/978-981-16-5473-2_9
220 A. Vindal et al.
With the turn of twentieth century, use of newer materials like nylon mesh, poly-
vinyl sponge, orlon cloth, teflon and silicon mesh was reported in hernia repair. But
these were soon discarded either due to reported complications or due to less than
optimal results. The start of second world war, lead to an increased demand of steel
and tantalum for military equipment, ultimately raising their cost and scarcity.
Together with this, there was a boom in the plastic and polymer industry. Both of
these events forced the surgeons and manufacturers to develop newer prosthesis
based on these newer polymers. In 1955, Usher focused his attention on newer
materials that could solve the problems with the existing biomaterials, and he was
the first to use a woven mesh made from a new polyolefin material (Marlex). This
new material had large pores, which facilitated incorporation of the prosthesis in
presence of infections. Despite the success, Usher continued to develop better mesh
units. He soon found that knitted polypropylene had many additional advantages: it
could be autoclaved, it had firm borders, had two-way stretching, and could be rap-
idly incorporated in the body [11, 12]. In 1958, Usher published his surgical tech-
nique using a polypropylene mesh. Almost 30 years later the Lichtenstein
“tension-free” mesh repair was popularized for hernia repair [12].
A switch from metal-based prosthesis to polymers lead to the development of
materials like polypropylene, polytetrafluoroethylene (ePTFE) and polyester. These
three materials are still the backbone of most meshes and today are most commonly
used in prosthetic meshes around the world [13–17].
Tissue Engineering Principles of Mesh Design
The principles of functional tissue engineering [18] were initially developed to help
guiding the design of implants that help in the replacement or repair of body struc-
tures which have important biomechanical functions. The same principles also
apply to the mesh prostheses used for hernia repair.
The most important properties considered in hernia mesh design and manufac-
turing are as follows in Table 1.
Table 1 Properties of meshes

Property Definition Goals/characteristics
1. Biocompatibility Ability to be implanted without Non-toxic material inciting
producing an adverse effect. lowest amount of immune
reaction (all materials produce
some degree of reaction).
2. Mechanical properties
Tensile strength Maximum stress that a material can At least 32 N/cm2 in the
withstand while being stretched strongest direction, at least 16 N/
before failing or breaking. cm2 in the weakest [19].
Elasticity The tendency to return to its Maximum 30% at 32 N/cm2
original shape after being deformed. [20].
Can also be defined as the tendency
to be non-permanently deformed in
response to a force.
Surgical Meshes Used in Laparoscopic Procedures 221
Table 1 (continued)
Property Definition Goals/characteristics
Stiffness The extent to which an object Goals stated as measures of
resists deformation in response to elasticity (currently no
an applied force, and is the opposite standardized range of values).
of compliance.
Pore size Macroporous: >75 μm Neovascularization and tissue
integration are frequently
observed.
Microporous: <10 μm Impedes human cellular
penetration and tissue ingrowth.
Weight Lightweight <33 g/m2 Less intense foreign body
Heavyweight >100 g/m2 reaction in light weight meshes.
Degradation Disappearance of mesh biomaterial The mesh should last until scar
or gradual decline in its mass. or regenerative tissue replaces it
and matures to its maximum
strength.
Constitution Monofilament Multifilament meshes are more
Mutifilament pliable, have higher infection
rate and intense foreign body
reaction.
Anisotropy Degree to which mechanical Almost all synthetic meshes
properties differ in response to exhibit various degrees of
applied loads in different axes. anisotropy.
a b
Fig. 1 Difference between the mesh construction (a) Knit (b) Weave
An important consideration in the construction of a mesh is the difference

between ‘knit’ and ‘weave’. A continuous filament is looped around another in knit-
ting; while a series of parallel strands are alternately passed over and under another
set of parallel strands in weaving. In general, knitted fabrics are more porous and
flexible, while the woven fabrics usually exhibit similar mechanical properties in
each axis. Synthetic meshes are generally knitted, not woven [21] (Fig. 1).
Biocompatibility
The biocompatibility of mesh is dependent on a number of variables. It is a measure

of the degree by which the prosthetic material produces a foreign body reaction in
the tissues. Measures to quantify this reaction include the number of inflammatory
cells (macrophages and granulocytes) around the mesh, granuloma size, vascular-
ization, collagen deposition and mesh migration [22]. All materials used in mesh
prosthesis are chemically and physically inert, non-immunogenic and non-toxic.
However none of them are biologically inert and thus all biomaterials, including the
newer biological meshes [23], trigger some degree of foreign body reaction [24].
The predominant hypothesis for the foreign body reaction in inert non-
immunogenic materials is the protein adsorption theory. The body proteins nonspe-
cifically adhere to the surface of the biomaterials and subsequently lose patterns in
their tertiary structure. This reveals the hidden binding domains that elicit an
immune response in the body [25]. The difference in foreign body reaction is deter-
mined by the difference in adsorption. Ultimately granulomas form around the bio-
materials creating a capsule around it [26, 27].
Of the materials commonly used for making the meshes, polypropylene may
elicit the strongest foreign-body reaction [27]. Multi-filamentous polypropylene
mesh promotes additional fibrosis compared with monofilamentous polypropyl-
ene [28].
Mechanical Properties
Tensile Strength
Tensile strength is probably the most commonly discussed mechanical property of

any mesh. It is defined as the maximum force per cross sectional area that the mate-
rial can withstand before failure or break [20]. Tensile strength is measured in units
of pressure, Pa or N/cm2 [29]. The tensile strength of a mesh needs to be adequate
to withstand the forces exerted on the abdominal wall. Most commercially available
meshes exceed the required tensile strength to withstand the physiological forces of
the abdominal wall [19]. However, mechanical failure of synthetic meshes has been
reported in the literature and is a problem more associated with lightweight meshes
[30–33].
Elasticity
Elasticity, compliance and stiffness are terms that are frequently used interchange-
ably. Elasticity is the property of a material to return to its original shape after being
deformed. It indicates the amount of displacement in response to a specific amount
of force and is regarded as an important characteristic of the mesh. If a mesh is

stretched but does not return to its original size and shape, it will lead to an increased
rate of recurrence. The natural elasticity of the abdominal wall has been estimated
to be approximately 38% at 32 N/cm2. Thus, an elasticity >30% at 32 N/cm2 would
allow for more stretching than the normal abdominal wall permits and, therefore,
might not be suitable for a functional repair [20]. On the other hand, a mesh with
low elasticity would prevent abdominal wall distention, resulting in pain, stiffness
and ultimately mesh failure. It is recommended that the lowest range for mesh elas-
ticity should be between 4% and 15% at 16 N/cm2 [34].
Stiffness
Stiffness is defined as the extent to which an object can withstand deformity in

response to an applied force. Excessively stiff biomaterials can break and fail caus-
ing pain and stiffness on movement and recurrence of hernia [19].
Pore Size and Weight
Pore size and weight are important aspects of mesh design [35–38]. Pores <10 μm
do not allow human cellular penetration and tissue in growth [39]. Pore sizes
≤75 μm, may prevent the access of antimicrobial agents and host immune cells to
bacteria (which are smaller in size), thus, predisposing the prosthesis to bacterial
colonization and infection. Such meshes are sometimes referred to as microporous
meshes, as opposed to macroporous meshes with pore sizes >75 μm [40]. The ePT-
FEsheets (eg: Dualmesh {WL Gore and Associates, USA}) are the only micro
porous synthetic meshes in clinical use, and frequently require explantation when
infected [41–43].
Neovascularization and tissue integration are frequently observed as the pore
size increases to the range of 100–300 μm, but granuloma bridging remains a con-
cern [27]. Granuloma bridging is the phenomenon of coalescence of the foreign
body response around mesh fibres. It can clog the pores of the mesh and prevent its
further tissue integration [27]. In polypropylene meshes, when pore sizes are
<1 mm, granulomas can become confluent, encapsulate the mesh and create a stiff
plate with reduced flexibility [40, 44].
Although it was previously believed that a large pore size would delay tissue
incorporation, this has not been observed in practice. In fact, it has been seen that
the large-pore meshes (with lower surface-area-to-volume ratios) though resulting
in a milder foreign-body reaction, the tissue incorporation is adequate and is facili-
tated by the larger poresize. The caveat is that a reduced mesh material results in a
base mesh with reduced strength.
Weight
Mesh weight is partially dependent on the weight of the polymer from which it is
made [1] but is also dependent on its pore size [44]. With greater pore sizes, less
material is used to construct the mesh, and mesh weight is reduced. The lightweight
meshes generally weigh less than 33 g/m2, while heavyweight meshes generally
weigh more than 100 g/m2 [1, 20]. It is expected that lighter weight meshes will
have lesser foreign body burden [45] and a smaller biomaterial surface area [46],
thereby eliciting a less intense foreign body reaction. However, in practice, the
results have been found to be variable [33, 46].
In practice, large-pore lightweight meshes are reported to have a similar clinical
profile to small-pore heavyweight meshes [47, 48]. Infact one study reported higher
rates of shrinkage for large-pore lightweight mesh compared with small-pore heavy-
weight meshes [49]. Some studies have suggested that large-pore lightweight
meshes result in superior tissue integration [50], better elasticity [51] and a lower
incidence of pain [52], while other studies report a higher recurrence rate for large-
pore lightweight mesh especially in larger groin hernias repaired laparoscopi-
cally [53].
Degradation
Degradation means the disappearance of mesh or a gradual decline in its mass, and
it can be desirable or undesirable. In meshes that are degradable (absorbable), the
aim is to have the mesh provide support until the regenerative tissue replaces it and
matures to the maximum strength. Studies with Vicryl® and Dexon® meshes, have
shown that a three-month time frame for absorption is inadequate [54–56]. Other
studies with the Gore Bio-A® mesh suggest that a longer degradation time of
6 months could be successful [54, 57, 58]. However, the long-term recurrence rate
of the Gore Bio-A® mesh has been reported to be high, ranging from 13% to 37.5%.
It has therefore been suggested that 12 months may be a better time frame for mesh
absorption, to ensure full maturation of the scar tissue with adequate strength to
support the repair. Newer synthetic degradable meshes such as Phasix® and TIGR
Matrix®, that have even slower degradation rates, could be more useful in this con-
text. In clinical situations where the mesh is used to bridge the defect, the mesh is
required to remain indefinitely in place to provide structural support. In these situa-
tions, a degradable mesh is contraindicated and will lead to an early 100% recur-
rence rate [59]. However one must remember that even non-degradable meshes may
slowly degrade over time.
Polyester meshes have been known to have the drawback of long-term degrada-
tion, thereby making them unsuitable for long-term support [60]. Recently, similar
behaviour has also been observed with polypropylene, which is one of the most
widely used biomaterials for meshes [61]. It has been postulated that this degrada-
tion is accelerated with exposure of polypropylene to heat during the manufacturing
process [62]. Degradation of a mesh that is not meant to degrade may contribute to
mechanical failure of the prosthesis and hernia recurrence.
Another important consideration is to understand what replaces the mesh once it
has degraded: scar or regenerated tissue. Regenerated tissue exhibits a greater
degree of cellular infiltration, degradation, deposition of extracellular matrix, neo-
vascularization, lower inflammatory cell response, and less scar encapsulation,
whereas scar tissue has limited host cell and vessel infiltration, more fibrotic matrix,
and aligned collagen deposition. The meshes that are more antigenic are replaced by
scar, whereas those that are less antigenic are replaced by regenerated tissue.
Constitution
Synthetic meshes can be monofilament (mesh fibres are made of single filaments)
or multifilament (mesh fibres consist of multiple filaments). Examples of multifila-
ment meshes include
• Mersilene® (synthetic non-degradable)

• Vicryl® (degradable)
• Vypro® and Parietex® (composite multifilament).
Multifilament meshes are more pliable than monofilament meshes [63]. Reports
suggest that multifilament meshes have higher infection rates compared to the
monofilament meshes due to the presence of inaccessible crevices between the fila-
ments and a stronger foreign body reaction due to the larger surface areas [64].
Anisotropy
Anisotropy is the degree to which mechanical properties differ in response to

applied loads in various axis for a given mesh [65]. Almost all synthetic meshes
exhibit various degrees of anisotropy. This can be the result of the mesh being a knit
material as opposed to a woven fabric. It has therefore been recommended that this
anisotropy should be identified and marked on the meshes to help surgeons orient
meshes during implantation to optimize postsurgical outcomes [65, 66]. However,
the rationale that the meshes should be aligned to maximally resist forces has yet to
be tested or verified [66].
Classification of Meshes
Amid et al. [67], were the first to attempt to classify the meshes according to the
pore size and found pore size was decisive for compatibility. They defined four dif-
ferent types of meshes based on pore size:
1. Macroporous: >75 μm e.g., Prolene, Marlex.

2. Microporous: <10 μm e.g., ePTFE
3. Macroporous with multi-filamentous and microporous components e.g., braided
polypropylene or Dacron mesh;
4. Prosthesis having submicronic pores e.g., silastic.
A complex interaction of biological and host response is seen during the tissue
reaction to the mesh material. Mesh architecture and mesh design also affect the
response apart from the material used. Weyhe et al. proved in 2006 that lighter
weight mesh does not necessarily mean lesser biological and host response during a
comparison between light weight and heavy weight prosthesis [68]. In fact, some
heavy weight meshes also show a very good tissue biocompatibility due to the large
pores which decreases scar bridging. Reduced bridging of scar is found to be associ-
ated with reduced mesh contraction [69, 70].
On seeing the increasing popularity of intra-abdominal mesh placement during
laparoscopic procedures, Deeken et al. felt the necessity to further sub-classify the
meshes with additional barrier function [71]. Prosthesis were attempted to be clas-
sified on basis of their properties of elasticity and biomechanical stability. This clas-
sification system could not be popularised due to marked anisotropy giving different
values in different axes [21, 65, 72, 73].
An attempt was made by Klinge et al. to overcome the limitations of anisotropy
[44], and to categorize and subclassify meshes into classes, taking the textile data of
the mesh into consideration and suggest the concept of “mesh porosity”. To nullify
the effect of anisotropy, “effective porosity” was suggested to classify meshes as:
1. Class 1 mesh—large pore (>60% textile porosity or >0% effective porosity)

Large pore meshes were further sub-classified as:
(a) Monofilament mesh;
(b) Multifilament mesh;
(c) Mesh with mixed structure or combination of multiple polymers i.e., combi-
nation of different non-absorbable materials or combined non-absorbable
and absorbable polymers.
2. Class 2 mesh—small pore (no effective porosity but <60% textile porosity).
These meshes too were sub-classified as:
(a) Monofilament mesh;
(b) Multifilament mesh;
(c) Meshes with mixed structure or combination of polymers.
3. Class 3 Mesh—having special type of features e.g., meshes with special surface
coatings, composite meshes or covered meshes usually developed for intra-
abdominal usage.
4. Class 4 Mesh—with films i.e., meshes with submicronic pores or without any
porosity.
5. Class 5 Mesh—‘3’ Dimensional i.e., meshes or devices which are pre-shaped
and differ from the routine flat mesh.
6. Class 6 Mesh—biological prosthesis.
These were sub-divided as:

(a) Meshes which are cross linked;
(b) Meshes which are non-cross linked;
(c) Meshes having special feature.
The mesh porosity concept lost favour with researchers with advent of various
new materials in the market, changes in mesh designing and fibres as well as diffi-
culties in measuring porosity. Coda et al. proposed a classification taking into con-
sideration the two important factors i.e. mesh density and weight: [74].
1. Heavy weight mesh ≥140 g/m2.

2. Standard weight mesh 70–140 g/m2.
3. Light weight mesh 35–70 g/m2.
4. Ultralight weight mesh ≤35 g/m2.
In 2008, Earle and Mark proposed another classification [75]:
1. Ultra-light weight: <35 g/m2

2. Light weight: 35–50 g/m2
3. Medium weight: 51–90 g/m2
4. Heavy-weight: > 90 g/m2
While a heavy-weight mesh is produced with heavy materials, small pore size
and high tensile strength, a light-weight is composed of thin filaments with large
pores, generally larger than 1 mm.
Before deciding which mesh to be used in a given clinical situation, an under-
standing of different raw materials is important. Different clinical situations make it
necessary to use different raw materials. Many surgeons consider the ease of mesh
handling as one of the important factors during laparoscopic mesh repair while
choosing a mesh. Characteristics of mesh handling usually have a bearing over both
the operative time and results.
The meshes can also be classified as uncoated, coated or barrier and biologi-
cal meshes.
Uncoated Meshes (Fig. 2)
Originally, these meshes were made of either polypropylene or polyester. These

fibres can be manipulated into weaves or knits of varying design and density.
However these meshes are not recommended for intra peritoneal use or in contact
with the viscera.
1. Polypropylene biomaterials
The advantages of this material are that it is flexible, strong, can be cut easily,
resists infection and may be used in contaminated fields. However, it has the
a b
Fig. 2 Uncoated Meshes (a) Polypropylene biomaterial (b) PTFE biomaterial (c) Polyester
biomaterial
inherent disadvantages of a high rate of complications and forming extensive

and dense adhesions.
Some brands available in the market are:
Parietene (Sofradim International), Prolene/Prolene Soft (Ethicon), Prolite/
Prolite Ultra (Atrium Medical Corp.), Surgipro (Covidien/Medtronic), Trelex
(Meadox Medical Corporation), Marlex (Bard/BD), Biomesh (Cousin Biotech),
Ultrapro (Ethicon)
2. Poly-tetra-fluoro-ethylene (PTFE) biomaterials
It is a fairly popular biomaterial but has some important concerns like high
cost, intolerance to infection (being microporous, it has to be explanted) and a
high incidence of seroma formation.
MotifMesh (Proxy Biomedical), Mycromesh (W.L. Gore & Associates),
Mycromesh Plus (W.L. Gore & Associates)
3. Polyester
Polyester satisfies most of the criteria of an ideal mesh and Incorporates well
into the tissues. It is hydrophilic and has good handling properties.
Parietex (Covidien/Medtronic), Mersilene (Ethicon), Versatex (Covidien/
Medtronic).
A newer mesh Progrip (Covidien/Medtronic) is made of monofilament
Polyester and has absorbable Polylactic acid grips for clinging onto the parietal
surface.
Coated or Barrier Meshes
Tissue separating meshes were developed to overcome the challenge of placing

mesh intra-abdominally. The ideal intraperitoneal prosthetic would have two sides
with opposite functions: the surface exposed to viscera would completely repel any
adhesions or ingrowth, while the peritoneal surface would integrate through the
peritoneum and peritoneal fat into the musculo-fascial abdominal wall. The mesh
needs to be protected for 7–14 days until a neoperitoneum is created over it.
The coating or barrier on these meshes can either be permanent, or an absorbable
one. Some of the commonly available brands with their composition are as follows:
1. Permanent barrier (Fig. 3):

(a) Expanded polytetrafluoroethylene (ePTFE)—The parietal side is textured,
while the visceral side is smooth to prevent formation of adhesions. Example:
DualMesh, DualMesh plus (WL Gore), Dulex (Bard/BD)
(b) Polypropylene—Expanded poly tetra fluoro ethylene: Composix (Bard/
BD), E/X: heavyweight PP, L/P: lightweight PP
(c) Titanium coated Polypropylene: TiMesh (Medizintechnik GmbH)
2. Absorbable barrier (Fig. 4):
(a) Lightweight polypropylene—polydioxanone—oxidized regenerated cellu-
lose: Proceed (Ethicon)
(b) Lightweight polypropylene—omega 3 Fatty Acids: C—Qur (Atrium)
(c) Polyester—Atelocollagen type 1—poly ethylene glycol—glycerol: Parietex
Composite/Optimized Composite PCOx (Covidien/Medtronic)
(d) Polypropylene—Polyglecaprone 25: Ultrapro (Ethicon)
a b
c d
Fig. 3 Coated meshes with a permanent barrier (a) DualMesh® (b) Composix E/X® (c) Composix
L/P® (d) Ti mesh®
a b
Fig. 4 Coated meshes with an absorbable barrier (a) Proceed® (b) Parietex Composite® (c)
Ultrapro® (d) Sepramesh® (e) Dynamesh® (f) Parietene DS®
(e) Lightweight polypropylene—carboxy methyl cellulose—sodium hyaluro-

nate—polyethylene glycol: Sepramesh, Ventralight ST (Bard/BD)
(f) Polypropylene—Polyvinylidenedifluoride: DynaMesh (FEG)
(g) Macroporous Polypropylene—glycolide—caprolactone—trimethylene car-
bonate—lactide: Parietene DS (Covidien/Medtronic)
Biological Meshes (Fig. 5)
These are based on collagen scaffold derived from a donor source. The tissues are
decellularized to leave only the highly organized collagen architecture with the sur-
rounding extracellular ground tissue. Removal of all live cells and all nuclear tissue
a b
d e
Fig. 5 Biological meshes (a) Strattice® (b) Xenmatrix® (c) Surgisis® (d) Tutopatch® (e) Surgi
Mend® (f) Collamend® (g) Flex HD®
is done to prevent rejection by the host. Cross linking is done between either inter
molecular or intra molecular amino acids along protein structure to resist degrada-
tion and increase longevity.
1. Human dermis
AlloDerm (LifeCell)
AlloMax (Bard/Davol)
FlexHD (MTF/Ethicon)
2. Porcine Dermis
Permacol (TSL/Covidien)
Collamend (Bard/Davol)
Strattice (LifeCell)
XenMatrix (Brennan Medical)
XCM Biologic (Ethicon/DSM Biomedical)
3. Porcine small intestine submucosa
Surgisis (Cook)
4. Foetal bovine dermis
Surgi Mend (TEI Biosciences)
5. Bovine pericardium
Tutopatch (Tutogen Medical)
Veritas (Synovis)
Another way in which the meshes have been classified is based on their deriva-
tion (synthetic/biological) and their absorbability.
1. Non-absorbable and synthetic materials: polypropylene (PP), polyester (PE),

and expanded polytetrafluoroethylene (ePTFE)
2. Non-absorbable and synthetic with a barrier: These are primarily used intraperi-
toneally for preventing bowel adhesions with the prosthesis (as happens with
uncoated meshes). These are designed in such a way that there is a barrier coat-
ing on one of their surfaces to facilitate direct contact with the viscera and pre-
vent formation of adhesions. e.g.: ePTFE, polyurethane, oxidised regenerated
cellulose, omega-3 fatty acids, collagen, or beta glucan.
3. Synthetic and partially-absorbable meshes: These meshes combine non-
absorbable with absorbable components. The advantage is mainly to reduce the
density of the biomaterial and the reaction it will cause while maintaining the
intraoperative handling characteristics and long-term wound strength. e.g.:
fusion of non-absorbable polypropylene and absorbable materials like polyglac-
tin 910 and poliglecaprone 25
4. Combined Meshes: Main purpose of combined mesh material is to prevent the
complications by taking advantages of the best traits from two different bioma-
terials. In case of polyester and PTFE combined meshes, while polyester allows
the abdominal wall tissue in-growth, the latter prevents the occurrence of intes-
tinal adhesions [76].
6. Biological meshes
These constitute of collagen rich tissues from human or animals, which have
been stripped of all cellular contents and the resultant extracellular protein struc-
ture being stabilized. It is thought to act as a collagen scaffold for the in growth
and deposition of fibroblast and collagen [76, 77].
Yet another classification divides the meshes according to their composition or
type of material as:
1. First generation (synthetic non-absorbable prosthesis),

2. Second generation (mixed or composite prosthesis), and
3. Third generation (biological prosthesis).
Other Newly Engineered Meshes (Fig. 6)
1. Zenapro (Cook Medical): It is a hybrid mesh with a combination of a biologic

with a synthetic component. The biologic component is composed of ECM and
is present on the visceral surface while the synthetic component made with large
pore polypropylene (PP) forms the parietal surface. The PP component provides
long term strength and acts as a scaffold for the tissue ingrowth to occur while
the ECM acts as a temporary biologic barrier to prevent the formation of adhe-
sions between the mesh and the intraperitoneal viscera.
2. Absomesh (Meril): This new mesh is composed of a combination of
Polyglecaprone 25 (PGP)—Polypropylene (PP). The PGP gets absorbed over a
period of time, reducing the foreign material in the body and the non-absorbable
PP continues to provide required support.
3. Phasix/Phasix ST (Bard/BD): This newly developed mesh is made of a biologi-
cally derived monofilament scaffold Poly-4-hydroxybuterate (P4HB) and has an
absorbable hydrogel barrier that lasts for 30 days. P4HB is a naturally occurring
human metabolite found in the brain, heart, liver, kidney and muscle. It provides
a fully absorbable scaffold that lasts for about 52 weeks and metabolizes into
CO2 & H2O. This mesh provides the repair strength of a synthetic mesh and
remodelling characteristics of a biologic.
4. Rebound HRD (MMDI): This mesh is composed of condensed PTFE with a
self-expanding super elastic metallic frame of Nitinol alloy (Ni + Ti). This metal-
lic frame is claimed to keep the mesh in position and helps in proper positioning
and deployment of the mesh intra-peritoneally. It may also prevent mesh con-
traction in the long term.
5. Ventralex/ST, Ventrio/ST (Bard/BD): This mesh is made of polypropylene
with either an absorbable (hydrogel) or permanent (ePTFE) barrier, and a self-
expanding elastic monofilament ring made of Polydioxanone (PDO). The ring
helps in proper positioning and deployment of the mesh intra-peritoneally.
6. Symbotex Composite Mesh (Medtronic): It is monofilament macroporous
polyester in 3D architecture with a bioabsorbable collagen film. Additionally,
b c
Fig. 6 Newer meshes (a) Zenapro® (b) Absomesh® (c) Phasix® (d) Rebound HRD® (e) Ventrio®
(f) Symbotex composite® (g) Progrip® (h) 3D-Max®
Fig. 6 (continued)
the parietal surface has an abdominal wall clinging effect which helps to keep
the mesh on position while the fixation is being done.
7. Progrip (Medtronic): It is a self-gripping light-weight mesh with large pore
sizes (1.1–1.7 mm) composed of monofilament polyester and polylactic acid
micro-grips. The immediate adherence to tissue is provided by resorbable micro-
grips, and therefore additional fixation is not needed anymore.
8. Preformed mesh-Bard 3D Max: It is a plain, non-absorbable, large pore size
polypropylene mesh, with an anatomical shape, already precut and reinforced on
the margins. Grossly it has a blue marker for the medial orientation, crest for the
axis of inguinal ligament and an inferior notch for alignment with the external
iliac vessels. These features help in proper placement of the mesh, avoid migra-
tion and ultimately reduce hernia recurrence.
The different surgical mesh classes along with their various advantages and dis-
advantages are listed in the Table 2. The meshes that get absorbed or remodel with
time and are ultimately replaced by either scar tissue or regenerative matrix are
termed as ‘degradable’.
Table 2 Different classes of available meshes with their comparison

Class of mesh Advantage(s) Disadvantage(s)
Synthetic Inexpensive Not recommended for infected surgical
(non-degradable) Low recurrence rates fields.
Higher rates of infection, discomfort,
as well as adhesions.
Degradable Better side-effect profile than High recurrence rates
non-degradable Insufficient evidence
Lower cost than biological
Biological Can be used in complex/ High recurrence rates
(degradable) infected fields Expensive
Complications
Hernia Recurrence
Hernia recurrence is the most common complication following use of a surgical

mesh [78–81]. Various studies have reported on the results of laparoendoscopic her-
nia repair and recurrence rate is estimated to be less than 5%, ranging from 0.5% to
10%. One needs a thorough knowledge of the anatomy and surgical technique to
minimize recurrences.
The factors which are associated with higher incidence of recurrences are high
BMI, defect size, number of trocars used, smoking and previous failed repairs.
Fundamentally, the causes of recurrence include early mesh degradation, early
mesh removal (as necessary following infections) or mesh failure [82–84]. Mesh
failure can be the result of central mesh failure (mesh fracture) [30–33], or fixation/
suture line failure [85]. Central mesh failure is usually seen in lightweight and only
rarely with heavyweight meshes. Suture line or fixation failure is common and is
typically dependent on the technique of fixation or suturing. Mesh fixation has
remained the subject of numerous researches over the years.
Mechanisms of recurrences in laparoscopic hernia repair, proposed are:
1. Recurrence at the edge.

2. Recurrence at site of original incision left uncovered by mesh.
3. Recurrence at transfascial suture site.
4. Recurrence due to central mesh failure.
5. Port site occurance
6. Pseudorecurrence.
Pain and bulge are the most common way of presentation of any recurrence, a
small percentage of patients may present with obstruction or strangulation.
Diagnosis is generally made by clinical examination, ultrasound and a CT scan.
Treatment of hernia recurrence is more complex than the primary surgery due to the
fact that there will be adhesions, a larger defect, and an unfavorable patient
condition like obesity, comorbidity, etc. Choice of surgical repair will depend on
several factors such as previous surgery, mechanism of failure, obesity, size and
complexity of defect.
Mesh Infection
Open ventral incisional hernia repair has reported an infection rate of 6–10% [42]
mostly compounded by flap necrosis. Incidence of infection is rare after laparo-
endoscopic hernioplasty, due to the limited physical contact of the mesh with the
skin or surgical wound during the surgery. Gram positive bacteria (Staphyococcus
aureus, Streptococcus spp) and Gram negative bacteria (Enterobacteriaceae) are the
most common organisms causing mesh infection. Patient co-morbidity and proce-
dure related risk factors such as obesity, abdominal aortic aneurysm repair, chronic
obstructive pulmonary disease, use of the same incision to perform other procedures
at the time of repair, previous surgical site infection, longer operative time, lack of
tissue coverage of the mesh, enterotomy and enterocutaneous fistulas are some
problems associated with a higher incidence of mesh infection [42]. Various mesh-
related risk factors include the utilization of larger mesh sheets, microporous meshes
or ePTFE mesh [42].
Mesh infections are classified as superficial and deep infections and have been
reported to occur 2 weeks to 39 months from the day of mesh implantation [42].
Infections of the mesh generally respond very poorly to antibiotic treatment.
Superficial infection is treated by intravenous antibiotics and drainage of any col-
lected pus and might have a slightly better prognosis. Prolonged antibiotic treatment
with percutaneous or open drainage of abscess is needed for limited deep seated
infection. In case of extensive infection, a biofilm develops which limits antibiotic
penetration in the infected area. Therefore, in cases like these, the mesh needs to be
removed and surgical debridement of the infected tissue has to be done.
Various preventive measures like following strict aseptic protocol including
change of gloves before handling the mesh and using a no- touch technique as far as
possible helps in minimizing the incidence of mesh related wound infection.
Prophylactic antibiotic coverage is often used but guidelines do not recommend use
of antibiotics in laparoendoscopic hernia repair, although protocols vary institu-
tion wise.
The most debilitating unrelenting infection occurs due to atypical mycobacteria
(Mycobacterium cheloneii). The commonest source is improperly sterilized laparo-
scopic instruments using liquid agents like glutaraldehyde which supports the
growth of these organisms [42]. Autoclaving instruments prevent these infections.
Treatment consists of drainage of any collection and use of anti-tubercular therapy,
however invariably mesh removal is also required. A rescue attempt can be made in
cases of macro porous meshes with extended broad-spectrum antibiotics, local
infected tissue debridement, wound irrigation and vacuum assisted drainage [42].
Complex, contaminated, or potentially contaminated fields are potential indica-
tions of the usage of biological prostheses, but whether and how they are safe for
use is still unclear [86]. Controversy lies in the safety of synthetic non-degradable
meshes in an infected field [86–88]. After the seeding of infection on the non-
degradable mesh, the main concern is inability to treat mesh infection and ulti-
mately mesh explantation. A potential alternative to the biological meshes in
complex or infected fields are the synthetic degradable meshes. High costs of bio-
logic meshes compel some authors to believe that there may be a definite place for
non-degradable meshes in infected fields [89–91].
Adhesion
Visceral adhesion to mesh remains a concern for meshes used in bridging repairs or
for meshes placed intraperitoneally. Various studies depict that bi-face [92] and
barrier-coated [93] composite meshes are effective in reduced adhesion formation.
Temporary barrier coated meshes have a potential problem of lack of specific time-
line for adhesion formation [94]; which may happen any time after mesh implanta-
tion. This issue has been partially addressed by stable hydrophilic coatings that do
not degrade with time but this solution is still in its early stages with limited long
term reports in existing animal model data [95]. ePTFE meshes have been found to
have least adhesion rates [96]. Lightweight meshes, due to their properties of less
foreign body reaction and better integration, have also been reported to show lower
adhesion rates [97].
Postoperative Pain
Postoperative pain is another important complication of laparoscopic incisional her-

nia repair [98]. The type of mesh used may also influence acute and early postopera-
tive pain which is likely also influenced in an equal measure by inflammation and
nerve damage during the procedure [1]. On the contrary, late-onset chronic postop-
erative pain is usually considered to be a complication of the mesh alone, and is
found most commonly associated with foreign body reaction, resulting in stiffness
and shrinkage, and the fibrous tissue engulfing the nearby bare nerves. Depending
on these data, it is thought that risk of chronic pain might be decreased with light-
weight mesh or fully degradable mesh.
Other Mesh: Related Complications
These include mesh: shrinkage, mesh migration and erosion into bladder.
Shrinkage up-to 20% of the original size of the mesh is expected and depends on
the material of the mesh. Primarily shrinkage is of the mesh textile itself, in con-
junction with collagen fiber shortening as part of wound healing. This is of para-
mount importance and has to be always kept in mind when mesh size is decided for
a given hernia defect. Improper size of the mesh can be a factor responsible for
hernia related morbidity including recurrence.
Mesh migration has been described with all types of inguinal hernia repair and
with all mesh materials. However, the lowest risk is with the use of a large flat mesh
in a tension free setting.
Mesh erosion into the bladder is a rare complication after laparo-endoscopic
inguinal hernia repair. It is mostly due to unrecognized bladder injury during the
hernia repair and is not related to the mesh material used. Patients may present with
recurrent urinary tract infection, bladder stone formation and hematuria.
There is a lifetime risk of mesh migration and erosion which increases with
increasing duration of mesh implantation, and these must be considered as possi-
bilities when a patient presents with relevant symptoms after hernia repair.
Characteristics of an Ideal Mesh
An ideal mesh should be:
1. Chemically inert
2. Non carcinogenic
3. Non inflammatory
4. Non allergic
5. Resistant to mechanical strain
6. Resistant to infection
7. Elastic and flexible
8. Have a good memory
9. Transparent
10. Have minimal shrinkage
11. Easy to handle
12. Minimal adhesion formation
13. Rapid incorporation
14. Inexpensive
As on date there is no way to predict the biologic interaction of each patient to

each available hernia mesh. Most of the choices are based on local availability and
the experience of the surgeon. It is therefore prudent to discuss the potential interac-
tions and complications with the patient pre-operatively.
Conclusions
It has been proposed that there should be no standardization of mesh within any
institution, allowing surgeons and patients to have options between different types
of available meshes. As on date, there are no long-term clinical or experimental data
to support the use of most mesh products, and the choices are usually dictated by
personal experiences of the surgeons and hospital policies.
Unfortunately, an ideal mesh has not been developed yet. The problems with the
current meshes include infection, recurrence, post-operative seroma and adhesions,
and these continue to torment the hernia surgeons.
Key Clinical Points

1. Switch from metal-based prosthesis to polymers led to the development of
materials like polypropylene, polytetrafluoroethylene (ePTFE) and polyester.
These three materials are still the backbone of most meshes and today are most
commonly used in prosthetic meshes around the world.
2. Essentially all the materials utilized in developing mesh are physically and
chemically inert, non-immunogenic and non-toxic, but none are biologically
inert. Thus all biomaterials, including the biological meshes, result in an array
of adverse events, ultimately causing a foreign body reaction.
3. Polypropylene may elicit the strongest foreign-body reaction among all the
materials commonly used as meshes.
4. Tensile strength is a very crucial mechanical property of a mesh. Adequate ten-
sile strength is needed to withstand the physiological forces that are exerted on
the abdominal wall.
5. Degradation of a mesh can be desirable or undesirable. Degradable meshes
should have the goal to last until replaced by a mature scar or regenerative tis-
sue providing the maximum support and strength.
6. A complex interaction of host and the prosthesis is seen during the tissue reac-
tion to the mesh material. Mesh architecture and mesh design affect the response
apart from the material used. Lighter weight meshes do not necessarily mean
lesser biological and host response.
7. Prior to deciding which mesh to be used, an understanding of different raw
materials is important. Different clinical situations make it necessary to use dif-
ferent raw materials. Many surgeons consider the ease of mesh handling as one
of the important factors during mesh repair while choosing a mesh.
8. Polyester satisfies most of the criteria of an ideal mesh and incorporates well
into the tissues. It is hydrophilic and has good handling properties.
9. Main purpose of combined mesh material is to prevent the complications by
taking advantages of the best traits from two or more different mesh
biomaterials.
10. Mesh failure occurs due to central mesh failure (mesh fracture), or fixation/
suture line failure. Central mesh failure almost always occurs in lightweight
meshes and only rarely with heavyweight meshes. Suture line or fixation failure
is common and is typically dependent on technique of fixation or suturing.
11. Most debilitating and unrelenting mesh infection occurs due to atypical myco-
bacteria (Mycobacterium cheloneii). Commonest source is improperly steril-
ized laparoscopic instruments using liquid agents like glutaraldehyde which
supports the growth of these organisms.
12. There is a lifetime risk of mesh migration and erosion which increases with
increasing duration of mesh implantation, and these must be considered as pos-
sibilities when a patient presents with relevant symptoms after hernia repair.
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Staging Laparoscopy in Intra-Abdominal
Cancers
Sudhir Kumar Singh, Farhanul Huda,
Rajkumar Kottayasamy Seenivasagam,
and Somprakas Basu
Introduction
The treatment modalities for intra-abdominal malignancies are decided by precise

tumour staging i.e. location and extent of the primary tumour, regional lymph node
involvement and the presence of distant metastasis. Preoperative staging of intra-
abdominal malignancy is important to assess its resectability and possibility of
curative resection. The clinical stage of the tumour is determined by clinical exami-
nation along with laboratory investigations and radiological imaging. Imaging
modalities like transabdominal ultrasound (US), computed tomography (CT), mag-
netic resonance imaging (MRI) and newer modalities like endoscopic ultrasonogra-
phy (EUS) and Positron emission tomography (PET)/Hybrid PET-CT are being
widely used in the assessment of intra-abdominal malignancy.
Although, the use of sophisticated imaging and interventional techniques has
increased the sensitivity of tumour detection, it is still a challenge to detect perito-
neal carcinomatosis and small liver metastasis. Various abdominal malignancies
such as pancreatic, oesophageal and gastric cancer are prone to disseminate intra-
peritoneally, which remains undetected by radiological imaging. Such lesions can
only be detected by direct visualization [1]. Open surgical exploration for detection
of peritoneal spread cannot be justified as it unnecessarily increases the morbidity
in patients with unresectable or noncurative disease.
Minimal invasive surgery has changed the face of modern surgery and is increas-
ingly being used for diagnostic as well as therapeutic purposes. Its utility has been
extended recently to the staging of intra-abdominal malignancies. In addition to
S. K. Singh · F. Huda · R. K. Seenivasagam · S. Basu (*)

Departments of General Surgery & Surgical Oncology, All India Institute of Medical
Sciences, Rishikesh, Uttarakhand, India
https://doi.org/10.1007/978-981-16-5473-2_10
248 S. K. Singh et al.
Table 1 Advantages of staging Improve accuracy of staging

laparoscopy Assess resectability
Decrease unnecessary exploratory laparotomy in
unresectable/metastatic disease
Decrease length of hospital stay in unresectable/
metastatic disease
Obtain biopsy samples
Offer palliative treatments in unresectable/metastatic
disease
direct visualisation of peritoneal cavity with the laparoscope, laparoscopic ultra-

sound (LUS) has improved the sensitivity of staging laparoscopy (SL). It is benefi-
cial in patients with an advanced disease as it avoids unnecessary laparotomies [2].
The main advantage of SL, therefore, is tumour staging, especially in terms of
peritoneal, liver, and lymphatic tumour spread. This affects the treatment plan as
peritoneal carcinomatosis and occult liver metastasis need to be excluded prior to
the application of neoadjuvant treatment regimens [3]. In addition, it may be uti-
lized as a method of obtaining tissue from solid organs like liver and lymph nodes,
directed biopsy and in obtaining cytological specimens from peritoneal lavage or by
fine needle aspiration technique. It is also helpful in assessment of specific lymph
nodes, involvement and infiltration of adjacent organs and named vessels [4]. SL is
reported to increase the rate of resectability while simultaneously decreasing non-
therapeutic laparotomies and length of post-operative hospital stay in unresectable
diseases [4]. However, the other view point states that laparoscopic staging, though
not accurate, may only guide about resectability of the tumors [5]. In general, peri-
toneal carcinomatosis, liver metastasis, direct extension of tumor to adjacent struc-
tures and vascular invasion are the criteria of unresectibilty on SL [1, 3]. The
avoidance of unnecessary laparotomy in intra-abdominal malignancy is the main
advantage of SL as its findings may upgrade the stage of disease (Table 1).
Technique of Staging Laparoscopy
After pre-operative clinical and radiological evaluation, SL is performed under gen-

eral anaesthesia. The patient is placed in supine position on the operation table
which can be converted to Trendelenburg or reverse Trendelenburg position during
the course of examination. This position is advisable, if subsequent laparotomy is
needed. An angled (30 to 45 degree) 10 mm laparoscope is preferred with a high
resolution camera while the use of two video monitors is optional. The laparoscope
is introduced through midline infra-umbilical port. Access to the abdominal cavity
via Hasson’s technique is preferred for infra-umbilical trocar placement. Additional
trocar placement depends on the area to be examined i.e. whether it is an upper or
lower abdominal malignancy. These may include two or three (10 mm or 5 mm)
trocars depending on the need i.e., for liver retraction or dissection of the lesser sac.
These ports may also be used for the introduction of grasping forceps, palpating
Staging Laparoscopy in Intra-Abdominal Cancers 249
probes and biopsy forceps (Fig. 1). Patients with previous abdominal surgeries may
require selective port placement to prevent intra-abdominal injuries.
After creating the pneumoperitoneum using carbon dioxide insufflation and
maintaining the intra-abdominal pressure at 10–12 mm of Hg, sufficient time should
be given for thorough inspection of the whole abdomen before any manipulation is
commenced. If ascites is present, the fluid must be collected for cytological exami-
nation (Fig. 2). Alternatively, in the absence of ascites, peritoneal lavage with
500 mL saline should routinely be performed to obtain fluid for cytological investi-
gation. To ensure that each site of the peritoneal cavity has been appropriately

staging laparoscopy
Fig. 2 Ascitic Fluid (F) in

Pelvis
Fig. 3 Laparoscopic USG

scanning of right lobe of
liver. (Image courtesy: Dr.
Deborshi Sharma)
cleaned, the operating table should be tilted to every side so that lavage fluid can
reach every part of the peritoneal cavity prior to reaspiration.
Abdominal exploration needs manipulation of the viscera and it should be started
from the left upper quadrant in reverse Trendelenburg position. Careful inspection
of the parietal and visceral peritoneum, the greater and lesser omentum, left lobe of
the liver, anterior wall of the stomach and spleen should be done. Inspection of
lesser omentum and cardia can be achieved by retraction of the left lobe of liver.
Sequential exploration of the right upper quadrant includes inspection of the perito-
neal surfaces, right lobe of the liver (especially inferior surface of the right liver),
the falciform ligament and the gallbladder. For lower abdominal exploration, the
patient is positioned in Trendelenburg position and rest of the abdominal and pelvic
viscera are examined subsequently.
Specific visceral exploration requires instrumentation and special manoeuvres.
To evaluate peritoneal metastasis in the lesser sac, it is preferably approached by
dividing the gastro colic ligament. Alternatively, it can be approached through divi-
sion of the gastro hepatic ligament. For detection of deep solid visceral lesions,
laparoscopic ultrasound is used with the help of a flexible ultrasound probe
(7.5 MHz) which is highly sensitive as compared to other radiological imaging
(Figs. 3 and 4). It is also helpful in evaluation of retroperitoneal lymph nodes and
tumour invasion or its proximity to the vessels.
Clinical Applications of Staging Laparoscopy
Cancer of the Oesophagus
Even after R0 resection of oesophageal cancer, the 5-year survival is very low
(range: 10–20%) [6]. However, combined modality therapy may improve the out-
come of patients with operable disease [7, 8]. Accurate staging is also essential for

scanning of left lobe of
liver (Image courtesy: Dr.
Deborshi Sharma)
inclusion of patients in clinical trials. Choice of therapy depends upon the tumour
stage e.g. T1/T2 tumour without lymphatic involvement can undergo upfront surgi-
cal resection while higher stages may require pre-operative chemo-radiotherapy fol-
lowed by surgery. Patients with metastatic disease require palliative treatment [6, 8].
Imaging techniques that are being used currently have a limitation in detection of
peritoneal carcinomatosis, small amount of malignant ascites and lesions smaller
than 1 cm in diameter [7]. Direct visualization by SL can bridge this diagnostic gap.
Thus staging laparoscopy can help detect disseminated disease and assess intra-
abdominal lymph nodes. Approximately in 20–30% of potentially resectable adeno-
carcinoma of distaloesophagus based on imaging, upfrontsurgery can be avoided by
laparoscopic staging with ultrasound as it leads to upstaging of the disease [9, 10].
SL, however, has no proven oncological benefit in squamous cell carcinoma of the
oesophagus as peritoneal carcinomatosis is rare [11].
After exploration of peritoneal, visceral surface metastasis and ascitic fluid sam-
pling, a 5 mm trocar is placed in the epigastric region for retraction of the left lobe
of liver which helps in further examination of the infra-hepatic space, esophago-
gastric junction and hepato-duodenal ligament. For lesser sac exploration, two addi-
tional ports are needed along the anterior axillary line in mid or upper abdomen.
After examination of the lower abdomen and pelvis, if there is no evidence of peri-
toneal spread, assessment of intra-parenchymal liver lesions and suspicious lymph
nodes in the hepatoduodenal ligament and para-aortic region is done by laparo-
scopic ultrasound. Biopsy is performed from the suspicious lesions. The lymph
nodal status in carcinoma oesophagus has a prognostic value on the outcome of the
disease, so laparoscopy and LUS should focus on the celiac axis lymph nodes which
is regional LN for the lower third of oesophagus while distant metastasis for upper
and mid oesophageal carcinomas. Assessment of para-aortic and hepatoduodenal
ligament lymph nodes must be done as their involvement is considered as distant
metastasis.
Only tumours of lower third of oesophagus canbe approached by laparoscopy

whereas for the assessment of upper and mid third oesophageal tumours, thoracos-
copy and endoluminal ultrasonography is required. Infiltration of the diaphragm in
lower oesophageal malignancy can be visualized and biopsied by laparoscopic
approach. Laparoscopy improves the accuracy of clinical staging and is an integral
part of the decision-making process in oesophageal cancer.
Gastric Cancer
In most patients with gastric cancer, curative resection is not possible due to detec-
tion of the cancer in advanced stage. Resection with tumour free margin i.e. R0
resection in early stage is the most important prognostic factor in gastric cancer
[12]. Preoperative staging of gastric cancer consists of various modalities including
clinical examination, liver function tests, CECT abdomen and endoscopic ultra-
sound (EUS). For T and N staging, EUS is superior to CT scan [13]. Because of
limitation of imaging, the role of laparoscopy combined with LUS is of utmost
importance for its staging. The reason behind this is the biology of gastric cancer
which is prone to trans-peritoneal metastasis and palliative resection, leaving small
peritoneal/omental metastasis and/or liver metastasis, does not improve the overall
survival when compared to patients under observation alone [14] (Fig. 5).
Laparoscopy plays a major role in identifying and distinguishing the patients with
early disease, who can undergo upfront gastric resection and lymph node dissection
from patients with a locally advanced disease who may benefit from neo-adjuvant
chemotherapy or palliation.
During SL for gastric cancer, two 5 mm ports are placed in the left and right
upper quadrants for ascitic fluid aspiration and saline lavage from bilateral sub-
phrenic spaces and the pelvis. Peritoneal adhesions, if any, should be divided and
thorough examination of peritoneal cavity must be carried out including both the
anterior and inferior surfaces of bilateral lobes of liver, parietal peritoneum of
Fig. 5 Large omental

deposit missed in CECT
(Image courtesy: Dr.
Deborshi Sharma)
diaphragm, anterior abdominal wall, pelvis, transverse mesocolon (both anterior

and posterior surfaces), small bowel and the mesentery. Further assessment of deep-
seated liver lesions and nodal disease along the root of the mesentery and the liga-
ment of Treitz is carried out with the help of LUS through a 10 mm port in the right
hypochondrium (Fig. 6).
Direct extension of the disease into the duodenum, liver, colon and spleen should
be ruled out. Posterior extension of tumour is evaluated after opening the lesser sac.
For assessment of lymph nodal status, LUS is the most accurate as it defines the
abnormal lymph nodes based on their size and echotexture (Fig. 7). Once the meta-
static disease is ruled out by SL, curative resection can be undertaken in the same
setting whereas on detection of a metastatic disease, the patient is planned for che-
motherapy. Peritoneal lavage cytology may be additionally beneficial.
As far as resectability of the tumour is concerned, immobility and adherence of
the tumour and direct invasion of the pancreas are the findings that can be confirmed
on laparoscopy and LUS. Manoeuvres required for this assessment are
Fig. 6 Metastatic deposit

in left lobe of liver (Image
Sharma)

over stomach to look for
retrogastric nodes (Image
Sharma)
Fig. 8 Cancer deposits

(Arrow) in lesser curvature
of stomach
demonstration of gastric mobility with forceps, opening of lesser sac and elevation
of posterior gastric wall off the surface of the pancreas. Sometimes laparoscopic
staging may be compromised due to the presence of intra-abdominal adhesions and
difficult manoeuvring during the assessment of transverse mesocolon and lesser sac
(Fig. 8).
Pancreatic Cancer
Adenocarcinoma of pancreas is the most common histological subtype of pancre-

atic cancer (80% of all pancreatic cancers). It usually presents in the sixth and sev-
enth decades [15]. Approximately 10–15% of the tumours are confined to the
pancreas at the time of diagnosis where as 40% are locally advanced and 50% meta-
static [16]. R0 resection is the only option for long term survival which mandates
accurate staging before surgery.
Though, CT scan can fairly predict local un-resectability, approximately 40% of
the patients predicted resectable on imaging are found to be unresectable during
surgical exploration due to missed metastatic disease on the serosa [17]. With the
help of a good quality dynamic contrast multidetector CT scan, it may be possible
to differentiate between unresectable, potentially resectable and resectable tumors
[18]. Findings of peritoneal, omental and hepatic metastasis, extra-pancreatic exten-
sion of tumour, invasion or encasement of the celiac axis, hepatic or superior mes-
enteric artery are acknowledged as criteria for unresectability. Whereas tumours
with encroachment on portal and superior mesenteric veins are considered as poten-
tially resectable [18]. Patients having potentially resectable disease or equivocal
disease based on CT findings are candidates for laparoscopic staging.
The goal of laparoscopic staging is to select the patient in which curative resec-
tion will be beneficial. Sub-centimetric hepatic, peritoneal or omental deposits can
be identified by laparoscopy. Additionally, peritoneal lavage fluid cytology at the
time of laparoscopy can detect micrometastasis which has a poor prognosis. Apart
from this, LUS can detect intra-parenchymal liver metastasis and vascular involve-
ment. Findings of suspicious involvement of lymph nodes and vascular invasion,
particularly celiac axis, superior mesenteric vessels and portal vein can be further
Fig. 9 Large lymph node

(Arrow) at base of
mesentery (Image
Sharma)
Fig. 10 Mesenteric node

biopsy (Image courtesy:
Dr. Deborshi Sharma)
Fig. 11 Multiple lymph

nodes (Arrows) near
inferior border of pancreas
Deborshi Sharma)
clarified on LUS (Figs. 9, 10, and 11). Combined staging with LUS is more valuable
in patients with advanced cancer of the pancreatic head and body as compared to
patients with peri-ampullary cancers. Adenocarcinoma of pancreatic tail is notori-
ous for being metastatic and unresectable at presentation; thus, SL is beneficial
particularly for detection of distant metastasis in these tumours. Nevertheless, SL

should not be considered as an alternative to high quality imaging.
SL for pancreatic cancer is done by using three ports; an umbilical port for tele-
scope and two additional ports in the right and left upper quadrant. Positioning of
the trocar should be in such a way that if laparotomy is required, these can be
included in the incision line (rooftop incision). Specific manoeuvre for pancreatic
tumours is done by placing the ultrasound probe along the pylorus and following the
duodenal convexity. In addition, relationship of the adjacent vessels with the tumour
can be identified. The only limitation of SL is difficulty in creation of a prophylactic
bypass in the same setting for anticipated subsequent biliary or gastric outlet
obstruction. Biliary obstruction can be dealt with non-operative intervention such as
endoscopic stenting. Nowadays, technique of laparoscopic biliary bypass and gas-
troenterostomy is well established. Proponents of laparoscopic staging suggest that
patients with unresectable disease should undergo non-operative palliative interven-
tions only when necessary.
Hepatobiliary Cancer
Complete resection is the only potential curative management of primary hepatobili-

ary malignancy and is beneficial only if there is no distant metastasis and there is
adequate functional hepatic reserve after hepatic resection [19]. The aim of preopera-
tive staging is to identify the patients who can undergo curative resection and to rule
out factors which preclude the resection like metastasis, concomitant hepatic disease
and vascular invasion. The incidence of hepatocellular cancer has increased in recent
times due to increasing incidence of chronic hepatitis [20]. In comparison to primary
hepatocellular cancer, metastatic disease of liver remains a more common indication
for SL. Most of the primary tumours involve the surface of the liver, hence laparo-
scopic assessment becomes important. A three-trocar technique i.e., an umbilical port
for laparoscope and two additional ports in the left and right upper quadrantsare used
for hepatic assessment. Sometimes division of triangular ligament may be required for
proper examination of the superior surface of liver. The characteristics of hepatic
lesions on laparoscopy are nodularity or a depressed/umbilicated lesion with hyperae-
mia due to increased vascularity, giving a volcano-like appearance (Fig. 6). The lesion
may be biopsied using a core needle or cup forceps and haemostasis is achieved with
the help of electrocautery along with pressure (Fig. 12). LUS and LUS-guided biopsy
can facilitate the difference between benign and malignant hepatic lesions. Along with
identification of features suggestive of unresectability like diffuse lesions in both
lobes and presence of extrahepatic disease, laparoscopy can identify a cirrhotic liver
which may be a contraindication for major hepatic resection.
Fig. 12 Punch Biopsy

being taken from
superficial liver metastasis
using biopsy forceps
Deborshi Sharma)
Gynaecologic Cancer
Most gynaecological cancers, except cervical and vaginal, are staged surgically. In
the past, staging was performed by laparotomy but with the advent of minimal inva-
sive surgery, laparoscopic staging of these cancers has gained popularity.
Carcinoma Cervix
Approximately 85% of cervical cancers occur in developing countries, where the
resources are limited. As a result, its staging is mainly dependent on clinical exami-
nation while expensive investigations like CT, MRI and PET-CT are not considered
mandatory. Even though lymph node metastasis is not included in the FIGO staging
of Carcinoma cervix, being an independent prognostic factor, lymphadenectomy
forms an integral part of the treatment of cervical cancer. The accuracy of CT, MRI
or PET-CT in detecting lymph node metastases is variable and the decision of
lymphadenectomy cannot be relied on these investigations. A systematic review
showed that 4%–35% of histologically proven para-aortic lymph node metastasis
was missed by CT, MRI or PET-CT. On the other hand, laparoscopic staging can
allow direct assessment of the lymph nodes in patients presenting with an early
disease. The mainstay of treatment in advanced cervical cancer is chemo-radiation.
Thus, by staging laparoscopy, the knowledge of the extent of lymph node involve-
ment can avoid unnecessary extended-field radiotherapy [21–23].
Carcinoma Endometrium
Laparoscopy in endometrial malignancies helps in collecting peritoneal washings
for cytology which has a prognostic significance in this malignancy along with
detection of lymph node involvement and need for lymphadenectomy. The need of
omentectomy can also be decided by laparoscopy [24, 25].
Table 2 Staging Laparoscopy Recommendations

• SL is done to identify any local, regional or distant spread of the disease that would
adversely affect the plan of curative resection.
• SL should be performed in an orderly manner. Biopsy should be taken from suspicious
lesions and cytology of ascitic fluid, if present, should also be done.
• According to the National Comprehensive Cancer Network (NCCN) Guidelines, SL is
useful in patients with adenocarcinoma of the intra-abdominal part of oesophagus.
• According to the consensus based guidelines from the NCCN, preoperative SL for gastric
cancer can be done in a medically fit patient who appears to have more than a T1 lesion on
EUS, no histologic confirmation of stage IV disease, and who would otherwise not require a
palliative gastrectomy because of symptoms.
• In pancreatic adenocarcinoma, SL to rule out metastases not detected by imaging (especially
of body and tail regions) is used in some institutions prior to surgery or chemo-radiation or
selectively in patients with high risk of disseminated disease (borderline resectable disease,
markedly elevated CA19-9, larger primary tumours or large regional lymph nodes).
Intraoperative Ultrasound can be used as an adjunct to SL. Positive cytology obtained from
peritoneal washings is considered as M1 disease.
• In retrospective and prospective studies, the overall yield of detecting unresectable biliary
tract cancer using SL ranges from 24 to 48 percent. The yield is greater for gall bladder
cancer (48 percent) as compared to cholangiocarcinoma (24 percent). SL is recommended
for patients with gall bladder cancers and proximal cholangiocarcinoma but not for distal
biliary cancers.
• SL in colorectal cancers is used very infrequently as resection of primary lesion is necessary
in most patients to control or avoid bleeding and/or obstruction. The role of SL is in limited
metastatic disease to the liver, which can be resected with curative intent.
• The role of laparoscopic staging in stage III-IV ovarian carcinoma is uncertain.
Laparoscopic scoring based upon parameters such as omental cake, peritoneal and
diaphragmatic carcinomatosis, mesenteric retraction, bowel and stomach infiltration and
superficial metastasis in spleen and/or liver has been proven to be accurate in predicting
resectability in advanced ovarian cancers and it could avoid unnecessary up front
laparotomy.
Carcinoma Ovary
Laparoscopic staging in ovarian malignancy is important as 16–39.5% of appar-
ently early-stage ovarian cancers are upstaged after a staging procedure.
Laparoscopic scoring using parameters such as omental caking, peritoneal and dia-
phragmatic carcinomatosis, mesenteric retraction, bowel and stomach infiltration
and spleen and/or liver superficial metastasis has proved accurate in predicting
resectability in advanced ovarian cancers.
It could also avoid unnecessary up front laparotomies, which might otherwise
result in suboptimal debulking [26, 27] (Table 2).
Conclusion
Staging laparoscopy is a simple and safe diagnostic tool to exclude metastatic dis-
ease. With laparoscopic ultrasound, the clinical value of SL has further increased. It
increases the resectability rates, decreases non-therapeutic laparotomies and
decreases the length of post-operative hospital stay in patients with advanced dis-
ease. Staging laparoscopy can help select those patients who would actually benefit
from neoadjuvant treatment, by upstaging the disease identified as early stage on
clinical and radiological staging. Another great advantage of SL is the palliative
laparoscopic procedures in patients with unresectable disease. Its disadvantages
include requirement of general anaesthesia and limited role in assessment of vascu-
lar invasion.
Key Clinical Points

1. Main indication for SL is to improve accurate staging by helping in detecting
peritoneal, omental, liver and lymphatic spread.
2. SL per se in esophageal cancers is primarily beneficial for adenocarcinomas
particularly of the lower third esophagus, and its role in squamous cell carci-
noma is limited.
3. Thoracoscopy in addition to laparoscopy is of additional benefit in staging
esophageal malignancies.
4. SL along with LUS and peritoneal lavage cytology is beneficial in gastric can-
cers to detect metastatic disease.
5. Presence of dense adhesions can limit assessment in SL, particularly of the
lesser sac region.
6. SL along with laparoscopic sonography is useful for the detection of sub centi-
metric tumor deposits on liver, peritoneum and omentum.
7. Detection of vascular involvement particularly of the coeliac axis, superior
mesenteric and portal venous system with SL can determine unresectability in
pancreatic adenocarcinoma.
8. SL is more useful in pancreatic head cancers as compared to periampullary
cancers.
9. SL should not be considered as an alternative to high quality imaging in pancre-
atic cancers.
10. SL is beneficial in determining the resectability of hepatocellular cancers.
11. SL facilitates identification of extrahepatic disease, bilobar involvement and
cirrhosis.
12. Metastatic liver disease is the most common indication for hepatic assessment
in staging laparoscopy.
13. SL useful in assessment of para-aortic lymph node status in cervical cancer.
Editor’s Note1
Clinical staging of malignancies has been traditionally limited to non-operative tech-

niques viz: history, physical examination, imaging and endoscopy. Staging laparos-
copy until lately was not a recommended modality of clinical staging in malignancies,
however recently its incorporation has been envisaged in selective patient subgroups.
Objective of staging laparoscopy: The main objective of staging laparoscopy is
to assess resectability and rule out peritoneal, omental, superficial visceral and other
intrabdominal metastasis which often eludes detection by current imaging modali-
ties. In addition, it provides an opportunity to obtain tissue diagnosis from primary
and metastatic lesions as also lymph node sampling particularly in situations where
previous core biopsy was not possible or inconclusive. It also aids in evaluation of
ascites in patients with malignancy. Any consequent upstaging of the disease can
help avoid unnecessary laparotomy in borderline resectable cases or high-risk
patients and procedures, thus minimizing morbidity and mortality. The relatively
painless quick recovery after staging laparoscopy aids in early initiation of adju-
vant/neoadjuvant treatment when compared with conventional laparotomy.
Additionally, other surgical procedures like splenectomy and oopheropexy in lym-
phoma and insertion of an enteral tube for feeding or palliative procedures can be
done when indicated. With the availability of adjuncts like laparoscopic ultrasound
the diagnostic accuracy of detection of liver lesions has improved over and above
other imaging techniques. Staging laparoscopy should be considered as an addi-
tional tool to help staging and not an alternative to high quality imaging.
Contraindication: Strong contraindications to use of staging laparoscopy are:
1. Patients unfit for general anaesthesia

2. Distant metastasis has been confirmed by imaging techniques and biopsy not
necessary/available.
3. Dense intrabdominal adhesions
Other relative contraindications are patients in whom a laparotomy is indicated

viz: Patients with early-stage malignancy or in advanced disease where a surgical
palliation is essential (for example in intestinal obstruction or gastrointestinal haem-
orrhage), due to its lack of perceived benefits and non-metastatic borderline resect-
able tumours where upfront neoadjuvant chemotherapy is planned.
Disadvantages: The noted disadvantages are:
1. The inherent risks of laparoscopic access and pneumoperitoneum

2. Procedure- and anaesthesia-related complication
3. False negative results may lead to unnecessary laparotomy
4. When staging laparoscopy is planned in separate sitting then there may be a
delay in definitive treatment
5. In situations where the yield is low it can add to unnecessary cost
1
6. Potential adverse oncologic effects of the procedure viz: peritoneal dissemina-

tion, port site inoculation, cyst rupture etc.
Opposition: Detractors of the procedure have put forth that with the availability
of recent imaging techniques a high accuracy has been achieved in detection of
distant metastasis and additional staging laparoscopy may be of limited benefit [1].
Adjuncts: Different Adjunctive techniques have been used to detect peritoneal
hepatic and lymphnode metastasis as well as vascular invasion [2–6].
Adjuncts used in staging laparoscopy to increase yield
1. Laparoscopic USG
2. Lavage Cytology + RTPCR (e.g., for carcinoembryonic antigen)
3. Near Infra-red Fluorescence Laparoscopy/Indocyanine Green Fluorescence
4. Five aminolevulinic acid Fluorescence
5. Fluorescent antibody imaging
Though most studies on fluorescence laparoscopy reported are in experimental

models’ literature in clinical scenariosare emerging.
Results of meta-analysis of trials evaluating staging laparoscopy in various
abdominal malignancies have been tabulated in Table EN1 [7–16].
Table EN1 The results of trials evaluating staging laparoscopy in gastrointestinal and hepatobili-
ary and gynaecological malignancies [7–16]
Authors/year
Type of data Type of malignancy Outcome of SL
Convie L/2015 Esophagogastric cancer Macroscopic metastasis detected in esophageal
Prospective adenocarcinoma (11.8%)
collected data & gastric adenocarcinoma (22.6%). Positive
[7] peritoneal cytology is similar in both types of
malignancy
Ramos RF, Gastric cancer Sensitivity 84.6%, specificity 100% for detection
2016 of peritoneal metastasis
Meta-analysis
[8]
Hariharan D, Hepatobiliary Sensitivity in detection of metastasis in
2010 malignancy 1. Pancreatic cancer: Liver metastasis 88%,
Meta-analysis peritoneal metastasis 92%
[9] 2. Proximal biliary cancer: Liver metastasis 83%,
peritoneal metastasis 93%
Coelen R JS, Perihilar Diagnostic accuracy of staging laparoscopy with
2016 cholangiocarcinoma reference to sensitivity for detection of
Meta-analysis unresectable disease 52.2%
[10]
(continued)
Authors/year
Type of data Type of malignancy Outcome of SL
Tian Y, 2017 Gall bladder and hilar Detection of unresectable disease in:
Metaanalysis cholangiocarcinoma Gall bladder cancer: 27.6%, 0.642 (95% CI:
[11] 0.579–0.701)
Hilarcholangiocarcinoma: 32.4%, 0.556 (95% CI:
0.495–0.616)
Pooled specificity for the SL was 100% (95% CI:
0.993–1.000) for all studies
Ta R, 2019 Pancreatic cancer Of patients deemed resectable in imaging 20%
Metaanalysis (range:14%–38%) had unresectable disease.
[12] Among patients with locally advanced disease
in imaging 36% were detected to have
metastasis. Failure rate to detect non resectable
disease was 5%
Bastiaenen VP, Colonic cancer pT4 Peritoneal metastasis detected in second look:
2019 second look/third look 10% & third look: 10%
COLOPEC 2 laparoscopy
multicentre
randomized
trial [13]
Park HJ, 2013 Early-stage ovarian Reported lower blood loss, upstaging in 22.6%
Meta-analysis cancer and conversion in 3.7%
[14]
Lu Y, 2015 Comprehensive staging Less blood loss, shorter hospital stay, lower
Meta-analysis for early-stage ovarian recurrence in laparoscopic group. One study
[15] cancer showed lower incidence of tumor rupture in
laparoscopy group
Bogani G, 2017 Surgical staging in In laparoscopy a longer operative time (weighted
Meta-analysis early-stage ovarian mean difference [WMD] = 28.3 min; 95% [CI],
[16] cancer −2.59 to 59.2), a lower blood loss
(WMD = −156.5 mL; 95% CI, −216.4 to −96.5),
a shorter hospital stay (WMD = −3.7 days; 95%
CI, −5.2 to −2.1), and a lower postoperative
complication (odds ratio [OR] = 0.48; 95% CI,
0.29–0.81), shorter time to chemotherapy
(WMD = −5.16 days; 95% CI, −8.68 to −1.64)
than laparotomic procedures. Upstaging
(OR = 0.81; 95% CI, 0.55–1.20) and cyst rupture
(OR = 1.32; 95% CI, 0.52–3.38) were similar
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Role of ICG Fluoroscence Imaging
in Laparoscopic Bowel Anastomosis
Deborshi Sharma, Sanjay Meena, Amanjeet Singh,

and Priya Hazrah
Introduction
Fluorescence imaging technology is a recently developed area which has initiated a

paradigm shift in surgical safety and outcome especially in minimal access surgery.
Use of indocyanine green with infrared imaging technology has galvanized its use
in a myriad of applications in surgical practice. 3-dimensional (3-D) system as well
as Hi-definition use has improved performance in surgical decision making, its con-
sequences and patient safety. This chapter describes the use of ICG fluorescence
imaging in laparoscopic surgery particularly in colorectal and bariatric operations.
Fluorescence Imaging (FI)
It is recently emerging as a technique for intraoperative visual inspection of the

extent of tissue permeability which can help in decision making.
The principal attributes of Fluorescence imaging are [1]:
• Good signal to noise ratio (SNR) which provides high contrast such that only the
target area is visible not the background because of different wavelengths used
for illumination and recording.
D. Sharma (*) · S. Meena

RML Hospital, New Delhi, India
A. Singh
Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of
Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Gurgaon, Haryana, India
P. Hazrah
https://doi.org/10.1007/978-981-16-5473-2_11
268 D. Sharma et al.
• It can give molecular information, make (bio)chemistry spatially and temporary

visible.
• It is highly sensitive and small concentration is sufficient for visualization
• Easy to use and interpret as normal anatomical image is visible
• FI is inexpensive in analysis and recording
• FI can be used as research tool for unique imaging modes.
All of the above features holds true for Indocyanine Green (ICG) with its well-
established clinical applications and is currently the most commonly used fluores-
cence agent. ICG was developed by the Kodak research laboratories in 1955 for
near infrared (NIR) photography and got US Food and Administration approval in
1959 for its clinical use [1].
ICG is sterile, non-toxic, anionic and water soluble. It is a hydrophobictricarbo-
cyanine compound with molecular weight of 751.4 Daltons, which is negatively
charged ion, belonging to large family of cyanine dyes [2]. Pharmaceutically avail-
able dry form is stable at room temperature [1].
As ICG is soluble in water (1 mg/mL) but not soluble in saline, it needs to be dis-
solved in water first and dilution with saline is done if it is required to make an iso-
tonic solution [1]. The solution can be administered intravenously or intra-arterially.
After intravascular administration, due to its high affinity towards plasma lipopro-
teins, it bind to them and confines itself to intravascular compartment with minimal
interstitial leakage. It is rapidly taken up selectively by hepatocytes and secreted in
bile after first pass metabolism for excretion within 3–5 min (half-life—t1/2) and
there is no absorption in intestinal mucous membrane, though this fluorophore has
tissue penetration of upto 5 mm. After a span of about 15 min a repeat dose can be
administered or until the ICG dye clears [3]. On extra vascular injection, it gets bind
to protein and reach the nearest draining lymph node within 15 min. After 1–2 h, it
binds to the regional lymph node and is also deposited into macrophages [4–7].
The toxicity of ICG is classified as low. However, in rare instances side effects
like sore throats, hot flushes, anaphylactic reaction (shock, tachycardia, dyspnoe
and utricaria) have been reported. Frequencies of mild, moderate and severe side-
effects are only 0.15%, 0.2% and 0.05% respectively; the mortality rate is 1:330000.
Its use should be avoided in patients allergic to iodine or iodinated contrast agents
(the agent contains 5% of sodium iodide) and in pregnant or lactating females [7].
The recommended dose of ICG for angiography to be injected peripherally is
0.1–0.5 mg/kg, with maximum dose not to increase 5 mg/kg body weight. The stan-
dard dose is injected into a peripheral vein as a bolus of 25 mg dissolved in 25 mL
of water. Within 1–2 s following injection, it binds to plasma lipoproteins and has a
half life of 3–5 min [1, 7].
The principle of ICG angiography in fluorescence imaging is simple that the tis-
sue of interest is illuminated at the excitation wavelength of about 750–800 nm
while observing it at longer emission wavelengths (over 800 nm). Both depend
largely on the solvent used and the concentration. Its maximum values are approx
810 nm in water and 830 nm in blood. ICG works in tissue optical window, that is,
the NIR light used both in excitation and fluorescence, penetrates tissue several mil-
limetres or even further [1].
Role of ICG Fluoroscence Imaging in Laparoscopic Bowel Anastomosis 269
The ICG device consists of a light source, and NIR sensitive sensor and filter
used to block the light at other wavelengths. This allows high resolution NIR images
without ambient and excitation light interference. Several intraoperative visualiza-
tion systems include: the AIM Platform, PINPOINT, the D-Light NIR/ICG,
IC-View, PDE-neo System, the SPY Elite Kit and the da Vinci Firefly robotic sys-
tem. These systems normally work in white light mode as a conventional laparo-
scope, and can be activated into NIR mode, in which ICG visualized as green on a
black background [8].
Clinical Applications of ICG [1]
1. Colorectal surgery, Bariatric and other GI Surgery: real time assessment of

intestinal perfusion to detect anastomotic leak
2. Oncology: Lymphatic mapping, sentinel lymph node detection in breast, mela-
noma, penile, vulvar and other cancers. Detection of metastatic lymph nodes.
3. Intraoperative ureter localisation to prevent iatrogenic ureteric injury.
4. Hepatobiliary surgery: liver mapping, cholangiography, tumor visualization,
and partial liver graft evaluation.
5. Laparoscopic cholecystectomy: real time visualization and identification of
biliary tree to avoid bile duct injury.
6. Reconstructive surgery and flaps: assessment of flap circulation and micro-
vascular anastomosis, postoperative flap monitoring, assessment of burn
injuries.
7. Urology: Renal blood flow
8. Ophthalmology: Retinal angiography
9. Cardiac function
Minimal Access Gastro-Intestinal Reconstruction
Currently minimal access gastrointestinal reconstruction surgery is a very com-

monly done procedure seen mostly after Colorectal and Bariatric surgery.
During open surgery the bowel condition along with its blood supply can invari-
ably be assessed by the tactile feedback. However, with minimal access the same is
not possible hence we depend on few things including visible bowel discoloration
which is actually seen only when blood supply is severely compromised. In detect-
ing borderline or the sub-clinical cases, it will be of great advantage if a perfusion
test can be done on table to confirm the stability of the reconstruction and avoid
post-operative complications.
Among complications after gastrointestinal reconstruction, anastomotic leak is
the most feared and devastating complication which can lead to substantial impact
on the quality of life and mortality. Anastomotic leak by definition is the disruption
of the continuity of the bowel, leading to communication of intraluminal compart-

ment with extra luminal, and subsequent spillage of contents [7].
Colorectal Surgery
The overall anastomotic leak rate after colorectal anastomosis is 1–12% and about
10–14% after low or ultralow colorectal resections and anasotomosis [9–11]. Leaks
can lead to increase in length of hospital stay, rise in reoperation rates, and economi-
cal stress to patient and health-care system. Leaks after colorectal anastomo-
sis increase morbidity and mortality as well as predispose to local cancer recurrence
[12–18]. Revision surgical intervention is required in 10–35% of cases after leaks in
whom mortality rate ranges from 6 to 22% [19, 20].
Identified risk factors as the possible cause of anastomotic leak include: faulty
surgical techniques, patient risk factors, suture material or devices malfunction and
inadequate perfusion at the resection margins with subsequent ischemic changes
leading to leak [9, 20–22]. The mechanical causes can be checked intraoperatively
by doing air-water tightness with air or methylene blue, local site intraoperative
endoscopic visualization and assessment of anastomotic doughnut [16]. Inadequate
anastomotic site perfusion with local ischemic changes and poor oxygenation result
in failure of anastomotic healing and leakage which is difficult to be assessed on
table without perfusion studies, particularly in minimal access procedures [23].
During left sided colorectal cancer surgery after high ligation of inferior mesen-
teric artery, the blood supply to the bowel relies on patency of middle colic vessels
through the Marginal artery of Drummond and Arc of Riolan [24, 25]. Aberrant
anatomy such as absent middle colic artery or inadequate vascularization of the
splenic flexure is seen in upto 25% of cases and it becomes a major risk factor for
anastomotic leak [26–28].
Till now most widely used technique to assess adequate perfusion at resection
margin depends upon visual judgement based on clinical findings, such as tissue
color, temperature, marginal vessels pulsations, bleeding from resected margins and
peristalsis. The clinical assessment and surgeon’s subjective evaluation underesti-
mate the prediction of anastomotic leak [8].
The degree of tissue perfusion can be assessed by marginal vessel status [29].
(a) Brisk, bright red, ≥1 cm projectile bleeding or pulsatile bleeding denotes good
degree of perfusion
(b) Two colour bleeding with bright red arterial and the dark red venous blood, not
pulsatile represent moderate degree of perfusion
(c) Only dark red venous blood observed show poor perfusion
(d) No bleeding suggests no perfusion.
Apart from visual inspection, intraoperative assessment of tissue perfusion can be

made by techniques like transabdominal Doppler ultrasound, transabdominal laser
Doppler flowmetry and oxygen spectroscopy. As these cannot be easily applied in
routine clinical practice and doesn’t have proven reliability hence are not widely
accepted [30–32].
Many a time even CT scan and water-soluble contrast enemas, could not identify
anastomotic leak early enough to allow timely intervention [16]. Proximal diverting
stoma doesn’t reduce the leak risk but do minimise the consequences after disinte-
gration of the anastomosis [33].
ICG in Laparoscopic Colorectal Surgery
Indocyanine green angiography (ICG-A) has come into action and has been suc-
cessfully used for intraoperative real time assessment of tissue perfusion during
colorectal surgery. Fluorescence imaging has become especially important in era of
minimally invasive surgery, with little tactile feedback afforded during resection
[34]. This can lead to change in the site of resection and/or anastomosis, possibly
affecting anastomotic leak rate.
ICG in laparoscopic colorectal surgery can be used at three stages
1 . Pre-operative colonoscopic marking of small tumours/polyp

2. Determining the transaction line in laparoscopic colorectal surgery
3. Confirm vascularity of anastomosis and decision for stoma
Pre-operative colonoscopic marking of small tumours/polyp: Pre-operative

colonoscopic marking within 6 days of planned laparoscopic colorectal surgery,
using ICG (25 mg/5 mL) can be done to help intra-operative localization of tumour.
Submucosal injection of ICG (0.1 mL) is pre-operatively done at two points near the
tumour or polyp which remains at the submucosal level and only the excitation
wavelength penetrates the outer layer helping in intraoperative detection. It’s supe-
rior to conventionally used methylene blue which can spread and stain tissue planes
and make dissection difficult. Even if ICG leaks, it does not affect vision by the
normal eye and as it only can be seen on changing the camera mode [35].
Determining the transection line in laparoscopic colorectal surgery:
Anaesthetist intravenously administer 3.75–7.5 mg of ICG bolus. This can be done
either after routine bowel mobilization and transection of rectum or after division of
rectal/colonic mesentery and central vessels before bowel resection to determine the
exact point of proximal colonic transection. Ischemic zone is evident immediately
after using fluorescence imaging as it takes approximately 10 min for appearance of
ischemic demarcation for visual inspection (Figs. 1 and 2).
ICG is visualized as green in a black background within 30–60 s when excited
with near infrared spectrum light with near infrared camera [36] (Fig. 3). The spe-
cific point is marked with either a clip or marked via an instrument after real time
assessment of perfusion is done to decide line of transection [37]. Perfusion of
planned transection margin is assessed as inadequate, adequate, or optimal. With
ICG imaging change in line of transection is seen in 40% patients undergoing mini-
mally invasive left sided colon or rectal resection [38] (Fig. 4).
Fig. 1 Image of the colon

on NIR mode before
injection of ICG
Fig. 2 Image of the colon

on NIR mode after
injection of ICG as the dye
is slowly visible
Fig. 3 Image of the

complete colon on NIR
mode after injection
of ICG
Confirm vascularity of anastomosis and decision for stoma: FI positively

affects the intraoperative management and patient outcomes, including anastomotic
leak incidence in colorectal surgery [8]. It has influenced surgical decision making
in 28% of patients in laparoscopic rectal cancer surgeries during LAR (low anterior
resection) [38–40].
The overall absolute anastomosis revision rate is reduced by 4% with fluores-
cence angiography, particularly in patient sub groups who had elective resection
Fig. 4 Image of the

transected colon (C) on
NIR with vascularity seen
upto transection line C
(White arrow)
Fig. 5 NIR Image after

circular anastomosis
(White arrow) between
Colon (C) & Rectum (R)
showing complete
vascularisation
C R
(3·1% vs 7·7%) and in those above 70 years (4·3% vs 11·9%) supporting the hypoth-
esis that indocyanine green fluorescence might substantially reduce the rate of
severe complications in colorectal surgery. The only problem with pre transaction
ICG injection is that, sometimes due to handling or stretching, the vascularity at the
transaction line of the same bowel gets changed after anastomosis. So the ICG test
should be ideally performed after the anastomosis to ensure vascularity (Fig. 5).
Some surgeons are exploring the idea to decide about creation of protective
ostomy based on ICG Fluorescence imaging. In future it might possible to avoid
ostomy after colorectal surgery based on ICG imaging, however as yet; it’s unan-
swered on evidence [8].
Major limitations of fluorescence imaging include:
(a) Subjective evaluation of fluorescence intensity

(b) Lack of quantitative means to measure tissue perfusion.
The difference between maximum and baseline fluorescence is the most indica-
tive factor available to quantify anastomotic leak, with sensitivity and specificity of
100% and 92.5% respectively. However, there is no correlation between anasto-
motic leak and time of ICG injection to the first visible fluorescence signal [41].
Bariatric Surgery
Obesity can lead to numerous non communicable diseases like diabetes, hyperten-
sion, osteoarthritis, sleep apnoea etc. It can be the result of modern dietary habits,
sedentary lifestyle apart from endocrinal abnormalities. Bariatric surgery is the
most effective treatment for morbid obesity and helps to achieve or maintain signifi-
cant weight reduction, mitigating various morbid conditions associated with it.
Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure
performed. It is technically simpler and provides comparable weight loss and
improvement in co-morbidities with minimal metabolic complications as compared
to other procedures like Roux-en-Y gastric bypass [42].
Leakage from the staple line is one of the most dreaded complication that can
lead to reoperation, increased length of hospital stay, increased patient and financial
burden of health-care system and can even lead to mortality in up to 6–17% cases
[43–48]. Presentation of leak in these populations is often delayed due to muted
clinical presentation of the abdominal pathology. They often present with sepsis
multisystem organ failure [49]. After LSG, staple line leak rate ranges from 0–2%
and approximately 0.01–2.3% after Roux-en-Y gastric bypass from either gastroje-
junal anastomosis or directly from the gastric pouch [50–52].
Staple line leak after any bariatric procedure is divided according to the time of
its presentation as:
1 . Early — within POD (post operative day) 0–4

2. Intermediate — from POD 5–9
3. Late stage — after POD10
Early leaks are due to technical issue, such as staple misfire and tissue injury,
while intermediate and late leaks, are mainly a result of ischemia along the staple
line. Most common site for leak is the “Angle of His” due to combined factors of
mechanical stress and ischemic factors [52–55]. Advancement in surgical technique
and staple formation lead to decrease in leak rates, but still ischemic factors have not
been addressed formally.
Proximal gastric blood supply is unequivocally mainly derived from left gastric,
right gastric and inferior phrenic artery [56, 57]. Sometimes, accessory left gastric
arises from left hepatic artery and is present in gastrohepatic ligament supplying the
cardia and fundus of stomach. Injuries to any of these blood vessels can happen dur-
ing laparoscopic dissection.
During bariatric surgery if one or two branches of left gastric are severed, the
vascular submucosa plexus allows replacement of blood flow, but if three branches
are stapled, the blood supply gets compromised. Similarly branches of inferior
phrenic artery can be injured if associated hiatus hernia is repaired and accessory
gastric artery in gastro hepatic ligament may be inadvertently injured.
Over sewing the staple line, adding buttress material such as seam guard or
bovine pericardium and applying fibrin glue and other sealants are among the
techniques used to avoid complications, mainly bleeding. None have any significant
evidence in their efficacy in reducing leaks [50, 58–63].
Routine methods to detect staple line leak intraoperatively are [64]:
1. Methylene blue dye test: In this methylene blue at high pressure (to increase
sensitivity) is administered intraluminally via orogastric tubing near the staple
line and concurrently visualized by laparoscopic camera to detect extravasation
of blue dye. In addition a gauze pad can be placed adjacent to the staple line to
detect blue stain in case of any leak.
2. Gastroscopy with insufflation: The staple line is submerged in saline and gas-
troscopy is done. Air is insufflated into the remnant gastric lumen and presence
of air bubble if any visible by laparoscopic camera indicates a faulty staple line.
These tests may have an ill effect on the newly constructed anastomosis and
might induce the leak either due to the pressure of methylene blue instillation or
endoscope insertion and insufflation [55, 65]. Methylene blue leaves a permanent
stain and if it leaks, the operative field gets obscured, hence compromising safety of
subsequent leak repair. Gastroscopy with insufflation requires an experienced
endoscopist, an available endoscope in operation room, increase operative time
along with the cost of instruments and personnel involved.
These disadvantages can be simply avoided by instilling ICG via orogastric bou-
gie intraluminally to the remnant gastric lumen and checking the staple line.
Role of ICG in Laparoscopic Bariatric Surgery
ICG fluorescence by intravenous administration is a newly developed technique to

assess tissue perfusion and to perform vascular mapping during surgery thus poten-
tially preventing leaks as well as perfusion-related complications [66]. This method
can provide information like
1 . Arterial inflow and venous return from a target tissue area

2. Rate at which perfusion of tissue occurs between arterial and venous phases
3. Identification of the variable blood supply patterns at GE junction, to prevent
ischemia-related leaks.
Most importantly ICG is rendered invisible once the NIR spectrum light is dis-
engaged and does not interfere in further surgery.
Methods
ICG angiography: Dissection is done along greater curvature as standard tech-

nique. Branches of right and left gastroepiploic vessels to the stomach are
coagulated along with the short gastric vessels using energy device. ICG, 1 mL
(1 mg/mL) is administered intravenously before sleeve creation to assess blood sup-
ply and its pattern. Placing 36-french lighted bougie in place the sleeve is created
with an attention to preserve the identified blood supply to the GE junction and
gastric tube. After the sleeve is created, 3 mL of ICG is injected to ensure preserva-
tion of pertinent blood vessels.
Intraluminal method: Laparoscopic bariatric procedure is performed in stan-
dard manner. ICG (2.5 mg) is mixed with water and then diluted in 100 mL of sterile
saline. After completion of procedure at the usual time of leak test (100 mL in LSG
and 60 mL in LRYGB laparoscopic Roux en Y gastric bypass) the ICG-saline dilu-
tion is instilled intraluminally by anaesthologist through orogastric bougie. Near
infrared laser of the camera is enabled and the passage of ICG observed and contin-
ued for approximately 30s afterwards. The staple line is highlighted with fluores-
cent green dye. If there is any leakage of fluorescence it denotes positive leak test
while absence of any leak depicts negative leak test. If positive, repair of the leak is
done in a standard fashion. Once the laser is disengaged the ICG is rendered invis-
ible and standard lighting is resumed facilitating leak repair unlike while using
methylene blue [65].
The intraluminal ICG method has sensitivity of 100% & specificity of 98.28% in
detecting clinically significant gastric staple line leakage, with negative predictive
value of 100% [65].
Future of Fluorescence Imaging
While we await randomised controlled trials to define the standards for use like dos-
age schedules and timings, fluorescence angiography continues to have a consider-
able clinical benefit in minimally invasive colorectal surgery and bariatric surgery.
Future studies will need to address the fluorophores used in fluorescence imaging.
At present, only two near-infrared fluorophores that support image-guided surgery
are available clinically: indocyanine green and methylene blue. However, neither
fluorophore provides optimum specificity and stability for targeted image guidance
[67]. Therefore, the development of near-infrared fluorophores to target this unmet
clinical need is of paramount importance. New fluorophores are being developed
that are water-soluble and biocompatible, with absorption and emission maxima
within the desired near-infrared spectra and have improved fluorescence perfor-
mance [68–70]. Novel fluorophores are being tested in animal models, and some are
being used as endoscopic molecular tools, providing an enhanced visual picture of
the mucosal and molecular targets [71, 72]. Fluorophores can also be used to label
antibodies and other biomarkers, converting a therapeutic tool into a diagnostic tool
[73–79]. Thus, development of fluorophores with the properties that are absent in
the dyes used at present might contribute towards the ongoing expansion of near-
infrared-fluorescence guidance in surgical practice. With this vast potential for
expanded use, studies will need to define the cost-effectiveness of fluorescence
imaging in laparoscopic surgery. The cost of the new technology can be prohibitive
for resource-limited health-care systems, restricting widespread application.
Conclusion
Initially developed for hepatic, cardiac, renal function evaluation and retinal artery
angiography, ICG fluorescence imaging has become a valuable tool and is now
widely used in laparoscopic gastrointestinal surgeries especially in colorectal and
bariatric procedures. As the location of these operative regions are difficult to
approach in case of a leak in post operative period and is associated with severe
morbidity and mortality, it is of paramount importance to identify such possi-
ble cases on table. The absence of tactile feedback sensation in laparoscopic era
makes the use of FI more important. The applications of fluorescence imaging using
ICG continue to evolve because of its safe, feasible and beneficial character.
Although fluorescence imaging seems to have a cost benefit in reducing compli-
cations and guiding appropriate resections, more studies on the true value of this
modality that consider outcomes, costs, and patient experience are warranted.
Key Clinical Points

1. Fluorescence imaging technology has initiated a paradigm shift in surgical safety
and outcome especially in minimal access surgery. Indocyanine green imaging
under infrared light is being investigated in a myriad of surgical applications.
2. It is highly sensitive and a small concentration is sufficient for visualization.
Further its easy to use and interpret as normal anatomical image is visible.
3. As ICG is soluble in water (1 mg/mL) but not soluble in saline, it needs to be
dissolved in water first and dilution with saline is done if required to make an
isotonic solution.
4. The recommended dose of ICG for angiography to be injected peripherally is
0.1–0.5 mg/kg, with maximum dose not to increase 5 mg/kg body weight. The
standard dose is injected into a peripheral vein as a bolus of 25 mg dissolved in
25 mL of water.
5. Pre-operative colonoscopic marking within 6 days of planned laparoscopic
colorectal surgery, using ICG (25 mg/5 mL) can be done to help intra-operative
localization of tumour.
6. The overall absolute anastomosis revision rate in colorectal surgery is reduced
by 4% after using ICG. In future it might be possible to avoid ostomy after
colorectal surgery based on ICG imaging
7. The intraluminal ICG method has sensitivity of 100% & specificity of 98.28% in
detecting clinically significant gastric staple line leakage, with a negative predic-
tive value of 100%
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Minimizing Pain in Laparoscopic Hernia
Surgery
Naveen Sharma, Deborshi Sharma, and Sanjay Meena
Introduction
Hernia is one of the few conditions afflicting the human body which has only a
surgical cure. The most common type of hernia is the inguinal hernia and for ages,
recurrence was the bugbear of hernia repair and the huge number of types of hernia
repair only attested to the fact that most operations had less than optimal results.
This problem was mostly solved by the Lichtenstein tension free mesh repair which
many considered as gold standard as it consistently gave a low recurrence rate in the
hands of most surgeons. It also lent itself well to performance under local anes-
thetic. The Achilles’ heel of the Lichtenstein tension free mesh repair is the rela-
tively high frequency of chronic groin pain [1]. Over the years methods and
techniques with modifications have been suggested to overcome this chronic issue.
Type of Pain After Hernia Surgery
Acute and Chronic Post-operative pain
Most defined chronic pain as pain persisting beyond 3 months. However a range of
definitions is used ranging from 3–12 months. Pain in post operative period can be
due to neuropathic pain [Architectural damage of nerves] or Nociceptive pain
[Damage of tissue or organs leading to release of substance].
N. Sharma (*)
Department of Surgery, All India Institute of Medical Sciences, Jodhpur, India
D. Sharma · S. Meena
Dr RML Hospital, New Delhi, India
https://doi.org/10.1007/978-981-16-5473-2_12
284 N. Sharma et al.
Pre Peritoneal Repairs
Rives and Stoppa independently advocated the use of the preperitoneal space for
placement of a large mesh for management of groin hernia. This operation was
performed through a long lower midline incision. With laparoscopy coming of age
in the early 1990s, the same preperitoneal space was approached either extraperito-
neally during a totally extraperitoneal repair [TEP] or transabdominally while per-
forming a transabdominal preperitoneal repair [TAPP]. A large mesh of 15 × 10 cm
or larger could be deployed in the space after reducing the hernial sac using two
5 mm ports and one 10 mm port [Common technique].
Reducing the size of the large incision required for performing open inguinal
hernia to just 1 cm for laparoscopic surgery led to a remarkable decrease in early
postoperative pain and the large mesh kept the recurrence rates consistently low.
Research started shifting from recurrence as an endpoint to addressing endpoints
like acute postoperative pain and chronic groin pain [2].
Laparoscopic Repair
Laparoscopic [which would also include preperitoneal repairs for purpose of this
article] inguinal hernia repair [LIHR] is usually performed under general anesthe-
sia. While some papers have suggested that it is possible to perform LIHR under
spinal, epidural or even local anesthesia [3], very few surgeons perform LIHR under
these alternate anesthesia techniques; most repairs are performed under general
anesthesia. Some surgeons even advocate the use of a robot for minimal access
inguinal hernia repair but a large number of surgeons fail to appreciate the benefits
of using robot for inguinal hernia repair as compared to a LIHR [4].
Most LIHR surgery is performed using three ports, the commonest combination
being one 10 mm port and two 5 mm ports. Use of only two ports to accomplish
LIHR with and intent to further decrease pain and improve cosmesis is suggested,
but the technique never found its widespread use [5] (Table 1).
Table 1 Steps of surgery or modifications which can reduce acute postoperative pain
1. Preemptive analgesia
2. Choice of the type of ports used
3. Size of ports
4. Telescopic dissection vs balloon dissection
5. Completely reducing the indirect hernia sac vs proximal ligation and transection
6. Using a Transversus abdominis plane [TAP] block
7. Mesh material
8. Mesh size
9. Mesh fixation: Non fixation, Suture fixations, glue, absorbable tackers are modifications
over the conventional nonabsorbable titanium tack
10. Instillation of local anesthetic in dissected space
11. Closure of port sites and Skin closure
Minimizing Pain in Laparoscopic Hernia Surgery 285
Note: Most surgeons consider general anesthetic to be within the purview of the
anesthesiologist. This chapter will not address the nuances or difference in anesthe-
sia techniques used for laparoscopic inguinal hernia repair. There are mixed reports
regarding the role of Gabapentin or similar drugs administered preoperatively to
decrease the incidence of chronic postoperative inguinal pain.
odifications to Prevent Acute Post Operative Pain After

M
Laparoscopic Hernia Repair and their Management
Pre-emptive analgesia: It is the pre-incision port site infiltration with local anes-
thetic, so that the central pain circle is not created.
Pre-emptive analgesia using infiltration of port sites using lignocaine has proved
efficacious in laparoscopic cholecystectomy and decrease in postoperative pain has
also been demonstrated after infiltration of port sites during LIHR [6]. Infiltration
with local anesthetics can have benefits and specific effects have been seen in com-
parison to placebo. However no difference is seen in the long term to decrease
postoperative pain after infiltration of skin with local anesthetic either before mak-
ing the incision or before closure or at both times. In any case the risk of infection
and cost associated with this intervention is low and its routine use may be consid-
ered by the surgeon.
Radial dilating or cutting ports: A decrease in postoperative pain is seen after
using radially dilating trocars particularly in TAPP since these port sites do not
require suture closure [7, 8]. The trocars used during robotic surgery are also dilat-
ing trocars; therefore, the pain score after robotic surgery is reported to be the same
as after LIHR. However, a word of caution is sounded as port site hernias are gener-
ally reported after using 12 mm ports’ [9–14] incisional port site hernias have also
been reported through 8 mm robotic trocar port site [13, 14].
Size of ports: Reducing port size might help but it might not very significant.
Most surgeons perform LIHR using two 5 mm ports and one 10/12 mm port for the
telescope which is also used to insert the mesh. Some surgeons have attempted to
use 3 mm working ports instead of 5 mm working ports while using only a 5 mm
port as the optical port. They have reported that the pain is significantly less in the
early postoperative period with the use of smaller size ports [15–20]. However,
systematic review comparing single incision laparoscopic surgery versus multiple
incision laparoscopic surgery for inguinal hernia failed to reveal a statistically sig-
nificant difference in postoperative pain between the two groups [21].
Telescopic dissection vs balloon dissection: There are two commonly employed
techniques to create the initial space in totally extraperitoneal repair. The space is
either created using a forward viewing telescope or using either a commercial or
indigenous balloon made of glove fingers. Few RCTs comparing the two have
reported lower pain scores at 6 hrs in balloon dissection group compared to the
telescopic dissection [22] while similar trials have also given conflicting reports that
both techniques are similar in postoperative pain profile [23].
Avoiding Peritoneal tear: Pneumoperitoneum is associated with shoulder pain.

Since most studies do not report increased pain after TAPP as compared to TEP, it
is reasonable to assume that a peritoneal breach in TEP is not likely to increase
postoperative pain. However small amount of dissection fluid or blood trickling into
the peritoneal cavity through peritoneal tears during TEP, is often unseen, and can
cause some amount of pelvic peritoneal irritation leading to pain in immediate post
operative period. The same blood/fluid is obviously easily seen during TAPP and
same is always taken care of before or after closing the peritoneal flap.
Completely reducing the indirect hernia sac vs proximal ligation and trans-
action: The pain scores are comparable in patients who underwent ligation and
transection of the distal hernia sac to those in whom a complete reduction of the
hernia sac was performed [24]. However similar studies do report decreased pain
scores and operative time when simply the sac is transected using harmonic shears
compared to a ligation with suture followed by transection of the distal sac [25].
Mesh material, type of mesh and size of mesh: The commonly used meshes
are made up of polypropylene or polyester. Polypropylene meshes are differentiated
on basis of weight, pore size, knit etc. Some have a partially absorbable component;
others have impregnated titanium. Weight of the mesh [g/m2] is always taken into
consideration in post operative pain, particularly in chronic pain. The lighter, larger
pore meshes are associated with less postoperative discomfort compared to their
heavier, denser cousins and reduced density meshes decrease postoperative pain [1].
The worry that this decrease in pain comes at a cost of increased mesh migration
and recurrence has not been substantiated [1, 26].
Anatomical meshes and 3D meshes are used for ease of deployment and for
reducing the necessity for fixation. There is no evidence that their use decreases
postoperative pain after LIHR however use of a self-gripping mesh can decrease the
postoperative pain. Sizes of mesh have a direct proportional relation to post opera-
tive discomfort [27].
Mesh Fixation: Mesh fixation is done using various means and it has always has
been compared to no fixation of mesh. Recurrence rates do not differ between LIHR
with permanent mesh fixation and without permanent fixation of mesh [1]. The pain
scores are significantly lower in patients in whom the mesh is not fixed by tacks.
Guidelines do often recommend no fixation after TEP repair [1]. However, not all
surgeons feel confident in deploying the mesh without fixation and they choose
nonabsorbable tacks, absorbable tacks, fibrin glue, transfascial sutures, or endocor-
poreal suturing to fix the mesh to the Cooper’s ligament. Many studies report that
fixation using glue causes less pain than tacks [1]. Mesh fixation is always recom-
mended in patients with large direct hernias [M3-EHS classification] undergoing
TAPP or TEP to reduce recurrence risk [28].
Instillation of local anesthetic in the dissected space: Instillation of local
anaesthetic just before deflating the abdomen has many takers. It can theoreti-
cally after TEP procedure where no peritoneal breach has been created can
desensitize the exposed nerves and prevent immediate post-operative pain. The
pain free period depends upon the half-life of the anaesthetic used. Numerous
studies do show slight improvement after local anaesthetic installation. However,
a meta-analysis of randomized controlled trials on this subject did not demon-

strate a significant difference in postoperative pain [29]. Indwelling catheters
providing continuous anaesthetic using patient controlled analgesia pumps can
also reduce acute post-operative pain. Above all meticulous dissection in the
proper planes is a better alternative to reduce pain.
Closure of port sites and Skin closure: Fascial closure of 10 mm plus ports are
always advocated to avoid port site hernia. The final step of approximating the skin
incisions can be accomplished by suture, staple clips or cyanoacrylate glue. No
significant difference is found after any type of skin closure.
Chronic Pain After Laparoscopic Repair
Pathogenesis of Chronic Pain After Laparoscopic Repair
Perioperative injury to nerves or nerves entrapped by sutures or more commonly by

fixation devices such as tacks can lead to a chronic pain. Nerves overlying or near the
mesh can also be trapped in mesh shrinkage and later in the peri-mesh inflammatory
process. Often it is that small peri-mesh “meshoma” which entraps the nerve [30].
Hence during laparoscopic repair care should be made not to completely bare the
nerve of its surrounding fascia or tissue. Some tissue between the mesh and nerve is
always welcomed [31]. Diagnosing the specific cause and type [neuropathic or noci-
ceptive] of pain is very difficult at times. During laparoscopic inguinal hernia repair
commonly involved nerves in the space of Bogros are the lateral cutaneous nerve of
thigh and genital branch of genito-femoral nerve lying just medial to it.
Assessment and Severity of Pain
Concept of mapping the sites of pain (+, 0, −) have also been proposed. Images can
be preserved of the areas involved [abdomen, groin, thigh etc] and changes in site of
pain are compared with subsequent images to plan a management strategy [32].
These maps can provide broad ideas about the probable nerves involved [33] (Fig. 1,
Table 2).
Other recognized method of Quantitative sensory testing (QST) uses procedures
like pain on pin prick, pain on pressure, pain on contact with hot or cold. These are
regarded as a more conventional methods but is more time taking and difficult to
arrange in daily clinical scenario [34].
Management of Chronic Pain After Laparoscopic Repair
Incidence of chronic pain in hernia repair is less after laparoscopic surgery [28]. All
causes of chronic pain have their own special treatment hence knowing the probable
cause of pain is of paramount importance.

showing the nerves in
groin area and the local
nerve supply of the thigh
region. 1: Iliohypogastric
[T12-L1], 2: Ilioinguinal
Nerve [T12-L1], 3:
Genitofemoral nerve
[L1-L2], 4: Lateral
cutaneous nerve [L2-L3],
5: Femoral branch of
genitofemoral, 6:
Ilioinguinal nerve
supplying medial side of
thigh, 7: Genital Branch of
genitofemoral [S: Scrotum,
M: Medial side of thigh, L:
Lateral side of thigh]
Table 2 Indicators of presence or absence of pain Plus (+): Active pain

during area mapping Minus (−): Area of numbness
Zero (0): No pain or numbness
Hold back policy: Most pain after inguinal hernia repair tends to reduce with
time. So a complete explanation of the situation at times is helpful and active inter-
vention directed at pain can be hold back [35]. However few patients can get
depressed and start living an inactive life which should be particularly avoided [36].
Local anesthetic injection at site: These can cause temporary benefit depending
upon the half life of the drug used. However if these anaesthesia blocks are given
properly, they can definitely identify the nerve involved in the cause of pain [37].
Drug therapy: Advised medications vary from case to case. Mostly used are
NSAID, gabapentins, tricyclic antidepressants and selective serotonin/norepineph-
rine reuptake inhibitors with routine analgesics [38]. Lidocaine or diclofenac
patches have been used, but they generally don’t have any benefit [39].
Surgical management: Ranges from removal of the specific tack or removal of
the mesh to laparoscopic retroperitoneal neurectomy which should be done by
experts only. Patient need to understand that pain can be often due to damage of
nerves and removing the mesh might not alter the nerve injury and the patient can
still continue to perceive pain [31].
Conclusion
Strategies for minimizing acute postoperative pain in LIHR which are likely to be
most useful are pre-emptive infiltration of port sites with local anesthetic, choosing
radially dilating ports [if costs are not a major concern], avoiding mesh fixation
whenever possible, using suture or glue when mesh fixation is deemed essential and
performing a TAP block [under laparoscopic vision]. The most important measure
for preventing chronic pain is to avoid any type of fixation below the iliopubic tract.
Key Clinical Note

1. In Laparoscopic surgery reducing the size of the large incision required for
performing open inguinal hernia repair had a remarkable effect on early postop-
erative pain & the large mesh kept the recurrence rates consistently low.
2. Pre or post incision analgesia using infiltration of port sites using lignocaine has
proved effective and decreases in postoperative pain in comparison to placebo.
3. Single incision laparoscopic surgery versus multiple incision laparoscopic sur-
gery for inguinal hernia has no significant difference in postoperative pain.
4. TEP can have an inconspicuous peritoneal tear through which blood or fluid
can trickle into lower abdomen which can lead to peritoneal irritation and pain.
5. Weight of the mesh [g/m2] is taken into consideration in post operative pain,
particularly in chronic pain.
6. Mesh fixation is not required in all hernias as it may increase post-operative
pain and is recommended in patients with large direct hernias [M3-EHS] to
reduce recurrence risk.
7. Nerves overlying or near the mesh can be trapped in its shrinkage and the peri-
mesh inflammatory “meshoma” can also entrap the nerve.
8. Diagnosing the specific cause and type [neuropathic or nociceptive] of post
hernia repair pain is extremely difficult.
9. Pain area mapping can provide information of nerve involved and progress of
disease.
10. Most cases with pain after inguinal hernia repair tend to improve with time and
don’t require any specific therapy.
11. No uniform drug schedule is available for these cases. It varies from patient to
patient.
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doi.org/10.1213/ANE.0b013e31824d6168.
38. Bjurstrom MF, Nicol AL, Amid PK, Chen DC. Pain control following inguinal herniorrhaphy:
current perspectives. J Pain Res. 2014;7:277–90. https://doi.org/10.2147/JPR.S47005.
39. Bischoff JM, Ringsted TK, Petersen M, Sommer C, Uçeyler N, Werner MU. A capsaicin
[8%] patch in the treatment of severe persistent inguinal postherniorrhaphy pain: a random-
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org/10.1371/journal.pone.0109144.
Extended-View Totally Extraperitoneal
Approach (eTEP) for Inguinal Hernia
Repair
Deborshi Sharma, Gautam Anand, and Priya Hazrah
Introduction
Inguinal hernia repair is one of the commonest surgeries performed worldwide [1].
New technology and advancement in technique which has improved the post opera-
tive quality of life has almost nullified the role of conservative treatment in hernia.
Recent universal acceptance of minimally invasive surgery in treatment of inguinal
hernia repair has led to its most significant metamorphosis [2]. Chronic groin pain
is almost negligible after laparoscopic repair and patients do return to normal activ-
ity and work earlier [3, 4]. Over the years of observation and familiarity, it has been
seen that laparoscopic procedures are absolutely safe in experienced hands.
Presently four laparoscopic techniques are commonly described in repairing an
inguinal hernia:
1. Totally extraperitoneal (TEP) repair

2. Transabdominal preperitoneal (TAAP) repair
3. Intraperitoneal onlay mesh (IPOM)
4. Extended view totally extraperitoneal (e-TEP)
Surgeons interested in laparoscopic surgery should be accomplished in all tech-

niques so that they can tailor their approach as per need of the patient. Among them
many surgeons prefer a totally extraperitoneal approach based on Rives-Stoppa
technique in which the peritoneal cavity is not entered [5]. This lessens the risk of
intra-abdominal organ injury and adhesion formation [6–8].
D. Sharma (*) · G. Anand

Department of Surgery, Lady Hardinge Medical College and Associated Dr RML Hospital,
New Delhi, India
P. Hazrah
https://doi.org/10.1007/978-981-16-5473-2_13
TEP all these years has shown a few drawbacks which surgeons all over face and
try to master with time. Among them confined space for dissection, difficulty in
mesh spreading due to inadequate space, cramped port placement and very impor-
tantly, a longer learning curve for young surgeons [1]. These limitations restrain its
use by the regular surgeon in spite of routine execution by laparoscopic experts
[9, 10].
Anatomically the inguinal extra peritoneal space can be reached from virtually
anywhere on the abdomen. The preperitoneal space in the lower abdomen is con-
tinuous with the retro rectus space beyond the arcuate line. Considering the above,
extended view totally extra peritoneal repair (eTEP) was designed [10, 11] and ini-
tially described by J Daes. “e” stands for extended view (Fig. 1).
Fig. 1 Pre-peritoneal spaces which can be approached from many areas

Extended-View Totally Extraperitoneal Approach (eTEP) for Inguinal Hernia Repair 295
Important principal advantage points of eTEP [12]
1. Large area of extraperitoneal space.

2. Different workable areas for port placement depending upon hernia and patient
characteristics.
3. Ease of tissue dissection which includes proximal peritoneal dissection as well
as distal sac dissection.
4. Larger space allows pneumoperitoneum to adjust better within the space with
very rare extravasation into the peritoneal cavity or subcutaneous space.
5. Better ergonomics, ease in maintaining triangulation.
Indications of eTEP
eTEP technique can be used to repair all cases of inguinal hernias; nonetheless, in
some specific scenarios eTEP is particularly helpful,
1. eTEP approach particularly is easier to grasp for the new surgeon. Concepts of
starting laparoscopic inguinal hernia surgery through TAPP and then moving to
TEP for trainees can be left aside, as eTEP technique can prime them early for
the extra-peritoneal approach.
2. Large abdomen or thick abdominal walls: Obesity is always a relative contrain-
dication for beginners because of the difficulty to negotiate the thick belly apron.
Further it is considered that the abdominal subcutaneous tissue is thinner in the
upper abdomen facilitating entry in eTEP.
3. In general the distance between umbilicus and pubic symphysis should be around
15–18 cm [13]. In patients in whom this length is lower it becomes very difficult
to accommodate the vertical three ports as it often leads to a chopstick effect of
the instruments during TEP.
4. TEP after pelvic surgery is difficult and is often avoided. However eTEP where
the dissection starts from far above the arcuate line creating space, previous pel-
vic surgeries don’t remain an absolute contraindication.
5. Difficult inguinal hernias in the form of large inguinoscrotal hernias occupying
most of groin space, and in patients with large irreducible hernias or large sliding
hernias, eTEP can be helpful as the ports are away from the area of dissection
and no cramping for space is felt.
In some clinical scenarios even the eTEP technique is comparatively difficult to

perform, like patients with previous lower midline laparotomy presenting with
bilateral hernia, or large sliding hernias and patients with previous history of radical
prostatectomy.
Expert surgeons might not see the benefit of e-TEP initially but slowly they iden-
tify cases in which they were doing TAPP or open procedures, now possibly those
cases can be managed by eTEP technique.
Technical Aspects of the eTEP Approach
Strong hernia repair mandates adequate dissection, proper mesh placement with
good overlap. eTEP technique can provide exactly the same without entering the
peritoneal cavity [14].
Instruments
Extended view TEP requires almost the same instruments as in TEP or

TAPP. Comfort of using all the same instruments within the large space is clearly
evident.
• Laparoscope: Any one scope of 10 mm or 5 mm is sufficient. Visual perspec-

tive of 300 or 00 depends on the surgeon. In the initial recto-rectal dissection
definitely 00 is helpful, however once the arcuate line is crossed a 300 is
preferable.
• Access ports: One 10 mm and two 5 mm is the standard. Additional 5 mm might
be required in rare cases.
• Hand instruments: Maryland dissector, L-Hook, Babcock’s grasper or any spe-
cific fenestrated grasper.
• Mesh: Polypropylene mesh of 15 × 15 cm is preferred. In selected cases even
larger meshes can be used however no direct benefit is seen. Lightweight mesh
or absorbable mesh in particular should be avoided as these large hernias where
eTEP is indicated can have increase incidence of local recurrences with
these meshes.
• Fixation devices: Considering the large area dissected one or two fixations are
always advocated. Sutures or fixation tacks have the same results like any other
Laparoscopic hernia repair.
Steps of Surgery
Patient is in a supine position with hands tucked at the side. Monitor is at the foot
end. Surgeons stand at the sides. Right handed surgeon generally prefer standing on
the left side of the patient while the camera holding assistant can be on the same side
or opposite side depending on the camera position. The operating table can be bro-
ken at the level of the costal margin which increases its distance to pubic symphysis
creating little more space to work with.
Camera Port Creation of the first port is by an incision of 10–12 mm, made at a

point which is 4 cm above and 4 cm lateral to the umbilicus (4/4). Side of the inci-
sion depends on the side of hernia, hernia characteristics and also on the orientation
of the surgeon. Hernia characteristics which are to be considered are unilateral her-
nia or bilateral hernia, if unilateral hernia which side (Right or Left) and in case of
bilateral hernias which side is larger or complicated (Including recurrent hernias).

Hernias in eTEP can be approached from both sides (Same side or opposite side).
Ports can be in-axis maintaining triangulation with adequate manipulation angle or
off-axis in some cases where the manipulation angle is reduced (Figs. 2 and 3).
Fig. 2 Camera (C) and

ports positions (P1 & P2)
for unilateral or
uncomplicated hernia (UH)
a b
Fig. 3 (a) Camera (C) and ports positions (P1 & P2) for Bilateral hernia (LH—Large Hernia &
SH—Small hernia). (b) Camera (C) and ports positions (P1 & P2) for Bilateral hernia (LH—Large
Hernia & SH—Small hernia)
In general during bilateral hernias, the camera is kept on the side of larger or
complicated hernia and working ports are off-axis on the opposite side (Fig. 3a, b).
While operating on unilateral uncomplicated hernia, the camera port can be on
the same side while maintaining triangulation of ports (Fig. 2). Right handed sur-
geons might at times find operating easy from the left side with the right hand work-
ing port to the right of the umbilicus. Port positioning overall is absolutely a surgeon
preference and can be acquired with practice.
Space Creation Through the 10–12 mm incision made at the decided site for cam-
era port, the anterior rectus fascia is exposed by sharp dissection and using the small
‘S’ retractor to retract the subcutaneous tissue and taking care not to create a subcu-
taneous tunnel. A no 11 size blade is used to incise the anterior rectus sheath in line
with the incision and both the lips of the cut rectus sheath are held with small Allis
clamps. Using a Kelly forceps the underlying rectus muscle is split in line of its
fibres and perpendicular to the sheath incision. Once that is done, the ‘S’ shaped
retractors are used to separate the fibres further. Then one can use a small peanut
swab (1 × 1 cm) mounted on the tip of a curved artery forceps or bluntly surgeon
can use his finger to create aspace between the muscle and the thick posterior sheath.
The dissecting finger or swab slides down into the retro rectus space and can be
swiped to right and left to create an initial space.
Balloon dissector (Standard available at market or indigenously made—Fig. 4)

can be used, which is carefully inserted directed towards the pelvis and with the
opposite hand the surgeon needs to pull the abdominal wall upwards so to maintain
appropriate orientation and avoid inadvertent entry into the peritoneal cavity.
The tip of indigenous balloon that we use is kept about 2/3 inches below the
umbilicus so that once inflated it does not enter the retro pubic space. Many experts
have avoided use of balloon for dissection. However, reports advocate routine use of
a balloon dissector which reduces the duration of surgery and bleeding. Once the
space is created (3 min inflation time), the balloon is removed and a trocar cannula
of 11 mm size inserted (Plastic transparent cannula) and same is fixed to edges of
incision using 2-0 silk to avoid gas leak. Once this port is inserted and secured, a
laparoscopic camera is introduced through it (Fig. 5).
Fig. 4 Indigenous made

gloved finger tied over
5 mm suction cannula
Fig. 5 Image after

creation of space. The
arcuate can be seen (White
arrows), in distance the left
hernia (H) and inferior
epigastric vessels (Red
arrows)
H
Once this space is created, hernia dissection can proceed further with either tele-
scopic dissection or working ports can be inserted to start dissecting. Every time
during dissection it should be checked that the inferior epigastric has not fallen
down and is always at the roof.
Working Ports Due to the large dissection, working port site can be flexible with
e-TEP. The initial entry port incision is placed in the upper quadrant on the same
side of the large hernia, usually 4 cm above and 4 cm lateral to the umbilicus. This
port might need to be higher in some cases particularly in very obese patients.
Subsequently 5 mm working port (Figs. 2 and 3 {P1}) is placed just below and lat-
eral (away from large hernia side) to the umbilicus and the next 5 mm port is placed
on the opposite lower inferior quadrant (Figs. 2 and 3 {P2}). An accessory 5-mm
port particularly in bilateral hernias is placed on the inferior quadrant opposite to PI/
P2 (Figs. 2 and 3 {A1}). Using this configuration hernias on both sides can be oper-
ated, however the surgeon some times needs to change sides and use ports P1 + P2
(Off-axis) or ports P1 + A1 (On-axis) for either hernia (Figs. 2 and 3). In Bilateral
hernias the working ports in general should be at a higher level to avoid interference.
Few authors advocate use of the flank opposite the hernia side about 3 cm above
and 5 cm lateral to the umbilicus for the first camera port. Following this one 5-mm
working port can be placed at or next to the umbilicus, and the other can be placed
inferior and lateral to the camera on the same inferior quadrant (Opposite to Hernia),
thus achieving perfect triangulation (Fig. 6).
Proponents advocating this approach mention about advantages of a large surgi-
cal field for large or complex hernias, less arcuate arch interference and achieving
visual triangulation for both sides.
Arcuate Arch Division If the visualization is not proper the arcuate arch which
extends midway between umbilicus and pubic tubercle might need division. This is
Fig. 6 Camera (C) and

ports positions (P1 & P2)
for unilateral hernia on
opposite side. (S) Surgeon
and (A) Camera Assistant
are on same side
Fig. 7 Sharp cold

dissection done to release
the arcuate arch
more frequent when the camera is used higher up in the abdomen. A small lateral
cut is usually good enough to improve vision. A midline cut on the arcuate line is
generally avoided as the posterior sheath and peritoneum are adherent in the midline
and it can create a rent leading to leakage of gas. (Fig. 7) Leakage of gas into peri-
toneal cavity is mostly not an issue in eTEP as the wide dissection helps to maintain
space inorder to perform surgery.
Fig. 8 Large mesh

16 × 14 cm accommodated
in the dissected space and
fixed to Cooper’s ligament
(White arrow)
Repair of Hernia Descriptive explanation is beyond this chapter but all principles
of laparoscopic inguinal hernia repair have to be followed which includes the con-
cept of critical view of Myopectineal orifice of Fruchaud(MPO) [15]. This is char-
acterized by proper exposure of the anatomy before placing a mesh.
Identification of pubic tubercle, symphysis pubis and Coopers ligament: In case

of large direct hernia preferably the opposite side is dissected first creating space
before visualization of the structures. Once the orientation is done by identifying the
structures, space of Bogros is created beyond and up to the anterior superior iliac
spine, sweeping it back inferiorly. Nerves need not be identified and seen but dissec-
tion has to be done adequately to accommodate the mesh. Retro-pubic space is dis-
sected staying away from the bladder and the femoral ring identified to check for
any femoral hernia. Sac and peritoneum is dissected from the cord (parietalization
of cord). This is done for at least 4 cm from deep ring or till when the Vas turns
medial or uptill the midpoint of psoas muscle. Any lipoma of cord is removed and
ultimately the mesh should lie flat; any dissection in triangle of doom should be
avoided. Meshes of size 16 × 14 or 15 × 13 are used and can be placed flat, avoiding
rolling up at the edges with mandatory little overlap in midline and covering the
MPO. Fixation is done to Cooper’s ligament and any extra fixation if required
should always be done above the iliopubic tract to avoid nerve injury, especially to
the ilioinguinal nerve (Fig. 8).
A blunt grasper from both or either of the lateral ports can keep the mesh in posi-
tion at the lateral-inferior corners in particular while deflation is being done so that
the mesh doesn’t rolls up at its edges. Implementing the theory of critical views of
safety for inguinal hernia i.e. Inverted Y and five triangles [16], the complications
and recurrences are reduced which ultimately improves patient care.
Closure of Ports Preperitoneal space is then deflated under vision and fascial clo-
sure of all port sites above 10 mm are done using synthetic absorbable sutures.
Post-Operative Care Fluids are restricted orally for 4 hours after surgery and then
started on clear fluids and later soft diet on the same day evening or the morning
after. Patients are advised regarding early mobilization and are usually discharged
the next day of the procedure.
Complications Local complications of eTEP are similar to TEP.
Conclusion
The concept of eTEP has recently revolutionized the approach for inguinal hernia
repair with young surgeons finding the learning curve less steep. It has been very
well documented that once the confluence of the arcuate line and semilunar line is
separated, it provides a limitless extraperitoneal space to work with. Regardless of
a difficult body habitus e-TEP provides a better anatomical and sound TEP repair,
compliant with the concepts of CV of the MPO, especially for residents / junior
faculty early in their experience.
Key Clinical Points

1. Surgeons interested in laparoscopic inguinal hernia surgery should be accom-
plished in all techniques so that they can tailor their approach as per need of the
patient.
2. Confined space is the main draw back of TEP, which surgeons all over face and
tries to master with time.
3. Anatomically the inguinal extra peritoneal space can be reached from virtually
anywhere on the abdomen and is continuous with the retro rectus space beyond
the arcuate line.
4. eTEP with fast and easy creation of the large extraperitoneal space can be used
to repair all cases of inguinal hernias; nonetheless, in some specific cases eTEP
is particularly helpful.
5. A flexible port setup is adaptable to many situations, which leads to easy pari-
etalization of the cord structures, easier management of the distal sac in cases of
large inguinoscrotal hernias with improved tolerance of pneumoperitoneum.
References
1. Krishna A, Bansal VK, Misra MC, Prajapati O, Kumar S. Totally extraperitoneal repair in ingui-
nal hernia: more than a decade’s experience at a tertiary care hospital. Surg Laparosc Endosc
Percutan Technol. 2019 Aug;29(4):247–51. https://doi.org/10.1097/SLE.0000000000000682.
2. Daes J. Minimally invasive surgical techniques for inguinal hernia repair: the extended-view
totally extraperitoneal approach (eTEP). In: Davis Jr S, Dakin G, Bates A, editors. The SAGES
manual of hernia surgery, vol. 33. Springer; 2019. p. 449–60.
3. Schmedt CG, Sauerland S, Bittner R. Comparison of endoscopic procedures vs Lichtenstein

and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized
controlled trials. Surg Endosc. 2005;19:188–99.
4. McCormack K, Scott NW, Go PM, et al. Laparoscopic techniques versus open techniques for
inguinal hernia repair. Cochrane Database Syst Rev. 2003;1:CD001785.
5. Daes J. Reparolaparoscopico de la hernia inguinal. Experiencia de la Unidad deLaparoscopia.
Clinica Bautista, Barranquilla, Colombia. Rev Colomb Circ. 1999;14:97–103.
6. Wake BL, McCormack K, Fraser C, et al. Transabdominal preperitoneal (TAPP) vs totally
extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database
Syst Rev. 2005;1:CD004703. https://doi.org/10.1089/lap.2008.0212.
7. Leibl BJ, Jager C, Kraft B, et al. Laparoscopic hernia repair—TAPP or/and TEP? Langenbeck’s
Arch Surg. 2005;390:77–8.
8. Ferzly G, Sayad P, Vasisht B. The feasibility of laparoscopic extraperitoneal hernia repair
under local anesthesia. Surg Endosc. 1999;13:588–90.
9. Ismail M, Garg P. Laparoscopic inguinal total extraperitoneal hernia repair under spinal anes-
thesia without mesh fixation in 1,220 hernia repairs. Hernia. 2009;13:115–9.
10. Daes J. The enhanced view-totally extraperitoneal technique for repair of inguinal hernia. Surg
Endosc. 2012;26:1187–9.
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repair. In: Novinsky YW, editor. Hernia surgery: current principles, vol. 2016. New York:
Springer; 2016. p. 467–72.
12. Daes J. Endoscopic repair of large inguinoscrotal hernias: management of the distal sac to
avoid seroma formation. Hernia. 2014;18:119–22.
13. Abhyankar SV, Rajguru AG, Patil PA. Anatomical localization of the umbilicus: an

Indian study. Plast Reconstr Surg. 2006 Apr;117(4):1153–7. https://doi.org/10.1097/01.
prs.0000204793.70787.42.
14. Ng SC, Lau SYC, Wardill D. How to do an extended totallyextraperitoneal mesh repair for
groin hernias. ANZ J Surg. 2019;89(10):1324–5.
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16. Furtado M, Claus CMP, Cavazzola LT, Malcher F, Bakonyi-Neto A, Saad-Hossne

R. Systemization of laparoscopic inguinal hernia repair (TAPP) based on a new anatomical
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Mini Gastric Bypass
Anshuman Poddar, Om Tantia, and Tamonas Chaudhuri
Introduction
Obesity is a problem of pandemic proportions in both developed and developing

countries. Numerous procedures have been described and many such as jejuno-
colic, jejuno-ileal bypass and Mason’s loop gastric bypass have been abandoned
due to various complications. Various operations performed as surgical treatment
for obesity nowadays are: Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve
gastrectomy (LSG), Mini-gastric bypass (MGB) to name a few. These procedures
have their short and long-term benefits and complications. Fear of these complica-
tions make a surgeon or a patient, think and rethink before undertaking a bariatric
procedure [1].
MGB was first performed by Dr. Robert Rutledge in 1997 [2, 3]. The procedure
faced a lot of criticism from the time of its inception but now it is regarded as one of
the most popular and widely practiced metabolic surgical procedure. The adoption
of correct technique for performing MGB ensures best results and also avoids any
short and long term complications.
MGB is primarily a malabsorptive procedure unlike LSG or RYGB which are
restrictive procedures. The gastric pouch and the gastrojejunostomy (GJ) in MGB
are intentionally designed to be a non-obstructive conduit for food from its inlet to
its outlet. The diameter of the gastric pouch is made similar to the oesophageal
lumen. A moderate size bypass is made between the gastric pouch and jejunum
which induces rapid gastric emptying into the mid-jejunum and produces an exag-
gerated post gastrectomy syndrome that makes sweet and liquid calories induce
discomfort and passage of moderate to large number of fatty foods relatively
A. Poddar · O. Tantia (*) · T. Chaudhuri

Dept. of Minimal Access and Bariatric Surgery, ILS Hospitals, Kolkata, West Bengal, India
https://doi.org/10.1007/978-981-16-5473-2_14
306 A. Poddar et al.
intolerable [2]. Here in the chapter we will try to focus on the correct technique in
creation of the gastric pouch, the Bilio-Pancreatic limb and end to side gastro-
jejunostomy during Mini Gastric Bypass.
Principles and Technique
A procedure is regarded as a “safe procedure” when its pre-operative preparations

are simple, the procedure is easily reproducible and with minimum incidence of
complications [3].
Ergonomics and Patient Position
Patient is placed in supine position and is under general anesthesia. Urethral cathe-
terization is done and dynamic limb compression device is applied. Patient is
strapped to the table and all pressure areas padded with soft cotton. The surgeon and
the camera surgeon are on the right side of the patient and assistant surgeon on the
left. The patient is placed in steep head rise and a tilt of 45° towards the right [4].
Port Position (Fig. 1)

5-port technique is commonly used. The port positions are as underlined [4]:
• A—12 mm, subxiphoid 2 cm below the xiphoid process

• B and D—12 mm, Right and Left subcostal 2 cm below costal margin at MCL
Fig. 1 Port placement

Mini Gastric Bypass 307
• C—12 mm, 18 cm below xiphoid

• E—5 mm, Left anterior axillary line below costal margin
M—Monitor, S—Surgeon, CA—Camera assistant, A1—Assistant.
Creation of Lesser Omental Window
Diagnostic laparoscopy is performed followed by creation of the lesser omental

window. Dissection is started beyond the crow’s foot on the lesser curvature of the
stomach about 3–4 cm proximal to the pylorus. All the adhesions of the stomach are
released and a window is created for about 2–4 cm to enter the lesser sac [4] (Fig. 2).
Antral Division
A 45-mm gold/green cartridge stapler is engaged across the antrum of the stomach
at right angles to its axis. More than 60% of the antral width should not be tran-
sected in the first firing. This takes care of the passage of the contents from the
bypassed remnant stomach. Twist should be avoided by grasping both the walls of
the stomach equally which will also help to avoid “bird beaking” of the edges
thereby avoiding trouble during gastro-jejunostomy as well in the next subsequent
firing [4].
Fig. 2 Creation of lesser

omental window. LC
Lesser Curve
Creation of MGB Gastric Pouch
The MGB pouch in contrast to RYGB pouch is different in the respect that it is
restrictive not obstructive. In contrast to RYGB, it also has a large pouch with a
wide GJ [2]. The MGB pouch is again different from the sleeve gastrectomy tube in
the respect that it’s a wide tube with no stress on OG junction dissection. The MGB
pouch is designed for relatively rapid non-obstructive transport of food from the
esophagus into small intestine which results in post gastrectomy syndrome. The
pouch length, GJ and loop Billroth II or GJ are designed to recapitulate the surgical
analogue of antrectomy and Billroth II reconstruction. The pouch should start just
distal to crow’s foot as this helps in prevention of Gastro-esophageal Reflux Disease
(GERD), pouch should lie as such that the medial aspect, formed by the mesentery
of the lesser curvature points directly to the 9 o’clock to the patient’s right and the
neo greater curvature points to the patient’s left at 3 o’clock with anterior and pos-
terior walls of the pouch being equal. Proper control of bleeding during pouch cre-
ation is a necessity; hence the prime maneuver is proper compression by the stapler
for around 30 seconds before firing. Rapid firings of stapler should be avoided as it
may lead to oozing and subsequent compromise of the staple line. After antral divi-
sion, gastric pouch creation is started by second firing, done from the right hypo-
chondrial port. The axis of division is kept perpendicular to the first firing (Antral
division) and parallel to lesser curvature [3] (Fig. 3).
Bougie of 36-Fr is then inserted and engaged until it reaches the tip of the pouch
Subsequent firings are done with the bougie as a guide. Care should be taken to cre-
ate a moderate-sized gastric pouch which is never too tight on the bougie (Fig. 4).
Dissection during MGB should be lateral to the left crus of the diaphragm and a
proper and safe dissection around the hiatus is mandatory to create an adequate
Fig. 3 First transverse

firing (Antral division)
Fig. 4 Second stapler

firing for creation of
gastric pouch (P)
Fig. 5 Creation of
window near the angle of
his. MGB Pouch (P),
Remnant stomach®
space for stapler engagement. Care is taken to avoid inadvertent injury to short gas-
tric, inferior phrenic vessels and the spleen (Fig. 5). The final staple firing is to be
placed at least 2 cm lateral to the GE junction to avoid leaks near the junction in
spite of the fact that it is a low-pressure drainage system at the GJ (Fig. 6), so back
pressure at GE junction is minimum. During MGB it is even acceptable to leave a
small amount of fundus in exchange for leak prevention [5].
Bowel and stomach should be checked to avoid any kink or twist. One should
avoid a Bird’s beak deformity at the distal tip of gastric pouch and try to create a
Fig. 6 Image showing the

distance from GE junction
which should be
maintained while firing the
last stapler (Image
Courtesy: Dr Deborshi
Sharma)
Fig. 7 Cobra head shape of distal end of gastric pouch
wide cobra head effect of the distal tip to provide a wide perfusing field for the lat-
eral aspect of the distal gastric portion of the GJ [4] (Fig. 7).
Bilio-Pancreatic Limb (BPL) Length
The performance of MGB in general never requires division of the omentum as it

might increase the risk of internal hernia and bowel obstruction [2]. The omentum
should be retracted medially and the small bowel length should be measured with
the help of marked atraumatic bowel grasper. The small bowel being a dynamic
organ changes its length and so the perfect bowel length is impossible to determine
at operation. It is important to leave atleast 3 metres of small intestine distal to gas-
trojejunostomy to avoid malnutrition [2]. The length of the BPL should be tailored
according to the patient’s profile and co-morbidity with 150 cm for obese and
180 cm for super obese being mostly favored.
BPL length of >200 cm should be reserved for revision cases. A longer bypass
results in more malnutrition without significant effect on co-morbidity resolu-
tion [6].
Creation of Gastro-Jejunostomy (GJ)
Creation of GJ is one of the most important steps in MGB. The goal is a wide open
and non-obstructive GJ that allows easy, rapid emptying of the gastric pouch which
is similar to the passage of food through esophagus. GJ thus created contributes to
the induction of post gastrectomy syndrome which ultimately modifies the type of
food intake, amount of foods along with timing of foods [2].
After identifying the site on jejunum for GJ, the small bowel loop is moved to the
left upper quadrant making sure not to twist the afferent and efferent limbs.
Anterior gastrostomy is made just above the gastric staple line midway between
the medial and lateral angle but the GJ anastomosis is always posterior. The size of
the gastrostomy should be equal to the diameter of the stapler anvil. The bougie can
be used to stabilize the pouch during gastrostomy and also act as a guide by stenting
the pouch (Fig. 8).
Since the gastrojejunostomy is posterior (i.e. made between the posterior wall of
stomach pouch and jejunum) the jejunostomy should be made 5 mm away from the
anti-mesenteric border of the jejunum towards the posterior wall to avoid twist. The
opening again should be made equal to the stapler cartridge [4] (Fig. 9).
Fig. 8 Creation of gastrotomy (Anterior to the stapler line)

Positioning of GJ Stapler
Invariably a posterior gastro-jejunostomy is performed using a 45-mm blue car-

tridge. The GJ staple line should never cross anterior to the lateral staple line of the
gastric pouch as it will compromise the security of the staple line (Fig. 9). While GJ
is being done it should be kept in mind to have jaws of the GJ stapler more than
1 cm from the GJ anastomosis staple line, basically there should be visible space on
the posterior gastric wall between the lateral gastric staple line, the staple cartridge
and anvil [2, 4]. One should also be careful to keep the gastric mesentery out of the
GJ staple line (Fig. 10). The staple-line should always be inspected for bleeding [4]
(Fig. 11).
Fig. 9 Creation of jejunotomy 5 mm posterior to anti mesenteric border (White arrow)
Fig. 10 Gastrojejunos-
tomy done to posterior
wall of gastric pouch.
Lateral stapler line of
gastric pouch (Green
Arrow) should be anterior
to the GJ (Blue arrow) as
shown in image (Image
Courtesy: Dr Deborshi
Sharma)
Fig. 11 Stapple line

(Orange arrow) should be
always inspected for any
bleeding (Image Courtesy:
Dr Deborshi Sharma)
Fig. 12 Posterior
Gastrojejunostomy and the
gastric calibration tube
being pushed into jejunum
before closure (Green
Arrow) (Image Courtesy:
Dr Deborshi Sharma)
GJ Closure
Final step is closure of gastro-jejunostomy. Both stapled or a hand-sewn closure

anastomosis of the GJ is acceptable. Sutured closure is done in either one or two
layers, and if done properly one-layer anastomosis gives best results, as it avoids GJ
narrowing [2]. One can also insert the gastric calibration tube through the anasto-
mosis into jejunum to a avoid tight closure (Fig. 12). The completed anastomosis
should be checked for any kinks or obvious leaks (Figure 13).
Hemostasis
A perfect hemostasis is mandatory for better outcome of both intra-operative and

post-operative stages after MGB. Hemostasis can be attained by hemostatic clips,
sprays, foam or by suturing. Bleeding signifies loose improperly fitted staplers
which later might give way for leaks if not taken care on table during procedure.
Fig. 13 Final closure of

gastrotomy and enterotomy
Leak Test
Leak test after MGB though not mandatory is done either by using intraluminal
75 mL diluted methylene blue or air leak test, after clamping both the efferent and
afferent loop. Recently Intraluminal ICG also has been used to check for any extrav-
asation. Recognizing leaks as early as possible is preferable and the mainstay for
any successful bariatric surgery, hence on table detection if any is the cornerstone of
management. A flat drain is placed between the gastric pouch and the bypassed
stomach [2, 4].
Advantages and Disadvantages of MGB [7]
Mini Gastric Bypass is an attractive option of choice for metabolic surgery as it

offers many advantages to the patient as well as to the surgeon:
(a) Single Anastomosis

(b) Shorter operative time
(c) Less chances of anastomosis leaks due to fewer possible sites for leaks
(d) Extremely low risk of internal herniation
(e) Shorter learning curve
(f) Easier to reverse to normal anatomy
All the above advantages are the reasons why MGB is becoming one of the fast-
est acceptable metabolic procedures.
But it also has its share of disadvantages, as fear of:
(a) Symptomatic biliary gastritis andoesophagitis

(b) Increased risk of barrett’s oesophagus
(c) Increased risk of gastric/oesophageal cancer
Complications
The complications of MGB are basically divided into two groups
(a) Early complications—those occurring within the first 30 post operative days [8].
(b) Late complications—beyond 30 days to 10 years after surgery [9].
Early Complication
1. Bleeding: It is the most common complication which is either endo-luminal or

intra-abdominal in nature.
(a) Endoluminal bleeding (0.93%) is either from gastric pouch or anastomosis.
Mostly it is managed by conservative methods or endoscopic intervention
may be required.
(b) Intra-abdominal bleeding (0.78%) occurs in sites where stapler cartridge of
size >1.5 mm is used or interrupted closure of anastomosis is done or in
patients having pre-operative hypertension. It often needs laparoscopic revi-
sion with surgical haemostasis [10].
2. Leaks: These are the second most common complication (0.44%) and include
both anastomotic and gastric pouch leaks. The treatment of choice is a surgical
revision which varies from laparoscopic revision and defect repair, to a laparo-
scopic revision with a Braun’s anastomosis to a complete reversal operation
[10]. Though rarely done, conservative management can be tried as MGB anas-
tomosis creates a low pressure gastric pouch, with no sectioning of bowel and
completely intact jejunal vascular arcade.
3. Small bowel perforation: Marginal ulcer perforation though rare is also noted
in MGB (0.22%) like RYGB. It is more prevalent in smokers and can be treated
laparoscopically. Suture closure of the perforation is the treatment of choice. In
few cases conversion to RYGB might be necessary [11].
4. Anastomotic stenosis: MGB has 4.5–6 cm anastomosis in comparison of
1.2–1.5 cm in RYGB, hence anastomotic site stenosis is rarely reported after
MGB. In general any anastomosis of ≥2.5 cm is highly recommended to prevent
stenosis. Endoscopic pneumatic dilatation is the initial treatment of choice for
anastomotic site stenosis and later RYGB conversion might be needed rarely [12].
Late Complication
Late complications are seen in around 11% cases after primary surgery and 7% after
redosurgery.
1. Gastro Esophageal Reflux Disease (GERD): Gastro esophageal reflux disease

is defined as the presence of duodenal contents in the esophagus [13, 14]. It
results in heart burn, regurgitation and esophagitis. In the presence of symp-
toms—Upper GI endoscopy is used to detect any damage caused by alkaline
reflux in an acidic environment [13, 14] and 24 hr pH impedance studies can
quantify the severity of reflux. Treatment includes dietary and life style modifi-
cations, PPI and sucralfate as first conservative line of management [15]. If it
fails a surgical revision to RYGB or Braun’s side to side anastomosis between
afferent and efferent limb might be required [10].
2. Weight Regain: Weight regain is measured as both post-operative Body Mass
Index (BMI) and Excess Weight Loss (EWL) % changes. It is mostly due to
abnormal pouch and loop size particularly during the learning curve. A surgical
approach to refashion the pouch and loop limb length resizing might be required
in some cases [10].
3. Marginal ulcer: The incidence of Marginal ulcer in MGB is low as compared to
RYGB. It is commonly diagnosed with endoscopy [16]. The first line of treat-
ment is PPIs, Sucralfate and Helicobacter pylori eradication. When the conserva-
tive management fails, surgical therapy is undertaken invariably when the
mucosal ischemia is suspected [9].
4. Nutritional deficiencies: MGB might result in a range of nutritional deficien-
cies and may also predispose to malnutrition in case of inappropriate limb length
selection mostly within 2–3 years of surgery. Most common deficiency follow-
ing MGB is iron deficiency leading to anemia. It is common in female of repro-
ductive age [17–21]. One-third requires oral supplements beyond the expected
time for intestinal adaptation, and up to 1.3% may require parenteral iron. Longer
lengths of by passed limbs result in hypoglycemia and hypoproteinemia [22, 23].
Vit-D3 and Vit-B12 deficiencies are also prevalent following MGB [22, 23].
Most patients are generally controlled and treated on an ambulatory basis and
recover with dietary recommendations once intestinal adaptation is complete.
Excess weight loss due to bypassed limb length of >250 cm is also common [6].
The number of patients developing severe malnutrition requiring hospitalization
and parenteral nutrition is very low. The causes of nutritional deficiencies are
malabsorption, psychological, social, family and even economic issues (Tables 1
and 2). Conversion to sleeve for malnutrition might be rarely required.
5. Rare complications: Internal hernias are extremely rare (0.1–0.4%) after
MGB. However the occasional abdominal wall port site hernia is seen, incidence
of which is similar to any other laparoscopic bariatric procedure.
Table 1 Nutritional deficiencies after MGB— Criteria

Indian data Number 100
Anemia –
Serum iron 43%
Serum ferritin 26%
Vitamin B12 10%
Albumin 5%
Vitamin D3 23%
Table 2 Multivitamin and mineral supplementation values

Amount per serving Amount per serving
Vitamin A 1875 IU Pantothenic acid 2.5 mg
Vitamin C 45 mg Calcium 300 mg
Vitamin D3 750 IU Iron 11.25 mg
Vitamin E 7.5 IU Iodine 37.5 mcg
Vitamin B1 3 mg Magnesium 100 mg
Vitamin B2 425 mcg Zinc 7.5 mg
Vitamin B3 5 mg Selenium 17.5 mcg
Vitamin B6 500 mcg Copper 0.5 mg
Vitamin B9 200 mcg Manganese 0.5 mg
Vitamin B12 140 mcg Chromium 30 mcg
Biotin 150 mcg Molybdenum 18.75 mcg
Effect of MGB on Type-2 Diabetes Mellitus (T2DM)
T2DM is one of the most common non-communicable diseases and is the fourth
leading cause of death in first world countries. Now it is also reaching epidemic
propositions in developing countries [24]. The global prevalence of T2DM is on the
rise because of the increase in the factors which favors obesogenic environment,
like sedentary lifestyle and easier access to calorie dense foods [24].
Medications and lifestyle modifications require patient compliance but still con-
trol over T2DM remains elusive. Metabolic surgery is effective in the treatment and
prevention of T2DM, thereby reducing the mortality rate in the long term when
compared with medical treatment.
Metabolic surgery involves any intervention that alters the passage of food
through the GI tract resulting in improved control of T2DM. The control of T2DM
is not related to weight loss precluding a direct antidiabetic effect [25].
Various mechanisms have been put forward as the possible explanation for
improvement in T2DM after bariatric surgery. They are:
1. There is upregulation or increased availability of insulin receptors, after calorie

restriction, which results in increased insulin sensitivity [26, 27].
2. The ghrelin secretion from stomach also decreases which results in decreased
appetite and hence better T2DM control [28].
3. Foregut theory—There is an improvement or augmentation of the action of
Gastro Intestinal Peptide (GIP) from the foregut following metabolic surgery
which in turn helps to control the blood glucose level [28].
4. Hindgut theory—Post metabolic surgery there is an increase in secretion of
incretins such as Glucagon Like Peptide I (GLP-I) from the L-cells in the lower
ileum due to duodenal bypass, which results in early transit of nutrients to the
ileum and stimulation of β cells, which then results in good diabetic control
[29–31].
T2DM remission has been reported to be of varying degrees after all current
bariatric operations. However, after sleeve gastrectomy (leaks, weight regain,
GERD) and after RYGB (weight regain, malnutrition, internal hernias and others)
numerous complications can occur [21, 31]. MGB has been documented to be a
dependable bariatric procedure in large series. It has shown superiority in resolution
of comorbidities in comparative studies to RYGB and sleeve gastrectomy. MGB has
resulted in T2DM resolution in 85–95% of diabetic patients followed >5 years,
requiring no medication, which is superior to sleeve gastrectomy and RYGB
[32–36].
Following MGB with the rapid passage of food into the small bowel, rapid eleva-
tion of GLP-I levels have been found compared to other operations. MGB and
sleeve gastrectomy can rapidly augment the incretin effect which persists upto
5 years. However, the MGB has a better effect than sleeve gastrectomy at longer
follow-up due to the increase in serum GLP-I levels [31].
Future Perspective
Robotic surgery is one of the most rapidly developing and upcoming techniques in
the field of surgery. It offers 3D vision and gives the control of the camera to the
surgeon. Along with the degrees of freedom, the robotic arms provide a distinct
advantage while suturing in small confined spaces. Robotic MGB is possible with-
out hybrid or dual docking as all dissection and anastomosis is in the supracolic
compartment, hence MGB is suitable technically for robotic surgery [37].
Initial studies show no difference between robotic assisted and conventional
laparoscopic surgery with respect to surgical time, post operative hospital stay, com-
plications or rate of conversion to open surgery but the anastomosis leaks have been
shown to be significantly less after robotic surgeries. Use of the robot has reduced
the ergonomic challenges of bariatric surgery in comparison to conventional lapa-
roscopy. The robot controlled telescope, tissue manipulator with alignment, robotic
suturing etc are easier along with being more accurate. The time taken for the pro-
cedure in both the techniques is equivalent. The main disadvantage of robotic
surgery is its increased cost which is especially important in developing countries

like India. At present Robotic MGB is to be reserved to tackle cases which are
assessed to be difficult pre-operatively, like super obese or revision surgery [37].
Revision to MGB from Other Procedures
Laparoscopic Adjustable Gastric Banding (LAGB) to MGB
Gastric banding was one of the most popular bariatric surgeries during 1990s and
early 2000s, because of its various complication like band slippage/erosion, inade-
quate weight loss to name a few, a large percentage of patients required a revision
surgery from LAGB. The various options for revision are LSG, LRYGB and
MGB. It has been seen that revision from an earlier restrictive procedure to a mal-
absorptive procedure leads to a more consistent and satisfactory weight loss. Hence
MGB is gaining consensus as a revisional surgery after LAGB.
The patient should learn dietary and behavioral changes atleast 3–6 months prior
to revision. A lack of willingness on the patient’s part for these changes should be
considered a contraindication for revision. The band has to be completely emptied
a few weeks before surgical procedure. Upper GI gastrograffin series, Upper GI
endoscopy and other routine necessary pre-operative bariatric investigations should
be done.
The surgeon may choose to go for a one stage or two stage surgery. The standard
technique for MGB is followed barring the following changes:
(a) Band is removed and the fibrous capsule is cut to prevent dysphagia in future.
(b) The vertical resection line while creating the gastric pouch is moved towards
the spleen to avoid the inflammatory tissue and band fibrous capsule in the last
stapler line. This helps to prevent complications in future and gives best results
post-operatively. Revision for LAGB to MGB can be a single and relatively safe
procedure which results in valid weight loss, rapid recovery with high level of
patient satisfaction [38].
Laparoscopic Sleeve Gastrectomy to Mini Gastric Bypass
Conversion from LSG to MGB is a safe, feasible and effective option and results in
significant weight loss. It is the operation of choice for morbidly obese patients who
are compliant in taking calcium and iron supplements. Patients having inadequate
weight loss following LSG due to non-anatomical causes are primary candidates for
conversion to MGB or RYGB, but the former is preferred because of its simple
technique, efficacy and reversibility [39].
Conclusion
Mini gastric bypass is a malabsorptive type of metabolic surgery which helps in

weight loss and co-morbidity resolution, especially diabetes remission. It has a sin-
gle anastomosis and there is no breach in the continuity of the omentum which
reduces various complications like leak, internal hernias etc. as compared to other
procedures like RYGB. The most important aspect of MGB is the selection of req-
uisite BPL length as per the patient’s profile. This can reduce the occurrence of
nutritional deficiencies in the post-operative period markedly. Long term follow up
data shows it to be superior to LSG and RYGB in regards to its outcome. The role
of robotics in MGB is only going to augment its future prospects.
Few Clinical Points

1. Obesity is a problem of pandemic proportions in both developed and develop-
ing countries.
2. MGB is primarily a malabsorptive procedure of single anastomosis, described
by Dr Robert Rutledge with a short learning curve.
3. The MGB pouch in contrast to RYGB pouch is a larger pouch with a wide GJ,
while in comparison to sleeve gastrectomy tube, MGB has a wide tube with no
stress on OG junction dissection. During MGB it is even acceptable to leave a
small amount of fundus in exchange for leak prevention
4. The length of the BPL should be tailored according to the patient’s profile and
co-morbidity with 150 cm for obese and 180 cm for super obese.
5. BPL length of >200 cm should be reserved for revision cases.
6. Longer BPL length results in more malnutrition without significant effect on
co-morbidity resolution
7. Bleeding is the most common complication after MGB which can be either
endo-luminal or intra-abdominal.
8. MGB might result in a range of nutritional deficiencies and may also predispose
to malnutrition in cases of inappropriate limb length selection, which mostly
happens within 2–3 years of surgery.
9. T2DM resolution after MGB is seen in 85–95% of diabetic patients followed
>5 years, who require no medication, making it a superior procedure to sleeve
gastrectomy and RYGB
10. Robotic MGB presently advised for super obese and revision surgeries is pos-
sible without hybrid or dual docking as all dissection and anastomosis is in the
supracolic compartment.
Editor’s Note1
Late Complications
Gastro eosophageal reflux disease: Main concern over the years for MGB has been
the fear of increased GERD and is reported to vary from 0.5 to 4%. A shorter gastric
pouch of <9 cm and presence of preoperative GERD can be inciting factors while
de novo GERD after MGB is seen in 2% [1]. Rate of revision for GERD is very rare
(0–0.7%) due to intractable bile reflux, if standard operating protocol is followed
[2–4]. Intragastric pressure is significantly diminished after MGB hence GE reflux
is not increased. Endoscopy sometimes reveals bile in the stomach with mild to
moderate pouch gastritis, however evidence of any esophagitis on endoscopy after
MGB is rare [LC 3–5].
Fig. EN1 Schematic diagram of OAGB
1
One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGB)
Essentially, both MGB & OAGB is similar in theory, where main idea it is to avoid
two anastomosis and two limbs. Still MGB & OAGB differs in many aspects techni-
cally. In OAGB (Figure EN1) the following steps are stressed upon over MGB
Total small bowel measurement (TSB): Starting from DuodenoJejunal Junction
(DJ) downward to Ileocaecal junction (IC) total small bowel measurement is done
in OAGB [6]. This is done with the view point that differences will remain in the
metabolic setup of a younger vs older patient, obese vs super-obese, male with cen-
tral obesity vs female with gynecoid obesity and all these with a patient with severe
metabolic syndrome. After knowing the TSB, both BP limb and common channel
(CCh) can be tailored and a ratio of 0.37–0.44 (CCh/TSB) is regarded to give best
weight loss success rate and improve co-morbidities [7]. Length of CCh can be
maintained between 180 and 220 cm [8].
Bi-Valving the greater omentum: As more length of small bowel is bypassed in
OAGB compared to MGB, the greater omentum might exert more tension on anas-
tomosis. Omentum from its attachment on transverse colon upto the greater curve is
opened longitudinally to make it into two halves.
Complete dissection of “Angle of His”: Left side of Phreno-esophageal mem-
brane is dissected until the left crus of diaphragm, almost up to the posterior border
of spleen. Thick fat “Belsey’s fat” pad which surrounds the esophago-gastric junc-
tion (EGJ) is also dissected down. This manoeuvre allows creation of a wide aper-
ture of the retro-gastric window avoiding the short gastric vessels and any splenic
tissue injury. Ultimately endostapler is also optimally positioned at this demanding
position [6, 9].
Gastro-hepatic ligament dissection: Dissection starting at the Pars flaccid upto
right crus is done along with remains of right Phreno-esophageal membrane. This
release helps in lengthening of gastric pouch and decreasing anastomotic tension.
Any hiatal hernia if present is also selectively repaired [10].
Creation of long and narrow gastric pouch: In OAGB a long narrow pouch of
about 15–18 cm is made which usually lies over the gastric antrum of remnant stom-
ach with its tip at the level of the transverse colon [7].
Anti-reflux mechanism: Continous suturing for 8–10 cm using reabsorbable
material of anti-mesenteric border of small bowel to the vertical staple line of gas-
tric pouch is done. This continous suturing also is advantageous as it creates perma-
nent posterior fixation of small bowel and gastric pouch creating proper alignment
of two lumens, preventing twisting of pouch later on and ensures no gap between
them for any internal hernia [7].
GJ over anterior wall of pouch: The anterior wall of gastric pouch and small
bowel is anastomosed for 2.5 cm using linear endo stapler, anterior to the continous
anti reflux suture in a lateral-lateral fashion. The enterotomies are closed in standard
fashion.
This vertical 2.5 anastomosis makes the BP limb content to go down into afferent
limb (CCh channel) directly due to gravity preventing reflux or marginal ulcers [11].
OAGB vs RYGB RCT: OAGB is a technically easier procedure and features

better glycemic control than RYGB, but has a mal-absorptive effect. However, the
bile reflux and abdominal pain controversies persists [12].
OAGB vs Laparoscopic Sleeve gastrectomy: RCTs have shown that both are
efficacious bariatric methods. While OAGB in the long term (5 years) is better than
LSG in terms of weight loss, comorbidity resolution and improvement in QoL [13].
Diverted Mini Gastric Bypass (dMGB)
RYGB is still considered by many to be the most effective and well balanced meta-
bolic/bariatric surgical technique [14]. RYGB is pulled down by some for its signifi-
cant unique complications such as internal hernias, marginal ulcers or
hyperinsulinemic hypoglycemias. Intermediate-term weight regain following
RYGB is also a concern [15, 16]. Weight regain or not maintaining 50% EWL on
follow up contributes to the overall failure rate [17]. dMGB proposes OAGB-MGB
procedure with a Roux-en-Y anastomosis added to the long narrow pouch.
After MGB-OAGB, a 100 cm into the efferent limb, from proximal to distal
beyond the gastro-jejunostomy a new side-to-side ileoileostomy or ileojejunostomy
is created between the afferent and efferent loop. The afferent is then disconnected
to the gastric pouch (Fig. EN2). The inter-mesenteric spaces hence created need
closure to prevent internal hernias. Initially this procedure was also called the Sleeve
gastric bypass. (Fig. EN3).
Fig. EN2 Schematic diagram of dMGB showing the limb lenghts

Fig. EN3 Schematic diagram of Sleeve Gastric bypass (Image Courtesy Dr. Gautam Anand)
Table EN1 Metaanalysis comparing various bariatric surgical procedures outcomes as: primary
procedure, for diabetes remission and as revisional procedure
Topic Study, author (first), year Result
Laparoscopic Comparison of safety and Advantages of MGBP over LSG
sleeve versus effectiveness between • Higher 1-year EWL% (excess weight
mini gastric laparoscopic mini-gastric loss),
bypass bypass and laparoscopic • Higher 5-year EWL%,
sleeve gastrectomy: A • Higher T2DM remission rate,
meta-analysis and • Higher hypertension remission rate,
systematic review. • Higher obstructive sleep apnea (OSA)
Wang F, 2017 [19] remission rate,
• Lower osteoarthritis remission rate,
• Lower leakage rate,
• Lower overall late complications rate,
• Higher ulcer rate,
• Lower gastroesophageal reflux disease
(GERD) rate,
• Shorter hospital stay and
• Lower revision rate.
RYGB versus Outcomes of Mini vs Advantages MGBP over RYGBP
MGB Roux-en-Y gastric bypass: • A higher 1-year EWL% (P < 0.05),
A meta-analysis and • Higher 2-year EWL% (P < 0.05),
systematic review. • Higher type 2 diabetes mellitus remission
Wang FG, 2018 [20] rate,
• Shorter operation time (P < 0.05).
No significant statistical difference was
observed in hypertension remission rate,
mortality, leakage rate, GERD rate, or hospital
stay between mini gastric bypass and
Roux-en-Y gastric bypass.
Comparative Network meta-analysis of BPD and MGBP achieved higher diabetes
analysis MGB the relative efficacy of remission rates than the other procedures viz:
and other bariatric surgeries for LAGB, LSG, RYGBP, DJ Bypass, duodenal
bariatric diabetes remission. switch greater curvature plication.
surgeries in Kodama S, 2018 [21]
remission of Comparative effectiveness • MGBP has greatest probability of
type 2 DM of bariatric surgeries in achieving diabetes remission in adults
patients with obesity and with obesity and T2DM,
type 2 diabetes mellitus: A • BPD was the most effective in long-term
network meta-analysis of diabetes remission.
randomized controlled • RYGBP most favourable alternative
trials. treatment
Ding L, 2020 [22]
Efficacy of Laparoscopic MGBP compared with LAGB, LSG, and
Mini Gastric Bypass for RYGBP,
Obesity and Type 2 • MGBP showed significant weight loss
Diabetes Mellitus: A [WMD, −6.58 (95% CI, −9.37, −3.79),
Systematic Review and P < 0.01 and comparable/higher T2DM
Meta-Analysis. remission
Quan Y, 2015 [23] • MGBP also had shorter learning curve
and less operation time than RYGBP
[WMD, −35.2 (95% CI, −46.94,
−23.46)].
(continued)
MGB as Roux-en-Y gastric bypass OAGBP/MGBP vs RYGBP
revisional versus one anastomosis- MGBP showed
surgery after mini gastric bypass as a • Lower rate of bleedings
restrictive rescue procedure following • Better weight loss (comparing pre vs post
bariatric failed restrictive bariatric revision BMI)
surgery surgery. A systematic • Shorter operative time
review of literature with • Similar rate of leaks
metanalysis.
Velotti N, 2021 [24]
One Anastomosis/ MGBP/OAGBP
Mini-Gastric Bypass • BMI/Weight loss mean initial BMI was
(OAGB/MGB) as 45.70 kg/m2, which decreased to 31.52,
Revisional Surgery 31.40, and 30.54 kg/m2 at 1, 3, and 5-year
Following Primary follow-ups, respectively.
Restrictive Bariatric • Remission of type-2 diabetes mellitus
Procedures: a Systematic (T2DM) following OAGB/MGB at 1-, 3-,
Review and and 5-year follow-up was 65.16 ± 24.43,
Meta-Analysis. 65.37 ± 36.07, and 78.10 ± 14.19%,
Kermansaravi M, 2021 respectively.
[25] • Remission/improvement rate from
gastroesophageal reflux disease (GERD).
• 7.4% of the patients developed de novo
GERD following OAGB/MGB.
• Leakage was the most common major
complication. OAGB/MGB
MGBP minigastric bypass, LSG laparoscopic sleeve gastrectomy, RYGBP Roux en Y gastric
bypass, LAGB laparoscopic adjustable gastric banding, BPD biliopancreatic diversion, OAGBP
one anastomosis gastric bypass, EWL excess weight loss, T2DM type 2 diabetes mellitus, GERD
gastroesophageal reflux disease, BMI body mass index
MGB-OAGB is thought to provide better results with fewer complications com-

pared to RYGB. This diversion solved weight regain and hyperinsulinemic hypo-
glycaemia associated with RYGB and it is as effective as the MGB-OAGB with
almost no incidence of GERD [18].
Table EN1 enlists various meta-analysis comparing MGB/OAGB with other bar-
iatric surgical procedures as primary surgery for obesity as also revisional surgery
after failed restrictive procedures.
1. Musella M, Susa A, Manno E, et al. Complications following the mini/one

anastomosis gastric bypass (MGB/OAGB): a multi-institutional survey on 2678
patients with a mid-term (5 years) follow-up. Obes Surg. 2017;27:2956–67.
2. Chevallier JM, Arman GA, Guenzi M, et al. One thousand single anastomosis
(omega loop) gastric bypasses to treat morbid obesity in a 7-year period: out-
comes show few complications and good efficacy. Obes Surg. 2015;25:951–8.
3. Lee WJ, Lee YC, Ser KH, et al. Revisional surgery for laparoscopic minigastric
bypass. Surg Obes Relat Dis. 2011;7:486–92.
4. Luque-de-Leon E, Carbajo MA. Conversion of one-anastomosis gastric bypass
(OAGB) is rarely needed if standard operative techniques are performed. Obes
Surg. 2016;26:1588–91.
5. Carbajo MA, Luque-de-León E, Jiménez JM, Ortiz-de-Solórzano J, Pérez-
Miranda M, Castro-Alija MJ. Laparoscopic one-anastomosis gastric bypass:
technique, results, and long-term follow-up in 1200 patients. Obes Surg.
2017;27:1153–67.
6. Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases.
Obes Surg. 2001;11:276–80.
7. Musella M, Bocchetti A. Late complications of MGB: prevention and treat-
ment. In: Deitel M, editor. Essentials of mini – one anastomosis gastric bypass.
Cham: Springer; 2018.
8. Carbajo MA, Luque-de-León E, Jimenez JM, et al. Laparoscopic one-
anastomosis gastric bypass: technique, results and long-term follow-up in 1200
patients. Obes Surg. 2017;27:1153–67.
9. Kular KS, Manchanda N, Rutledge R. A 6-year experience with 1,054 mini-
gastric bypasses— first study from Indian subcontinent. Obes Surg.
2014;24:1430–5.
10. Anand G, Katz PO. Gastroesophageal reflux disease and obesity. Gastroenterol
Clin N Am. 2010;39:39–46.
11. Musella M, Susa A, Manno E, De Luca M, et al. Complications following the
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Robotic Roux-en-Y Gastric Bypass
Vivek Bindal
Introduction
In the last decade, bariatric surgery has witnessed an ever-increasing demand with
rise in the prevalence of obesity. Laparoscopic Roux-en-y gastric bypass (LRYGB)
was described in 1990s [1] and currently more than 100,000 procedures are esti-
mated to be performed annually alone in United States [2]. According to American
Society for Metabolic & Bariatric Surgery (ASMBS) estimate published in July
2015, RYGB constitutes 26.8% of total bariatric surgery volume.
Bariatric surgery is a technically demanding surgery particularly in situations with
huge patients with large livers, thick abdominal walls and substantial visceral fat making
exposure, dissection and reconstruction difficult [3]. The super obese patients (SO) with
a body mass index (BMI) greater than or equal to 50 kg/m2 is a difficult to manage popu-
lation because of limited working space, excessive torque, on instruments due to thick
abdominal wall, co-morbidities and high-risk anesthesia [4]. The maneuvering of instru-
ments while performing LRYGB often becomes difficult, particularly while doing intra-
corporeal suturing. All these lead to a longer learning curve for LRYGB, which has been
estimated to be around 75–100 cases [5, 6]. Along with the difficulty, the surgeons
encounter very difficult ergonomic positions during LRYGB which can potentially be
career shortening, and whereas on one hand methods to improve the patient outcomes,
surgical technique and decrease complications are being targetted, on the other hand
concomitant reduction of the learning curve is being aimed.
Use of robotics in bariatric surgery has been evolving since Cadiere GB et al.
reported the first such case in 1999 [7]. Robotic surgery has provided the surgeons
with the advantage of three-dimensional vision, increased dexterity and precision
by downscaling surgeon’s movements enabling a fine tissue dissection and filtering
V. Bindal (*)
Institute of Minimal Access, Bariatric and Robotic Surgery, Max Super Speciality Hospitals,
Noida & Mohali, India
https://doi.org/10.1007/978-981-16-5473-2_15
332 V. Bindal
out physiological tremor [8, 9]. In morbidly obese it overcomes the restraint of
torque on ports from thick abdominal wall and minimizes port site trauma by remote
centre technology [10]. Consensus document on robotic surgery prepared by the
SAGES-MIRA Robotic Surgery Consensus Group, claims robotic surgery to hold
particular value for gastric bypass amongst general surgical procedures.
The main limitation of robotic surgery is its higher cost and robot setting up time
compared to laparoscopy, but with increased experience, it is seen that setup times
reduce and costs may also come down as material prices reduces [11].
Roux-en-Y Gastric Bypass (RYGB)
RYGB is often considered as the gold standard surgical procedure for morbid obe-
sity [12, 13]. Overall results are good in terms of both weight loss and comorbidity
resolution [14]. RYGB leads to an excess weight loss to the tune of 65.7%, while
remission rates of type 2 DM being 66.7% and for dyslipidemia being 60.4% [15].
RYGB is done by creating two gastrointestinal anastomoses namely gastrojejunos-
tomy and jejunojejunostomy. Robotic surgery is currently considered as a valuable
technology that could help perform RYGB, given its well described benefits [16].
Robotic RYGB (R-RYGB) is today the most studied robotic bariatric procedure
[17, 18].
Surgical Technique
There are many ways by which R-RYGB can be performed. The major variations in
technique are listed below:
(a) Single docking vs. double docking

(b) Hybrid (Laparoscopic + Robotic) vs. Totally Robotic
(c) Antecolic vs. Retrocolic alimentary limb
(d) Handsewn, linear or circular stapler anastomosis for gastrojejunostomy
(e) Staple line reinforcements or oversewing
The technique of choice at University of Illinois Health System is to perform a

single docking totally robotic RYGB with a handsewn gastrojejunostomy. We
describe this technique in the following paragraphs.
Instrumentation (Fig. 1)
The following 8 mm robotic instruments are used for a R-RYGB in a da Vinci

Si system:
(a) Cadiere forceps

(b) Large needle driver
Robotic Roux-en-Y Gastric Bypass 333
Fig. 1 Robotic Instruments
(c) Da Vinci Harmonic scalpel

(d) Permanent Cautery hook
(e) Fenestrated bipolar forceps
(f) Laparoscopic/Robotic staplers
All three arms of the robotic system are used with third arm coming from the left
side of the patient (explained in docking).
Patient Positioning & OR Setup (Fig. 2)
The patient is positioned in supine position with 15–200 reverse trendelenberg tilt
under general anesthesia. This position helps to complete the procedure in a single
docking, as both infracolic and supracolic portions of the procedure can be done
without changing the position. The abdomen is cleaned and draped and orogastric
tube/urinary catheter (optional) are placed. Assistant surgeon stands by the side of
the patient along with the scrub nurse. The master console should be placed in such
a way that the surgeon is able to freely visualize the operative field while sitting on
the console. It is important that two video monitors are placed on both sides of the
patient to enable the assistants to easily watch the monitor and if required to help at
every step of procedure, with ergonomic comfort. The anesthesia machine is also
kept on one side of the head end as patient cart comes in from the head end.
334 V. Bindal
Fig. 2 Operating room setup and patient cart positioning for robot assisted RYGB
a b
Liver
Retractor
2 3
Camera 1
Assistant
Fig. 3 (a) Schematic diagram of port positions for Robot assisted RYGB; (b) Port position for
Robot assisted RYGB
Port Position (Fig. 3a, b) and Docking (Fig. 4)
Pneumoperitoneum is achieved to 15 mm Hg using a Veress needle at palmer’s

point. All the distances between ports are measured after insufflation of abdomen as
Fig. 4 Operating room with a docked robot
they significantly change after pneumoperitoneum is created, especially in morbidly

obese with pendulous abdominal wall. The minimum inter-trocar distance recom-
mended in robotic surgery is 8–10 cm as the actual distance intraperitoneally in
morbidly obese individuals is markedly shorter than the distance measured on the
surface. This factor has to be always taken into consideration and trocars placed at
maximum possible distance to avoid internal arm clashing of robot. The port place-
ment needs to be adjusted based on the body habitus of each patient so as to prevent
external arm collision and also provide optimal exposure.
Camera port (12 mm diameter, 150 mm long trocar) is placed 20 cm below the
xiphisternum slightly to left of midline under vision using a zero degree 10 mm
scope to avoid any inadvertent visceral injury. Following this, one assistant and
three da vinci trocars are placed as follows:
• R1: (8 mm da vinci® cannula) is placed in left mid clavicular line approx. 20 cm
from xiphisternum
• R2 (8 mm da vinci® cannula) is placed in right hypochondrium in mid clavicular
line taking care that the entry of port is below the margin of liver.
• R3 (8 mm da vinci® cannula) is placed in left flank at the level of camera port.
• Assistant port (12 mm diameter) is placed in between camera port and R2 with a
distance of at least 10 cm from both of them.
336 V. Bindal
• A 5 mm epigastric port is made and used for placing Nathanson liver retractor for
retracting left lobe of liver.
The da Vinci® patient cart is brought from head end of the patient, and the arms
are docked to the ports placed. The third arm of the robot comes from left side of the
patient. To start the procedure, a permanent cautery hook is taken in R1, fenestrated
bipolar forceps in R2 and a Cadiere forceps in R3. The assistant surgeon stands by
the side for complementary maneuvers (i.e., suction, stapling, retraction etc.). A
sample OR setup for RRYGB is depicted in Fig. 2. Diagnostic laparoscopy is done
to look for any adhesions/hernias/inadvertent injury during abdominal wall access.
Creation of Gastric Pouch
Dissection should be started from the left crus by bringing the phrenoesophageal
membrane down using the hook after caudally retracting the fundus of stomach
(Fig. 5). Gastric pouch is created using perigastric dissection starting at the second
vessel from gastroesophageal junction. Third arm is used to retract stomach later-
ally while harmonic scalpel opens the gastro-hepatic ligament. Perigastric dissec-
tion is done using hook avoiding injury to vagus nerve and lesser sac is entered.
Stapler is fired horizontally which is done by the assistant using a 60 mm blue
Fig. 5 Initial dissection

around left crus: Bowel
grasper is retracting the
fundus caudally while
monopolar hook dividing
the phreno-esophageal
membrane. The gastric
pouch creation is
simplified by this
dissection
V. Bindal / E.F. Elli@UIC

cartridge. Dissection is continued further superiorly to free the posterior adhesions

of the stomach. Bougie may also be placed at this time to size the pouch. The verti-
cal firing is done and pouch creation is completed (usually a single 60 mm fire, but
two may be needed). The seven degrees of freedom help dissect in this area, espe-
cially around the left crus. Staple line reinforcements can be used in the vertical
firings.
Creation of Jejuno-Jejunostomy (JJ)
The camera now needs to focus towards the infracolic part. The transverse colon is
lifted up and ligament of trietz is identified. Jejunum is measured from ligament of
treitz for 60 cm and divided using stapler. Biliopancreatic limb is held static by the
third arm while 120 cm of roux limb is measured and the site for jejuno-jejunostomy
identified. Then the bowel loops are held together while enterotomy is created using
cautery hook (Fig. 6). Using the third arm to hold limbs together, time for a stay
suture is saved and the operation runs more efficiently.
A jejuno-jejunostomy is created using a 60 mm stapler (Fig. 7). The enterotomy
is closed using PDS 3-0 running suture with large needle driver. Omentum is divided
using harmonic scalpel and roux limb is taken up to gastric pouch for gastro-
jejunostomy (GJ). Polypropylene suture is used to close the mesentric defect after
GJ creation to avoid tension on the mesentery while roux limb is taken up to the
gastric pouch.
Fig. 6 While creation of

jejuno-jejunostomy the
second and third arm can
hold both the loops of
jejunum together saving
time. Enterotomy is
created by monopolar hook

338 V. Bindal
Fig. 7 Creation of
stappled jejunojenostomy
Fig. 8 Posterior layer of

gastrojejunostomy between
Pouch (P) & Jejunum (J)
Creation of Gastrojejunsotomy (GJ)
PDS 3-0 suture is used to create a completely handsewn GJ. Marginal ulceration

and stricture formation are seen if non absorbable suture is used. To create the GJ,
the third arm holds the gastric pouch and small bowel together while R1 & R2 has
two needle holders. Through and through continuous running suture is taken across
the staple line and roux limb of jejunum, from left to right (Fig. 8) which continues
as the posterior layer of GJ and importantly distributes the tension evenly across the
staple line. A 1.5 cm gastrotomy (Fig. 9) and enterotomy is made using cautery
hook which is estimated to be equal to three lengths of horizontal portion of hook.
The anastomosis is started from the left corner which is continued with a running
full thickness suture ultimately forming the posterior wall of GJ ending at the right
Fig. 9 Gastrostomy being

done using ultrasonic
dissector. (P—Gastric
Pouch)
Fig. 10 Creation of hand

sewn gastro-jejunostomy
using PDS 3-0 suture.
Stability is maintained by
the third arm, which is
holding the gastric pouch
and roux limb together
corner of anastomosis. Similar full thickness anterior layer of GJ is also done from
left to right with the ends of sutures knotted securely at the right side. Finally, the
anterior sero-serosal layer is completed from left to right side. Ambidexterity is the
basis of a robotic platform which allows the needle holder to be driven effectively
in all directions during creation of GJ. Often four pieces of 6 inches PDS 3-0 is
required to complete the 4 layered GJ (Fig. 10).
340 V. Bindal
Peterson defect is closed starting from the base of the ‘V’ type opening basically
by lifting up the transverse mesocolon and working towards the top. This is also
done using polypropylene suture, taking care that no mesentric vessel is injured in
this maneuvre. An intraoperative check esophago-gastroscopy is done with air leak
test in all the cases at end of the procedure.
Perioperative Care
Deep venous thrombosis prophylaxis by pharmacological (Low molecular weight

heparin) and mechanical (sequential compression devices, ambulation) methods are
mandatory. Antimicrobial prophylaxis with a single shot of cephalosporin and
patients started on liquid diet. They are often encouraged to walk in the evening of
surgery. No upper GI gastrograffin study is done except in very selective cases like
intolerance to liquids or prolonged nausea. The patients are kept on liquid diet for 1
week followed by a week of soft diet. Thereafter, they are progressed to normal diet
intake as per the schedule.
Outcomes and Results
Robotic surgery is a team effort, and more so in bariatric surgery, where the role of
an experienced OT table side surgeon cannot be understated, as he is also respon-
sible for stapling (if robotic staplers are used). Main surgeon in the console is always
slightly away from the patient while performing robotic surgery, hence the assistant
surgeon also has to be trained to perform difficult tasks and also to take care of any
emergency situation arising during the procedure. The entire team has to learn with
the surgeon and develop knowledge about patient safety, operating room setup,
types of instruments used or needed, thus leading to better OR times and better
patient outcomes. The role of a trained scrub nurse and operating room technician
is also very important in streamlining the conduct of the procedure and prevent any
wastage of time and resources.
Lesser operator fatigue and improved ergonomics are the main advantages of a
robotic platform. Ergonomics in laparoscopic surgery can be very challenging par-
ticularly with big patients and uncomfortable postures, which leads to fatigue and
work-related musculoskeletal problems [19]. Robotics provides the advantage of
more degrees of freedom, which is advantageous in performing difficult dissection
and sutured anastomosis. Many significant published series compare outcomes of
R-RYGB vs L-RYGB [20–29] where they primarily compare intra-operative and
post operative outcomes.
Duration of Surgery: Initially time taken for totally R-RYGB or Hybrid
R-RYGB is more compared to L-RYGB, as additional time is taken in docking and
undocking which is compounded by the fact that mostly a sutured anastomosis is
done in the robotic surgery while a stapled anastomosis is done in laparoscopic arm.
If done similarly, intra-operative step by step, procedure time if calculated can be

less in R-RYGB due to improve dexterity and 3-D vision with robotic surgery.
Further once the robotic team gets experienced the whole procedure time can also
decreases significantly [30].
Perioperative issues: Blood loss is comparable in both R-RYGB &
L-RYGB. GI-Bleeding, leaks and venous tromboembolism are regarded less with
R-RYGB due to its increased operative precision [31].
Post operative markers: Post-operative CRP values are always lower with
R-RYGB which can be regarded as a more precise and less traumatic approach.
Haemoglobin and leukocyte values have been insignificantly different [30].
Length of hospital stay: Unremarkably different in robotic and laparoscopic
patients. Many other compounding factors add to the hospital stay including co-
morbidities, national peculiarities of patient care and billing [30]. Average length of
stay is 5 days in robotic group vs. 7.1 days in laparoscopic group [32].
Issues with Gastro intestinal anastomosis: Various anastomotic techniques are
used for R-RYGB which includes linear stapler and circular stapler anastomosis or
one of the complete hand sewn suture techniques [33]. Hand sewn anastomosis
compared to circular stapler anastomosis results in lower wound infection rates and
lower gastro-intestinal bleeding. The average leak rate across studies is 0.9% in
R-RYGB vs 1.6% in L-RYGB, while the GJ stricture rate is 3.1% in robotic arm and
3.2% in laparoscopic arm [32].
GJ stricture rates are highest with 21 mm circular stapler verified by endoscopy
[31] as these cases often require repeated endoscopic dilatation over a 5 year period.
Use of 3.5 mm stapler height can ameliorate some problems of using circular sta-
plers [21, 34].
Readmissions, Re-operation & Revision operations: Readmissions rates
have been similar in all types of RYGB while re-operation & revisional surgery
after R-RYGB is less even during the first 100 cases of each surgeon [30, 31].
Common indications for re-operations other than acute leaks can be partial omen-
tal necrosis.
Costs: An obvious concern is about the cost of procedure every time when a
robotic system is considered as the direct costs are significantly higher for the
robotic approach in bariatric procedures like R-RYGB [35]. However, if taken into
account the total costs including the post-operative stay, complications and readmis-
sions, the cost of R-RYGB might be lower as compared to L-RYGB [25]. Major
saving is also due to decrease in number of staplers in robotic procedures, compen-
sated by a robotic hand sewn anastomosis.
Learning curve: The learning curve of both L-RYGB and R-RYGB has been a
matter of concern. Learning curve for LRYGB (75–100 cases) [5, 36] is much
higher to R-RYGB (14 cases) [16] in order to normalize complications by a surgeon
well versed in laparoscopic surgery but not in bariatric procedures and achieve mas-
tery in the particular type of surgery. Complications in first 100 cases of R-RYGB
are also comparatively less [37].
342 V. Bindal
Surgeon skill bias is at stake in majority of these reports as it is very difficult to

find a surgeon equally skilled in both robotic and laparoscopic techniques. Most of
the surgeons and their teams become proficient in either of the two techniques, but
large comparative studies and systematic reviews do offer some tendencies for
robotic bariatric surgery [38–40].
Conclusion
Big question to be answered is whether the use of robotics is going to stay or will it
perish with time like many fancy technologies. Looking at the basic concept of
computer assisted navigational surgery, robotics provide an enabling platform in
between surgeon and the patient. It provides augmented and higher quality inputs
from the patient to the surgeon and his output is refined to a superior quality before
reaching back to the target. All this should not be analyzed in terms of features of
the present machine that is available for use, but in terms of the potential in the
concept of using a digital interface to interact with patients and enhance the perfor-
mance of the surgeon. With the advent of newer technologies in robotics like fluo-
rescence, integration of images, virtual and augmented reality, telesurgery, single
site platforms, natural orifice surgery and haptic feedback, it is believed that digital
platforms will provide an empowering tool to the surgeons which can potentially
change the way surgery is practised today.
Key Clinical Notes

1. Robotic surgery is a team effort and more so in bariatric surgery. Role of an
experienced bedside surgeon cannot be understated, as he is also responsible for
many difficult tasks and also to take care of any emergency situation arising
during the procedure.
2. Robotic surgery has provided the surgeons with the advantage of three-
dimensional vision, increased dexterity and precision by downscaling surgeon’s
movements enabling a fine tissue dissection and filtering out physiologi-
cal tremor.
3. Robotic Surgery in morbidly obese overcomes the restraint of torque on the
ports from thick abdominal wall and minimizes port site trauma by their remote
center technology.
4. RYGB is often considered as the gold standard surgical procedure for morbid
obesity with good overall results in terms of both weight loss and co-morbidity
resolution.
5. In R-RYGB, patient is in supine position with 15–200 reverse trendelenberg tilt
which helps complete the procedure in a single docking fashion, as one is able
to perform both infracolic and supracolic portions of the procedure without
changing the patient position.
6. Actual intraperitoneal distance between ports in morbidly obese individuals is

significantly shorter than the distance measured on the skin. Hence inter-trocar
distance should be minimum 8–10 cm in robotic surgery to avoid internal arm
clashing of robot.
7. All enterotomies are closed with 3-0 PDS suture. Non-absorbable sutures are
avoided as it causes marginal ulceration and later stricture formation.
8. Peterson defect is closed starting from the base of the defect by lifting up the
transverse mesocolon and working towards the top, avoiding any mesen-
teric vessel.
9. Time taken for totally R-RYGB or Hybrid R-RYGB is more compared
to L-RYGB
10. Hand sewn anastomosis compared to circular stapler anastomosis results in
lower wound infection rates and lower incidence gastro-intestinal bleeding.
11. Readmissions rates have been similar in all types of RYGB while re-operation
& revisional surgery after R-RYGB is less.
12. Direct costs are generally significantly higher for the robotic bariatric proce-
dures like R-RYGB
344 V. Bindal
Editor’s Note1
Indications and Complications of RYGB
RYGB can be done as a primary procedure in (1) super obese (2) obese patients with
comorbidity (3) revisional procedure after failed restrictive surgery. Long term
nutritional deficiency remains an important concern with the procedure. The other
complications related to the anastomosis are bleeding from staple line, anastomotic
leak, gastro jejunal stomal stricture, marginal ulcers, bowel obstruction and forma-
tion of internal hernia. A higher incidence of biliary disease has also been reported
in patients undergoing RYGB [1].
Minimally Invasive Surgery Versus Open RYGB
Minimally invasive techniques viz. laparoscopic and robotic RYGB have definite
distinctive advantages over open surgery. In a systematic review and Bayesian net-
work meta-analysis comparing open, laparoscopic, and robotic approach the laparo-
scopic and robotic approaches had better outcome as compared to open related to
complication, surgical site infection, pulmonary infection and anastomotic leak
rates [2].
Laparoscopic Versus Robotic RYGB
A few meta-analyses have evaluated the outcome of laparoscopic versus robotic

RYGB(Table EN1) [3–5]. The technical advantage quoted of robotic RYGB over lapa-
roscopic RYGB is the ease of constructing a gastrointestinal anastomosis with the Endo
wrist instruments. In a meta-analysis comparing robotic and laparoscopic RYGB, sig-
nificantly less anastomotic stricture was noted in robotic as compared to laparoscopic
group [4]. However most other meta-analyses do not demonstrate any significant differ-
ence in leak rate, stricture or morbidity when comparing robotic and laparoscopic
RYGB (Table EN1) [3, 5]. The important quoted disadvantage of robotic RYGB is the
higher cost of the procedure. In construction of the gastric pouch a higher number of
stapler cartridge refills are required in the robotic Endo-wrist Stapling System (EWSS)
which is 45 mm versus 60 mm staplers used in laparoscopic surgery [6].Other tech-
niques being explored is the use of barbed suture in construction of anastomosis [7].
Antecolic Versus Retro Colic RYGB
In a meta-analysis comparing antecolic ante gastric (AC + AG), versus retro col-

icretro gastric(RC + RG) anastomosis in laparoscopic RYGB, a higher incidence of
1
Table EN1 Meta-analysis on outcome of robotic RYGB compared with laparoscopic and open
procedures
Study title, first author, year of
publication Result/conclusion
Roux-en-Y gastric bypass: Laparoscopic RYGB(L-RYGB) & Robotic RYGB
Systematic review and Bayesian (R-RYGB) vs Open RYGB (O-RYGB)
network meta-analysis comparing • 30-day mortality was significantly lower LapRYGB and
open, laparoscopic, and robotic RoRYGB versus OpenRYGB(risk ratio RR = 0.64, 95%
approach. Aiolfi A, 2019 [2] Crl 0.46–0.97, and RR = 0.49, 95% Crl 0.24–0.99,
respectively).
• Complication rate was significantly lower L-RYGB and
R-RYGB versus O-RYGB (RR = 0.63, 95% CrI
0.42–0.91, and RR = 0.60, 95% CrI 0.33–0.95,
respectively).
• Surgical site infection lower for LapRYGB and
RoRYGB versus OpenRYGB
(RR = 0.42, 95% CI 0.30–0.75, and RR = 0.24; 95% CI
0.13–0.58, respectively)
• Pulmonary complications lower for L-RYGB &
R-RYGB versus O-RYGB (RR = 0.57, 95% CrI
0.45–0.77, and RR = 0.42; 95% CrI 0.25–0.76,
respectively.
• Anastomotic leak rate was similar for L-RYGB and
R-RYGB versus O-RYGB(RR = 1.10, 95% CrI
0.67–1.81, and RR = 0.95, 95% CrI 0.45–2.12,
respectively).
No differences were found in:
• Postoperative bleeding,
• Thromboembolic complication,
• 30-day reoperation,
• 30-day hospital readmission rates.
Robotic Versus Laparoscopic Robotic RYGB (R-RYGB) versus laparoscopic RYGB
Roux-en-Y Gastric Bypass for (L-RYGB)
Morbid Obesity: a Systematic R-RYGB was associated with a longer mean operative
Review and Meta-Analysis. Wang time.
L 2018 [3] R-RYGB was not found to be superior to LRYGB.
Robotic vs. Laparoscopic Robotic-assisted RYGB vs laparoscopic RYGB
Roux-En-Y Gastric Bypass: a Robotic procedure had significantly less:
Systematic Review and • Anastomotic stricture,
Meta-Analysis. • Reoperations,
Economopoulos KP, 2015 [4] • Length of hospital stay
Robotic versus laparoscopic Robotic RYGB versus laparoscopic RYGB
Roux-en-Y gastric bypass (RYGB) No difference in:
in obese adults ages 18 to • Overall major or minor complications
65 years: a systematic review and • Anastomotic leak,
economic analysis. • Bleeding,
Bailey JG, 2014 [5] • Stricture,
• Reoperation
As expected costs for robotic RYGB ($15,447) were
higher than for laparoscopic RYGB ($11,956).
RYGB Roux-en-Y gastric bypass, R-RYGB Robotic RYGB, L-RYGB laparoscopic RYGB, O-RYGB
Open RYGB, RR risk ratio, CrI Credible interval
346 V. Bindal
bowel obstruction and internal hernias were reported in the retro colic/retro gastric
group (bowel obstruction in 1.4% patients in the AC/AG group and 5.2% patients in
the RC/RG group, P < 0.001). Internal hernias were reported 1.3%patients in the
AC/AG group and 2.3% patients in the RC/RG group (P < 0.001) [8].
Biliary Disease After RYGB
There is a growing concern regarding increased incidence of biliary disease after

RYGB. The two issues of contention are:
(i) performance of a concomitant cholecystectomy with RYGB

(ii) method of performance of ERCP after RYGB when needed.
A Metabolic and Bariatric Surgery Accreditation and Quality Improvement

Program propensity-matched analysis of Roux-en-Y gastric bypass with concomi-
tant cholecystectomy in 117,939 minimally invasive RYGB have noted no increase
in morbidity with performance of concomitant cholecystectomy [9].
The options available for performance of ERCP after RYGB are:
(i) Laparoscopy assisted ERCP

(ii) Balloon Enteroscopy assisted ERCP
Both procedures reported to yield equivalent results [10].
OAGB (One Anastomosis Gastric Bypass) vs RYGB
In a meta-analysis comparing OAGB with RYGB, leaks, marginal ulcer, dumping,

bowel obstruction, revisions, and mortality was similar between the two approaches.
OAGB was found to be superior with respect to weight loss and diabetes remission
but had higher malabsorptive complications [11].
Revisional RYGB
RYGB as a revisional surgery following restrictive procedures like sleeve gastrec-

tomy is done to achieve additional weight loss or due to complications. In a study
of revisional RYGB following sleeve gastrectomy the complications which neces-
sitated the conversion were: refractory GERD (40.5%), sleeve stenosis (31.0%),
gastrocutaneous fistula (16.7%) or gastropleural fistula (7.1%) fistula, and gastric
torsion (4.1%). The procedure could be performed safely both by laparoscopic
and robotic technique [12].
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7. Beckmann JH, Kersebaum JN, von Schönfels W, Becker T, Schafmayer C,
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8. Al Harakeh AB, Kallies KJ, Borgert AJ, Kothari SN. Bowel obstruction rates in
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348 V. Bindal
9. Falvo AM, Vacharathit V, Dove J, Fluck M, Daouadi M, Gabrielsen J, Horsley

R, Petrick A, Parker DM. A 3-Year MBSAQIP propensity-matched analysis of
Roux-en-Y gastric bypass with concomitant cholecystectomy: Is the robotic or
laparoscopic approach preferred? SurgEndosc. 2020 Sep 21. https://doi.
org/10.1007/s00464-020-07939-0. Epub ahead of print. PMID: 32959181.
10. Tønnesen CJ, Young J, Glomsaker T, Mala T, Løberg M, Bretthauer M, Refsum
E, Aabakken L. Laparoscopy-assisted versus balloon enteroscopy-assisted
ERCP after Roux-en-Y gastric bypass. Endoscopy. 2020 Aug;52(8):654–61.
https://doi.org/10.1055/a-1139-9313. Epub 2020 Apr 21. PMID: 32316042.
11. Magouliotis DE, Tasiopoulou VS, Tzovaras G. One Anastomosis Gastric

Bypass Versus Roux-en-Y Gastric Bypass for Morbid Obesity: an Updated
Meta-Analysis. Obes Surg. 2019 Sep;29(9):2721–30. https://doi.org/10.1007/
s11695-019-04005-0. PMID: 31172454.
12. Landreneau JP, Strong AT, Rodriguez JH, Aleassa EM, Aminian A, Brethauer
S, Schauer PR, Kroh MD. Conversion of Sleeve Gastrectomy to Roux-en-Y
Gastric Bypass. Obes Surg. 2018 Dec;28(12):3843–50. https://doi.org/10.1007/
s11695-018-3435-1. PMID: 30094577.
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Third Space Endoscopy
Ashok Dalal, Ujjwal Sonika, and Amol S. Dahale
Introduction
Scar less surgery has always fascinated the surgeons and patients alike. As the tech-
nology has improved in vision and optics, laparoscopic surgery has become the
mainstream. Still the incision less surgery eludes the medical field.
As the surgical field was developing, parallel development in the flexible endo-
scopes was going on during the period. Flexible endoscopes allowed us to go deep
into the stomach and intestine to visualize the lumen. Intraluminal procedures like
polypectomies and stricture dilatation are performed relatively with ease now a days
with these endoscopes.
In between, there were thoughts of moving into the peritoneum from the lumen,
through its wall and performing few surgical procedures [1], which was known as
Natural orifice transluminal endoscopic surgery (NOTES). “NOTES” was univer-
sally handicapped by the poor closing techniques of the lumen after the procedure.
Much new advancements were practised to perfect the lumen closure technique.
A mucosal flap technique was discovered where a potential space was created
between muscularis mucosae and muscularis propria by injecting a fluid and
expanding the space, thus allowing dissection within the space. This technique
allowed the closure of the mucosal side relatively well. Soon other applications of
this technique were discovered and the era of third space endoscopy started.
A. Dalal (*) · U. Sonika

Department of Gastroenterology, GB Pant Hospital, New Delhi, India
A. S. Dahale
Department of Gastroenterology, D Y Patil Medical College, Pune, India
https://doi.org/10.1007/978-981-16-5473-2_16
352 A. Dalal et al.
What Is Actually the Third Space Endoscopy?
First space refers to the lumen; Second space is outside lumen, usually peritoneal cav-
ity. Third space refers to the potential space between muscularis mucosa and muscula-
ris propria. Initially multiple experiments were done on animal models and the
accessories and instruments were invented to perfect this technique. First POEM (Per
oral endoscopic myotomy) in a human subject was first performed in 2008 [2]. Since
then, POEM has become the most commonly performed third space surgery worldwide.
Many other new applications of the third space have been invented since then.
These are enumerated as below:
1. POEM (Per Oral Endoscopic Myotomy)

2. Z-POEM (Zenker’s Per Oral Endoscopic Myotomy)
3. D-POEM (Diverticulum Per Oral Endoscopic Myotomy)
4. G-POEM (Gastric Per Oral Endoscopic Myotomy)
5. STER ( Submucosal Tunnelling and Endoscopic Resection)
Per Oral Endoscopic Myotomy (POEM)
POEM is usually done for the treatment of achalasia cardia. It can be performed as
the initial procedure and also for the recurrent cases, both post endoscopic as well
as post surgical achalasia management.
The indications to do POEM are [3]:
1. Achalasia (Types 1, 2 and 3)
2. Previous failed Heller’s myotomy
3. Previous failed pneumatic dilatation
4. Previous failed botulism toxin injection
5. Diffuse esophageal spasm
6. Jackhammer esophagus
The contraindications to do POEMS are [3]:
1. History of radiation therapy to esophagus
2. Previous ablation/resection of esophageal mucosa
3. Cirrhosis with portal hypertension
4. Any other comorbid condition of a patient making him/her unfit for surgery.
Preoperative evaluation: Preoperative upper gastrointestinal (UGI) endoscopy,

manometry and anaesthesia work up should be done before starting the procedure.
UGI endoscopy is mainstay of diagnosis and also rules out any proximal mass
lesion or stricture for which treatment might be different and YGIE also eliminates
any evidence of gastroesophageal (GE) junction growth which can mimick as acha-
lasia (secondary achalasia). Manometry is a useful tool for diagnosis as well as
prognosis and can serve as an effective talisman for recovery and failure if any. In
era of high definition UGI endoscopy and manometry, barium UGI series are left
redundant except in very few rare situations.
Third Space Endoscopy 353
Patient has to be nil per mouth for 12 h before the procedure and it is not a bad
idea to place a nasoesophageal tube for lavage and suction of the residual food in the
dilated oesophagus just before the procedure. Preoperative antibiotics should be
started 12 h before the procedure.
Using room air for doing POEM procedures may lead to more incidences of
pneumomediastinum, gas embolism and cardiac arrest. Thus POEM is typically
performed using the carbon dioxide gas. General anaesthesia and endotracheal intu-
bation is advocated to minimize any risk of aspiration.
Instruments Required:
1. Flexible UGI endoscope preferably with HD vision.

2. Electrosurgical unit
3. Water Jet
4. CO2 insufflator
5. Transparent distal cap attachment
6. Saline mixed with methylene blue or indigo carmine
7. J knife (Fig. 1)
8. Soft Coagulation grasper forceps
9. Hemoclips
Fig. 1 J knife (Inset

showing tip of J Knife used
for dissection)
354 A. Dalal et al.
Steps of POEM
Mucosal Incision: A high definition scope with an attached distal cap is inserted
into the esophagus. The first step is to identify the site of mucosal incision.
Two types of approaches are described (Anterior & Posterior). Posterior approach
is usually done at a 5 o’clock position just adjacent to the spine impression around
8–10 cm proximal to GEJ junction. In the anterior approach, mucosal incision is
made at 2 o’ clock position approximately 8–10 cm proximal to GEJ junction. Both
the approaches are similar in most aspects and considered equally effective for the
treatment of achalasia [4]. However in a patient of previously failed surgical Heller’s
myotomy, a posterior approach is favoured. In spasmodic disorders of oesophagus
a more proximal site is chosen as the myotomy in these cases can be quite long.
At the pre-decided site of mucosal incision, mucosal injection of saline mixed
with methylene blue or indigo carmine is done to create a submucosal bleb (Fig. 2).
This step raises the mucosa over the muscularis propria. It thus provides a space to
make an incision limited to mucosa and submucosa but not reaching up to the mus-
cularis propria as it provides a cushion effect. After raising this submucosal bleb a
linear incision is made using the knife and electrosurgical cautery (Fig. 3). Careful
dissection of the surrounding submucosal tissue is done to facilitate the entry of
scope into the submucosal area. The edges of the mucosal incision site may be
trimmed with electrosurgical cautery to prevent bleeding and later facilitating easy
mucosal closure.
Creation of submucosal tunnel: A submucosal tunnel is then created with the
dissection of submucosal tissue (Fig. 4). The submucosal tissue is also injected with
saline mixed with methylene blue to facilitate dissection. Dissection is done with a
knife using an electrosurgical unit. Maintaining orientation is of utmost importance
during this step. Utmost care should be taken to preserve the mucosal integrity. Any
large vessel seen is coagulated by soft coagulation grasper. The submucosal tunnel
is extended till 3–5 cm from the gastroesophageal junction (GEJ). The GEJ is
Fig. 2 Submucosal bleb

after methylene blue or
indigo carmine
Fig. 3 Linear mucosal

incision
Fig. 4 Creation of sub

mucosal tunnel (Image
Courtesy: Dr Pravin
Suryavanshi)
identified by appearance of small blood vessels, longitudinal muscle fibres and nar-
rowing of the submucosal space. This can be confirmed during endoscopy by the
blanching of mucosa just below cardia. If the endoscopist doesn't want to remove
his scope from the tunnel then another ultrathin scope can be passed by the side and
blanching below cardia can be noted to see the adequacy of submucosal tun-
nel length.
Myotomy: After creating this submucosal tunnel, Myotomy is performed
(Fig. 5). The circular muscle fibres are cut starting 3–4 cm above GEJ and till 2 cm
below GEJ. Ideally selective circular fibre myotomy is performed but it becomes
really difficult to distinguish between circular and longitudinal fibres. Endoscopist
many times perform a full thickness myotomy as no difference is seen between
partial thickness and full thickness myotomy [5]. It is more important to maintain
mucosal integrity rather than worrying about the myotomy thickness. Adequate
myotomy can be assessed by the ease of passing scope across the GE junction.
356 A. Dalal et al.
Fig. 5 Creation of
myotomy (Image
Courtesy: Dr Pravin
Suryavanshi)
Fig. 6 Closure of mucosal

incision
Closure: After doing the myotomy, a careful examination of the submucosal

tunnel is done to rule out any bleeding sources or any site of mucosal injury. The
scope is taken out from the submucosal tunnel and the mucosal incision site is
closed using clips (Fig. 6). Adequate closure is essential to prevent contamination of
the submucosal tunnel or mediastinum.
Methods used to close the mucosal incision are
• Clips
• Endoscopic suturing
• OTSC (Over the scope clip)
Usually, hemoclips are most commonly used given that they are cheaper, easily
applicable and removable. Endoscopic suturing is relatively new technique, yet to
be easily available commercially. Over the scope clip is a recent addition in clips

showing space of
dissection in PEOM
which has to be loaded on scope, their cost and difficulty in removing if misfired has
limited their use.
The patient can be kept nil by mouth for next 12 h. A gastrografin swallow is
done to rule out any leak. Patients can be started orally on a soft diet after 48 h. Oral
antibiotics should be prescribed for the next 7 days and Proton Pump inhibitors
should be advised for the next 2 weeks. Figure 7 is a schematic diagram of the space
of dissection in POEM (Fig. 7).
Outcomes of Poem
POEM has now established itself as a safe and reliable surgery for achalasia cardia.
Multiple meta-analyses of various studies have been done now. Clinical success
reported is around 98% in one year follow up [6]. In the long-term results have
shown a sustained clinical efficacy of 83–95% [7, 8].
Adverse Effects of POEM
POEM is very safe procedures as the incidence of serious adverse effects are very
low [6]. The adverse effects may be due to:-
a. Insufflations related adverse effects: Use of carbon dioxide decreases the

events related to insufflation. Still complications commonly associated with
358 A. Dalal et al.
POEM procedures are subcutaneous emphysema (7.5%), pneumothorax (1.2%),

pneumomediastinum (1.1%), and pneumoperitoneum (6.8%) [8]. Usually these
adverse effects have no clinical significance and rarely require any intervention
or change in management. If there is a clinically significant pneumo-peritoneum
or pneumo-mediastinum it may require decompression by needle insertion.
b. Mucosal injuries (Figs. 8 and 9): During POEM, mucosa is the only barrier left
between the lumen and mediastinum/ peritoneum. Any potential breach in this
barrier may lead to infection of these spaces. So it is of utmost importance to
maintain the integrity of these spaces. But even after taking outmost care, muco-
sal injuries do occur during POEM procedure. The incidence of mucosal injuries
is 4.8% during a POEM procedure [8]. These occur most commonly during the
learning curve of the endoscopist with the most common site being near the
gastroesophageal junction as there is very less space between muscle layer and
mucosal layer. Mucosal injuries range from just discoloration of the mucosal
surface to complete damage to the mucosa. Every effort should be taken to care-
fully inspect the mucosal surface after completion of the procedure. If mucosal
breach is detected then the closure should be done using the hemoclips. Larger
defects can be closed using the “Over The Scope Clips” (OTSC) or by using
endosutures. Rarely surgery may be required to manage much larger defects.
c. Bleeding: POEM involves a lot of cutting and dissection. Bleeding can occur at
any step of mucosal incision, dissection of submucosal tissue or during myot-
omy. Most of the bleeding is minor and can be controlled with the electro cau-
tery knife itself. If any large calibre vessels, especially near gastroesophageal
junction is encountered they can be handled using a coagulation forceps.
Bleeding requiring any further intervention or blood transfusion is extremely
rare and occurs in only 0.2% of cases [8].
d. Pain: Pain after POEM procedure is described in up to 79% of the patients in the
postoperative period [8]. It is usually mild and can be easily managed by using
Non-Steroidal Anti Inflammatory Drug (NSAID)or by Paracetamol.
e. Aspiration Pneumonia: The incidence of aspiration is usually low but can
occur in 0.1% of the patients [8]. These can be prevented by keeping the patient
on a liquid diet for two days prior to the procedure. Any residual liquid should
also be sucked out prior to the mucosal incision.
f. Infections: Loss of mucosal barrier can lead to introduction of bacteria into the
third space and cause infection. It may lead to dangerous complications like
mediastinitis, empyema, pleural effusion requiring drainage or pneumonia.
g. Gastro Esophageal Reflux Disease (GERD): All treatment options of achala-
sia management have GERD as a potential adverse effect. Various studies have
shown that GERD is an adverse effect in the range of 13–88% [9–11], but clini-
cally significant GERD is less common. Erosive esophagitis occurs in 7 - 50% of
the patients [9]. Most of these patients can be managed with long term Proton
Pump Inhibitors (PPI).
Fig. 8 Mucosal rent at EG

junction (Image Courtesy:
Dr Pravin Suryavanshi)
Fig. 9 Mucosal rent from

submucosal site (Image
Courtesy: Dr Pravin
Suryavanshi)
Comparison of POEM vs Laparoscopic Heller’s Myotomy
Traditionally in recent decades Laparoscopic Heller’s Myotomy (LHM) is regarded

as the gold standard for treatment of achalasia. Pneumatic balloon dilatation was the
only endoscopic method available but wasn’t very effective.
There are several meta-analysis now comparing the efficacy of POEM procedure
with other methods [10, 11] where it has been shown that postoperative dysphagia
resolution is better with POEM than LHM [12]. POEM is found to be superiorto
LHM in management of type 3 achalasia and other esophageal spasmodic disorders
as the length of myotomy in POEM can be increased in these cases. Therefore it is
now the management of choice in type 3 achalasia and esophageal spasmodic disor-
ders. It is equal to LHM in management of Type 1 and Type 2 achalasia.
There is no difference in GERD symptoms between POEM & LHM, but erosive
esophagitis secondary to reflux tends to be more common after POEM [12].
360 A. Dalal et al.
Z-POEM (Zenker’s Per Oral Endoscopic Myotomy)
Z-POEM is used for the treatment of Zenker’s diverticulum [13]. Zenker’s diver-
ticulum is a pulsion diverticulum at the upper end of the esophagus. It can lead to
dysphagia and can also lead to aspiration. The usual treatment of Zenker’s diverticu-
lum has been by open surgery and septostomy using either endoscopy or flexible
endoscopy. Third space endoscopy technique is now being also used in management
of Zenker’s diverticulum. In this technique, a submucosal tunnel is created on the
septum and the muscular septum is cut beneath the mucosa. The advantage of
Z-POEM over the endoscopic septostomy is that the muscular septum can be cut for
a longer length and thus chances of recurrence are lesser as compared to the septos-
tomy (Fig. 10). However, the success rate of endoscopic septostomy is 91% which
is similar to that of Z-POEM which is around 92% [13]. Recurrences can be suc-
cessfully managed by a repeat septostomy.
D-POEM (Diverticulum Per Oral Endoscopic Myotomy)
D-POEM is used for management of esophageal diverticula other than the Zenker’s
diverticulum. It is simple, safe and effective to relieve symptoms such as dysphagia,
reflux and chest pain caused by esophageal diverticulum, while avoiding invasive
surgery. The technique is similar to Z-POEM. Here after creating the submucosal
tunnel, the muscular septum is divided and then the mucosal incision site is closed.
Fig. 10 Schematic
diagram showing site of
myotomy in Zenker’s
Diverticulum
Fig. 11 Schematic
diagram showing G-POEM
being done
G-POEM (Gastric Per Oral Endoscopic Myotomy)
After the success of POEM in achalasia, a similar procedure was developed for the
management of gastroparesis in the stomach, where a submucosal tunnel is created
from 7 to 8 cm proximal to pylorus and pyloromyotomy is done (Fig. 11) [14]. The
results are so far good in gastroparesis but not for diabetic patients. So a careful
evaluation and selection of patients is mandatory before doing this procedure. As in
POEM where GERD is a major symptom post procedure, bile reflux is a common
sequel after G-POEM.
STER (Sub Mucosal Tunnelling and Endoscopic Resection)
Subepithelial tumours in GI tract are traditionally removed when the size is more
than 3 cm. With the advent of third space endoscopy technique a submucosal tunnel
is created 4–5 cm proximal to the lesion and the lesion is dissected from the sur-
rounding tissue using electrosurgical knives. The tumour is then removed through
the mucosal opening site. This technique can be challenging if the tumour is located
in fundus or lesser curvature of the stomach, tumour is larger >4.5 cm in size,
tumour is multilobulated or adherent to the deep structures.
Conclusion
Third space endoscopy has evolved over the last decade after the introduction of the
first case of POEM in 2008. It is now the method of choice for the type 3 achalasia
and other esophageal spasmodic disorders. For the management of type 1 and type
2 achalasia also it compares equally with LHM. Third space endoscopy is evolving
in the management of oesophageal diverticula and gastroparesis. STER is now
being routinely performed for excision of subepithelial tumours.
362 A. Dalal et al.
Key Clinical Points

1. First space refers to the lumen; second space is outside lumen, usually peritoneal
cavity third space refers to the potential space between muscularis mucosa and
muscularis propria. POEM is the most commonly performed third space
procedure.
2. POEM can be performed as the initial procedure and also for the recurrence post
endoscopic as well as post-surgical achalasia management. It is particularly
useful in type 3 achalasia.
3. UGI endoscopy is mainstay of diagnosis and also rules out any proximal mass
lesion, stricture for which treatment might be different) and also eliminates any
evidence of GE junction growth which an mimick as achalasia (Secondary
achalasia).
4. Anterior and Posterior approaches are similar in most aspects and considered
equally effective for the treatment of achalasia. However in a previously surgical
failed Heller’s myotomy a posterior approach is favoured
5. After myotomy is performed, circular muscle fibres are cut starting 3–4 cm
above GEJ and till 2 cm below GEJ. Ideally selective circular fibre myotomy is
performed but it becomes really difficult to distinguish between circular and
longitudinal fibres. No difference is seen between partial thickness and full
thickness myotomy.
6. Mucosal closure is very important. Usually hemoclips are most commonly used
given that they are cheaper, easily applicable and removable.
7. POEM is very safe procedures as the incidence of serious adverse effects are
very low.
Editor’s Note1
Third space endoscopy has emerged as an attractive option in upper gastrointestinal

motility disorders like achalasia, esophageal diverticular disease, esophageal stric-
tures and gastroparesis. Recently its use has been expanded to encompass resection
of submucosal tumors like GIST (gastrointestinal stromal tumors) and leiomyomas.
ewer Evolving Application of Third Space

N
Endoscopic Techniques
Authors are investigating the translation of the concept to treat
• lower gastrointestinal motility disorders as well like Hirschsprung disease

denoted as PREM (per rectal endoscopic myotomy), analogous to POEM (per
oral endoscopic myotomy) [1].
• POETRE (per oral endoscopic tunnelling for restoration of the esophagus) is
another emerging technique described in complete esophageal occlusion seen
after chemoradiation [2].
• The other potential arenas of its application being investigated are in mediasti-
noscopy, thoracoscopy and peritoneoscopy [3].
• Implantation of gastrointestinal pacemakers to treat motility disorders
(investigational)
Results of POEM Versus Laparoscopic Hellers Myotomy
The prominent application currently has been in the treatment of achalasia cardia.
Table EN1 enlists various published meta-analyses comparing outcome of laparo-
scopic Hellers myotomy (LHM) and Peroral endoscopic myotomy [4–13]. Most
studies report better dysphagia control with POEM than LHM [4–7, 9, 11, 12].
The quoted advantages of POEM are that it is a scarless surgery and has a relatively
shorter operative time and hospital stay [6–8]. Complications and serious adverse
events have been comparable between POEM and LHM across studies [6–13]. One of
the noted disadvantages of POEM in treatment of achalasia is the higher incidence of
GERD (gastroesophageal reflux disease) as compared to Laparoscopic Hellers myot-
omy in both subjective and objective assessments as evidenced by higher GERD
symptoms, abnormal pH studies and erosive esophagitis [4, 8, 9, 14].
POEM has been observed to have better dysphagia relief than PD (pneumatic
dilatation) with comparable adverse events [9–11]. As most Hellers myotomy is
coupled with a fundoplication, addition of an trans oral endoscopic treatment of
GERD to POEM viz: transoral incisionless fundoplication or electrical stimulators
might be able to decrease the incidence of GERD and thus emerge as a potential
topic of research in the near future. POEM can also be considered as a safe alterna-
tive in failed Hellers myotomy [15].
1
364 A. Dalal et al.
Techniques to Improve Visualization and Dissection in POEM
Third space endoscopy essentially uses the SEMF (submucosal endoscopy with
mucosal flap technique) [16]. Technical issues like ensuring a good vision and hae-
mostasis in POEM are paramount. Use of a lighted LED probe to help improve
visibility in submucosal tunnel creation as also for assessing completeness of myot-
omy has been proposed to be beneficial in this regard [17]. Use of saline jet or water
pump assisted dissection, balloon dilators and various knives are being evaluated.
Table EN1 Meta-analyses comparing POEM (Per oral endoscopic myotomy) with LHM (Laparoscopic Hellers myotomy)
Postoperative GERD gastroesophageal Other outcome parameters POEM
Study, Author (first), Year Dysphagia Relief POEM vs LHM reflux disease POEM vs LHM vs LHM
Laparoscopic Heller Myotomy Improvement in dysphagia at 12 Patients undergoing POEM were more Length of hospital stay was 1.03
Versus Peroral Endoscopic months were 93.5% for POEM and likely to develop following days longer after POEM (P = 0.04).
Myotomy (POEM) for Achalasia: 91.0% for LHM (P = 0.01) 1. GERD symptoms
A Systematic Review and (OR 1.69, 95% CI 1.33–2.14,
Meta-analysis P < 0.0001),
Schlottmann F, 2018 [4] 2. Erosive esophagitis
(OR 9.31, 95% CI 4.71–18.85,
P < 0.0001),
3. GERD evidenced by pH monitoring
(OR 4.30, 95% CI 2.96–6.27,
P < 0.0001).
Meta-analysis of clinical outcome POEM more successful than LHM
after treatment for achalasia based for both type I and type III
on manometric subtypes. achalasia (odds ratio (OR) 2·97,
Andolfi C, 2019 [5] 95% CI 1·09 to 8·03; P = 0.032) &
(OR 3·50, 1·39 to 8·77; P = 0.007)
The likelihood of success of POEM
and LHM for type II achalasia was
similar.
Peroral (poem) or surgical Greater mean reduction in Eckardt Post-Operative Gastroesophageal Reflux • No difference in operative time
myotomy for the treatment of score in POEM patients no significant difference (MD = −10,26, 95% CI (−5,6 to
achalasia: a systematic review and (MD = −0.257, 95% CI: (−0.512 to (RD: −0.00, 95%CI: (−0.09, 0.09), I2: 8,2), P < 0.001
meta-analysis. −0.002), P = 0.048) 0%) • Decreased length of hospital stay
Martins RK 2020 [6] for POEM (MD: −0.6, 95% CI
(−1.11, −0.09), P = 0.02),
• Similar rates of adverse events.
(continued)
365
366
Postoperative GERD gastroesophageal Other outcome parameters POEM

Study, Author (first), Year Dysphagia Relief POEM vs LHM reflux disease POEM vs LHM vs LHM
Systematic Review and Meta- Higher short-term clinical treatment No significant difference in No significant difference in:
Analysis of Perioperative failure rate for LHM 1. Postoperative GERD rate 1. Overall complication rate
Outcomes of Peroral Endoscopic (OR, 9.82; 95% CI, 2.06–46.80; (OR, 1.27; 95% CI, 0.70–2.30; 2. length of hospital stay
Myotomy (POEM) and P < 0.01). P = 0.44and 3. postoperative pain score
Laparoscopic Heller Myotomy 2. Long-term GERD 4. Operative time (longer in LHM)
(LHM) for Achalasia. (WMD, 1.06; 95% CI, 0.27–4.1;
Awaiz A 2017 [7] P = 0.08)
Surgery or Peroral Esophageal There were no differences between Significant reduction in symptomatic Length of hospital stay was
Myotomy for Achalasia: A POEM and LHM in reduction in gastroesophageal reflux rate in favors of significantly lower for POEM
Systematic Review and Eckardt score LHM (MD = −0.629, 95% CI: −1.256 to
Meta-Analysis. (MD = −0.659, 95% CI: −1.70 to (OR = 1.81, 95% CI: 1.11–2.95, −0.002, P = 0.049)
Marano L 2016 [8] 0.38, P = 0.217. P = 0.017). No significant difference in:
1. Operative time
2. postoperative pain scores
3. Analgesic requirements
4. Complications
Systematic Review and Bayesian 1. Postoperative dysphagia Postoperative gastroesophageal reflux No statistically significant
Network Meta-Analysis remission was statistically disease (GERD) rate was higher in differences were found comparing
Comparing Laparoscopic Heller significantly improved in POEM POEM than in LHM LHM and PD in any of the other
Myotomy, Pneumatic Dilatation, compared with LHM (RR = 1.75; 95% CIs = 1.35–2.03) analyzed outcomes.
and Peroral Endoscopic Myotomy (risk ratio [RR] = 1.21; 95%
for Esophageal Achalasia. credible intervals [CIs] = 1.04–1.47
Aiolfi A 2020 [9] 2. Postoperative Eckardt score was
significantly lower in POEM than
in LHM
(standardized mean difference
(smd) = −0.6; 95% CIs = −1.4 to
−0.2
A. Dalal et al.
Comparative efficacy of first-line Treatment success at 1 year No significant difference was observed Procedure-related serious adverse
therapeutic interventions for POEM (RR [risk ratio], 1.29; 95% between LHM and POEM (RR 1.09 event rate after POEM, LHM, was
achalasia: a systematic review and confidence intervals [CI], 0.99– [0.86–1.39]). 1.4%, & 6.7% respectively.
network meta-analysis. 1.69), and The incidence of severe esophagitis
Facciorusso A 2020 [10] LHM (RR, 1.18 [0.96–1.44]) after POEM, LHM, and PD was 5.3%,
over PD 3.7%, and 1.5%, respectively
Efficacy of surgical or endoscopic POEM was ranked first (RR of No difference Gastro-oesophageal No significant differences in:
treatment of idiopathic achalasia: failure of treatment 0·33, 95% CI reflux or erosive oesophagitis 1. Perforation rates,
a systematic review and network 0·15–0·71; P-score 0·89), then LHM 2. Need for re-intervention or
meta-analysis. (RR 0·45, 0·26–0·78, P-score 0·61). surgery
Mundre P 2021 [11] 3. Serious adverse events
Per-Oral Endoscopic Myotomy POEM group had a lower Eckardt No differences between the POEM
Versus Laparoscopic Heller score after surgery compared with and LHM groups in:
Myotomy for Achalasia: A those in the LHM group 1. Length of myotomy,
Meta-Analysis of Nonrandomized (MD = −0.30, 95% CI −0.42 to 2. Operation time,
Comparative Studies. −0.18; P < 0.001 3. length of hospital stay,
Zhang Y 2016 [12] 4. Complications
Peroral esophageal myotomy Symptomatic recurrence by Eckardt Gastroesophageal reflux not significant No significant difference between
versus laparoscopic Heller’s score not significant (OR = 1.00, 95% CI 0.38–2.61, POEM and LHM in:
myotomy for achalasia: a (OR = 0.24, 95% CI 0.04–1.55, P = 1.00). 1. Complications
meta-analysis. P = 0.13). 2. Pain score,
Wei M, 2015 [13] 3. Operating time,
4. Hospital stay
OR odds ratio, MD mean difference, WMD weighted mean difference, RD risk difference, CI confidence interval, RR relative risk
367
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Endoscopic Management of Pancreatic
Fluid Collection
Vaishali Bhardwaj and Vikram Bhatia
Introduction
Pancreatic fluid collections (PFCs) are an important sequela of acute pancreatitis

and if not managed appropriately can result in significant mobidity. The three main
approaches adopted for drainage of PFCs are: percutaneously, surgically or endo-
scopically. The latter can be performed either with endoscopic ultrasound (EUS)
guided cysto-gastrostomy and/or through endoscopic retrograde pancreaticography
(ERCP) and transpapillary drainage. The first report of endoscopic drainage of
PFC’s dates back to 1973 [1]. Recent advances in technology and technique has
revolutionized the treatment of PFCs. Here we highlight the concepts and technique
of endoscopic management of PFCs.
Classification and Natural History of PFC’S
Pancreatitis may be of two common types: interstitial edematous pancreatitis (IEP)

and necrotizing pancreatitis (NP). Further the necrosis may be pancreatic or peri-
pancreatic. The severity of pancreatitis is classified according to presence or absence
of local or systemic complications (i.e. persistent organ failure >48 h) into mild
moderate or severe. Local complications may be classified as early or late and
necrotic or non-necrotic. Pancreatic fluid collections (local complications) are of
four sub types as per the revised Atlanta classification [2]:
V. Bhardwaj (*)
Department of Gastroenterology, ABVIMS & Dr RML Hospital, New Delhi, India
V. Bhatia
Department of Hepatology, ILBS, New Delhi, India
https://doi.org/10.1007/978-981-16-5473-2_17
372 V. Bhardwaj and V. Bhatia
1. Acute pancreatic fluid collections (APFC):

≤4 weeks duration, non-necrotic collection, sequelae of IEP
2. Acute necrotic collections (ANC)
≤4 weeks duration, necrotic collection, sequelae of NP
3. Pancreatic Pseudocyst (PPC)
>4 weeks duration, non-necrotic collection, sequelae of IEP
4. Walled off necrosis (WON)
>4 weeks duration, necrotic collection, sequelae of NP
APFC normally develops after an episode of IEP and progresses to PPC if not
resolved in 4 weeks whereas, ANC develops after acute necrotizing pancreatitis and
if unresolved develops into WON. CECT further helps to classify the various pan-
creatic fluid collection. Pseudocysts have clear contents and a defined wall whereas
WON have walled off variable amount of solid necrotic debris. Cross-sectional
imaging after the first week can differentiate ANC and acute PFC. PFC have clear
contents whereas ANC appears loculated with variable amount of debris within the
fluid [2].
Evolving Concepts in Management
Acute collections (APFC or ANC) usually do not require any intervention as they
improve with conservative management [3]. However, a proportion of symptomatic
WON and pseudocysts require intervention. The various drainage options of PFCs
are: (1) percutaneous drainage (2) endoscopic drainage/stenting (3) surgical drain-
age, which may be open or by minimally invasive approaches. With advent of tech-
nical innovations in interventional endoscopy, invasive surgical procedures can be
avoided in majority of PFC patients.
Certain newer insights have come to picture, namely
(a) Outcome of a drainage procedure is better if performed once the collection gets
walled off or encapsulated (>4 week).
(b) Minimally invasive approach to the management of PFCs is better than the
conventional open surgical methods
(c) The outcome of endoscopic drainage depends on the nature of PFC i.e. pseudo-
cyst or WON [4–7].
Symptomatic PFC’s are initially managed by intravenous fluid, antibiotics and

nutritional support and later if symptoms persist by minimally invasive endoscopic,
percutaneous or surgical (Laparoscopic) drainage ± necrosectomy (Endoscopic or
surgical) which depends on presence of symptomatic necrosis and possible block-
ade of the newly created passage.
Endoscopic Management of Pancreatic Fluid Collection 373
Minimally Invasive Approach
Minimally invasive approach to the management of PFCs (especially WON) has

gained impetus after a recent landmark trial the Dutch “PANTER” trial. The trial
advocated a “step-up approach” i.e., attempts of initial per-cutaneous or endoscopic
transgastric drainage of infected pancreatic necrotic collection followed by mini-
mally invasive retroperitoneal necrosectomy if unresolved and has observed less
major complications and mortality with the approach as opposed to the open necro-
sectomy [5]. Necrosectomy performed by minimally invasive approach reduces
pro-inflammatory response as well as new onset organ failure by decreasing surgi-
cal trauma as compared to open surgical necrosectomy [5]. The results of the trial
has led to a worldwide acceptance of the step up approach and minimally invasive
necrosectomy as treatment options for PFC’s.
Specific Technology
Planning of Intervention in PFCs
Indications: Asymptomatic PFCs do not require treatment as they often spontane-

ously resolve. The former criteria of drainage namely “the rule of 6” i.e. >6 cm size,
>6 mm wall thickness and >6 weeks duration are no longer deemed valid.
The current indications for intervention for PFCs are presence of:
• Symptoms: (abdominal pain, biliary, gastric outlet or intestinal obstruction)

• Complications: (infection, rupture, haemorrhage)
• Rapid enlargement: (enlarging at a rapid rate to a large size)
Pre Procedure Investigations
It is prudent to rule out other causes of pancreatic cysts such as cystic neoplasm,
duplication cyst, as also complications like presence of pseudoaneurysm before
intervention. Evaluation of pancreatic duct integrity is also helpful to rule out DPDS
(disconnected pancreatic duct syndrome), which is associated with WON and com-
munication of pseudocyst with the duct. The following investigations can aid in
assessment:
• Contrast enhanced computed tomography (CECT),

• Magnetic Resonance Imaging (MRI)
• Magnetic resonance cholangio pancreatography (MRCP)
• Endoscopic Ultrasound (EUS).
• ERCP Endoscopic retrograde cholangiopancreaticography
Percutaneous Catheter Drainage and Necrosectomy
Image (CT/USG) guided percutaneous intervention such as aspiration or placement

of an external drainage catheter provides an alternative when the fluid collection is
infected and cyst walls are immature where laparoscopic or endoscopic approach
may not be feasible or as a primary procedure in step-up approach. It can also be
considered in salvage therapy of residual or infected collections.
A self-retaining catheter of 12–30 Fr size is preferred. The retroperitoneal route
avoids peritoneal contamination and minimizes chances of bowel injury and is
therefore preferred. Irrigation through catheter may also be beneficial. An initial
catheter drainage is helpful to control sepsis. If complete resolution does not occur
with simple catheter drainage techniques of retroperitoneal necrosectomy such as
VARD (video assisted retroperitoneal drainage) or percutaneous endoscopic necro-
sectomy may be helpful.
However, complications may be associated with percutaneous catheter drainage
such as secondary infections related to the catheter,
• occlusion of catheter,
• peri catheter cellulitis,
• sepsis and prolonged pancreatic fistula in presence of cysto-ductal
communication.
When percutaneous drainage is compared with endoscopic approach, endoscopic

approach is shown to have higher rates of treatment success with low rates of need
for second intervention/procedure and less number of days of hospital admission.
Therefore, this method of percutaneous drainage should be reserved for a selective
group of patients who have one of the following [5]:
1. Immature collections which are infected particularly in a moribund patient

2. Development of PFC after resection of pancreatic tail
3. Anatomical variants
4. Any contraindication for endoscopic therapy.
Endoscopic Drainage of PPC
Pancreatic pseudocyst have been traditionally drained surgically (open or laparo-

scopic approach) [8]. However high complication (upto 30%) and recurrence rates
have been noted [9]. Endoscopic drainage merits being a less-invasive and more
cost-effective option [9, 10]. An endoscopic approach should be attempted with
preferable support of interventional radiology and surgical team in the event of
complications during the procedure and is now emerging as the preferred first line
approach [9].
Various Endoscopic Approaches in PFC’s
Methods described for endoscopic drainage are as follows:
• Transmural—Esophagogastroduodenoscopy (EGD) based or EUS guided.

• Transpapillary—Under ERCP guidance.
• Combined/Hybrid approaches
–– Dual transmural and transpapillary route
–– Dual endoscopic and percutaneous drainage
Factors that Influence the Route of Endoscopic Drainage
1. Anatomic proximity of the PFC to the stomach and duodenum. This is an impor-
tant factor which helps in decision making regarding the choice of lumen for
drainage. If the collection is near the stomach and is producing a visible intramu-
ral bulge on the gastric wall (Fig. 1), it is amenable to drainage via EGD alone
method described in details later in this chapter. EUS is recommended if the PFC
is not bulging (Fig. 2) or is slightly away from the lumen wall.
2. Anatomy of the pancreatic duct with cystoductal communication (CDC) is
another factor. If the collection is communicating with main pancreatic duct
trans-papillary drainage is possible via ERCP.
3. Size of the collection with presence of necrosis in the cyst, helps in decision
making as collection with large necrotic content compared to fluid component
are not amenable to simple drainage procedures. Presence of necrosis might
require multiple attempts for total clearance.
4. Number of cysts and internal communication between them is an important fac-
tor while making decisions as communicating cysts are better amenable to endo-
scopic procedures compared to non-communicating ones.
Fig. 1 Large pseudocyst

(PPC) bulging into
stomach (Yellow Arrow)
[Image courtesy: Dr
Deborshi Sharma]
Fig. 2 Large pseudocyst

(PPC) with ≥1 cm gap
(Yellow arrow) between
stomach (S) and cyst
(PPC) [Image Courtesy:
Dr Deborshi Sharma]
5. Thickness of cysts wall: Cyst wall must be mature before attempting any kind of
drainage procedure so pre procedure radiological evaluation is mandatory prior
to venturing into any kind of drainage procedure.
Endoscopic Transmural Drainage of PFC
The main principle of endoscopic transmural drainage is to create an adequate

drainage portal which is accessible for repeated interventions and is associated with
minimal complications [9].
Preprocedure Preparation
• Bleeding/Coagulation disorders needs to be corrected

• Preprocedural antibiotics reduce risk of infective complications particu-
larly for WON
• Procedure is usually performed under sedation with analgesia but can also be
undertaken in general anaesthesia.
• Backup interventional radiology/surgical support should be arranged.
Esophago Gastro Duodenoscopy (EGD) Based PFC Drainage
Transmural drainage technique: The technique incorporates a standard sequence of

steps as follows:
• identification of the ideal puncture site under endoscopic guidance over the bulge,
• needle puncture at the site and through the PPC wall into the cyst and diagnostic
aspiration to look for haemorrhage or infection. The aspirated fluid should be
sent for microbiological analysis.
• insertion of guide wire through the needle
• coiling of guidewire inside the cyst cavity (can be confirmed with fluoroscopy)
• removal of needle
• dilatation of cystogastric tract using cystotome and balloon over guide wire
causes cyst fluid to gush into the stomach
• placement of stents (commonly double pigtail stents) communicating the cyst to
the stomach cavity (Figs. 3 and 4).
a b
c d
Fig. 3 (a) Needle knife papillotome making incision at the bulging site, (b) Balloon dilatation of
the tract, (c) Fluoroscopy picture of guide wire in situ, (d) Double pigtail stent draining from the
cyst into stomach
Fig. 4 Schematic Endoscope

illustration of endoscopic
transmural drainage
Liver
Spleen
Stents in
Cystogastrostomy
Pseudocyst
Pancreas
Transverse Colon
Plastic or metal stents are put to accomplish endoscopic drainage of PFC’s.

Whereas plastic stent alone may suffice in pseudocysts with only fluid content, fully
covered self-expanding metal stents or LAMS (lumen apposing covered self-
expanding metallic stents) may be preferable for WON to drain necrotic solid com-
ponent. EGD only based approach has been associated with certain disadvantage
like it requires an endoluminal bulge of the cyst (Fig. 1) for it to be successfully
performed and since it is a blind procedure high risk of bleeding is present from
intervening vessels or collaterals.
EUS Guided Transmural PFC Drainage (Fig. 5)
Benefits: The EUS guided transmural PFC drainage technique is similar to only
EGD guided technique with added perceived benefits as follows:
• helpful in non-bulging PFCs where endoscopic definable compression is absent.

• can be utilized to assess contents of the cyst for presence of necrotic material,
which can influence the choice of stents and drainage maneuvers (necrosectomy
or multiple stents may be desirable in WON).
• can identify associated pathology in pancreatic gland i.e. status of pancreatic
duct, stones, as also detect masquerading cysts/pancreatic tumors
• helps identify the route and site of drainage viz. transgastric versus trans duode-
nal drainage. The lumen which is in close proximity to the PFC is selected, which
ideally should be <1 cm from the cyst wall, with no intervening vital structures
between the cyst and lumen wall to reduce risk of injury or perforation
• helpful in PFCs in unusual locations (for example trans esophageal roue) [9].
• addition of doppler identifies interceding vessels, collaterals/varices or pseudoa-
neurysms (resultant due to portal hypertension secondary to portal vein or splenic
a b
c d
Fig. 5 EUS aided transmural drainage of PFC. (a) EUS image of pancreatic fluid collection, (b)
EUS guided dilatation of tract (Green arrow), (c) Placement of Lumen apposing metal stent
(LAMS), (d) LAMS in position draining fluid (Guide wire is also seen)
vein thrombosis) in close proximity to the identified tract of drainage/catheter

placement which have the potential to bleed during the procedure.
• can determine adequacy of guidewire and stent placement into the cyst cavity in
addition to fluoroscopy
• help detect post transmural puncture intracystic haemorrhage.
Use of “Forward viewing endoscope”: Traditionally an oblique viewing endo-

scope was used for EUS guided procedure which permitted puncture only at an
angulation. Recently a forward viewing endoscope has been utilized for drainage of
pancreatic pseudocyst which enables direct perpendicular puncture of PFCs and is
stated to yield better results [9, 11–14].
Use of multiple stents: Particularly for the drainage of WON, multiple stents or
catheters may be needed. Use of additional nasocystic catheter can assist in irriga-
tion and flushing out of necrotic debris from the cavity which can obviate the need
for necrosectomy in some cases. Necrotic debris in the cyst cavity can be flushed
with normal saline solution (100 mL every 4 h until the aspirate is clear) [9].
Techniques have evolved for insertion of multiple catheters using a single puncture
more commonly known as “one step double wire technique” [15, 16].
Pre procedure ERCP: Preprocedure ERCP has been used by some authors to
delineate ductal disruptions and perform a sphincterotomy or stenting before drain-
age (as discussed below).
rief Outline of the Standard Steps of the EUS Guided

B
Transmural Drainage
• Identification of optimal site by EUS (site of PFC <1 cm from posterior gastric/
medial duodenal wall with no interceding vascular abnormalities or viscera).
Rarely distal esophagus has been described as portal of drainage.
• Puncture of PFC and diagnostic aspiration of fluid content is performed with a
19-gauge needle under real time EUS guidance (to exclude any misdiagnosis and
to look for infection and hemorrhage within the cyst).
• Under simultaneous EUS and fluoroscopic guidance a guidewire (0.035-
inch × 440 cm) is inserted through the needle into PFC cavity with sufficient
length for looping it in the cavity. More than one guidewire may be placed if
multiple stents are to be used.
• Needle is removed after placement of guidewires
• Enlargement of the tract by sequential dilatation of the tract done with 6–10 mm
hydrostatic balloon dilator and/or cystotome to facilitate insertion of multiple
plastic stent (gush of cyst fluid occurs into the stomach following dilatation)
• Insertion of double-pigtail plastic stents (sizes between 7 and 10 Fr) under EUS
and fluoroscopic guidance. The double pigtail is designed to make it self-
retaining and prevention of migration into the cyst or bowel lumen.
• Most frequently two plastic double-pigtailed biliary stents are placed. Multiple
stents or a nasocystic catheter is deployed if indicated.
• In uncomplicated cases, number and size of plastic stent used or number of inter-
ventions done, does not affect outcome
• To evaluate response to intervention a repeat CT scan is done after 4–6 weeks [9].
Complications and Outcome
Some of the reported complications of endoscopic transmural drainage of PFCs are:
• bleeding
• perforation of viscera
• pneumoperitoneum
• fistula formation
• stent related problems (migration/occlusion) [17, 18].
Use of electrocautery along with knife cystotome has been tried to reduce bleed-
ing complications [18]. In a prospective randomized trial comparing only EGD
based (Blind Technique) and EUS-based approach in cysts >4 cm size, equivalent
results were noted [17]. It needs to be emphasized that whereas bulging PFCs are
drained with EGD only non-bulging PFCs are drained with combined EGD and
EUS technique which can confound comparisons [18]. Another prospective ran-
domized trial noted a higher technical success rate and lower complications with
EUS guided EGD when compared to EGD alone technique [19]. EUS should be
preferred as a first-line of treatment in all, particularly in nonbulging cysts [17–19].
Transpapillary Drainage of PFC (Fig. 6)
Need of Pre Drainage ERCP (Pancreatogram)
Before the advent of advanced imaging systems for the pancreatic duct like MRCP,
an ERCP-based algorithm was advocated to guide treatment of PFCs based on pan-
creatic duct morphology viz. ductal disruption, strictures, complete cutoff of the
duct and cystoductal communication (CDC) necessitating the need for pre proce-
dure ERCP [20, 21]. However, due to availability of noninvasive imaging like
MRCP, pre drainage ERCP pancreatogram is now not regularly used to guide the
drainage approach.
Transpapillary Drainage (ERCP Guided)
PFCs communicating with the main pancreatic duct can be managed with transpap-
illary stenting of the main pancreatic duct through the main or minor papilla which
may be accompanied with a sphincterotomy. Alternatively, drainage of the PFCs
through the transpapillary stent (cystopancreatic stents) has been advocated. Thus,
the stent may be placed into the collection or positioned close to the collection in a
Fig. 6 Schematic
illustration of
transpapillary stenting
Pseudocyst
Endoscope
Pancreas Disruption in
main pancreatic duct
Transpapillary Duodenum
Stent
manner to bridge the duct disruption/stricture, by coursing into the pancreatic tail
[22–24]. Insertion of a transpapillary nasocystic catheter can be used for irrigation
of the cyst cavity [22]. Even a simple stenting can improve flow dynamics of the
pancreatic duct by promoting flow of pancreatic secretions through the papilla (a
low resistance tract) rather than into the PFCs (a relatively high resistance tract).
Complete bridging of the disruption is preferable particularly in pancreatic body
and tail disruptions [25].
Disadvantages of Transpapillary Approach
• stents need to be routinely exchanged every 6–8 weeks

• a prolonged duration of treatment may be needed at times for 3–6 months [9,
23, 24].
• ERCP induced pancreatitis
• Scarring of main pancreatic duct due to stent
• Infection of the collection
• Inability to adequately drain large collections (transmural approach is preferred
for large collections) [25].
Advantages of Transpapillary approach: The potential benefits of transpapil-

lary approach over transmural procedure are:
• decreased risk of bleeding, particularly useful in context of gastric varices and

portal hypertension where a transmural procedure carries high risk of bleeding
• lower chances of perforation
• concomitant pancreatic gland pathology can be addressed viz. pancreatic duct
stones and strictures [25].
Contraindications to transpapillary stenting:
• completely intact PD
• completely disrupted/disconnected pancreatic duct syndrome with no communi-
cation between the downstream PD and PPC [9].
Transpapillary nasocystic catheter insertion: If necrotic debris are present

within the cyst cavity, a transpapillary nasocystic catheter can be inserted to facili-
tate aspiration of PPC/WON contents by repeatedly flushing the cyst cavity with
saline (a type of indirect necrosectomy) which also aids in faster liquefaction of the
cyst contents [22].
Combined Approach for Drainage of PFCs
Combined endoscopic transmural and transpapillary approach: Addition of a

transpapillary stenting to a transmural drainage may be particularly beneficial for
partial duct disruptions, but its role in complete duct disruptions is not as encourag-
ing [26].
Dual endoscopic and percutaneous technique: A combined endoscopic drain-
age along with radiological percutaneous drainage was investigated and found to be
beneficial for treatment of WON. It alleviated the need for surgical necrosectomy
and had lower incidence of percutaneous fistula [25].
Multiple transluminal gateway technique: It involves creation of multiple
transmural drainage tracts, one of which is used for nasocystic irrigation which
leads to higher clinical success rate [25].
Choice of Stents, Plastic Versus Metallic Stents
Plastic or metallic stents can be used for drainage.

Advantages of plastic stent:
• Less likely to erode into adjacent structures

• Can be left in situ for longer time
Disadvantages of plastic stents/double pigtail stents (DPS):
• Stent migration
• Plastic stents have narrow lumen necessitating placement of multiple stents
which is labor intensive and time consuming
• Due to their small luminal diameter, they are prone to occlusion
• Larger plastic stents are difficult to deploy through small calibre channels of the
endoscope [27].
• Stent end abutting against luminal wall can lead to incomplete drainage.
• If apposition of cyst wall and GI lumen walls is lacking plastic stents can cause
fluid leakage in the intervening space.
EMS (Self-Expanding Metal Stents) and LAMS (Lumen Apposing

S
Metal Stents)
SEMS: Fully covered SEMS which are commonly used to stent gastrointestinal
strictures were initially tested in drainage of PFCs to overcome the shortcomings of
DPS [27]. The main advantage of fully covered SEMS is having a larger diameter
than DPS and only a single stent is needed instead of multiple stents. However fully
covered SEMS still has potential risk of migration and modification with fins or
placement of DPS across the fully covered SEMS has been suggested to prevent
overt migration [28]. SEMS has not been beneficial over DPS for PPC but may be
more useful in WON [28].
LAMS: LAMS (AXIOS; Xlumena Mountain View CA, approved in USA &
NAGI; approved in Europe) are saddle-shaped, nitinol, braided, flexible stents fully
covered with a silicon membrane designed to overcome the drawbacks of DPS and
SEMS. The stent has bilateral double-walled anchoring barbell flanges designed to
hold the stomach or duodenal wall in direct opposition to the PFC wall, reducing the
risk of migration. This stent is available in 10 and 15 mm size diameters and mea-
sures 10 mm in length. A 15-mm diameter allows for the passage of conventional
upper GI endoscope for reinterventions such as repeated debridement, irrigation or
necrosectomy [9].
ndoscopic Management of WON and Endoscopic

E
Necrosectomy (Figs. 7, 8, and 9)
Management of WON differs from PPC as the former requires debridement, often
multiple interventions, which may be:
• indirect i.e. irrigation and catheter drainage technique (implemented as a step up

procedure)
• direct endoscopic necrosectomy.
The various endoscopic approaches described in the treatment of WON are:
Fig. 7 Necrotic debris

seen through the LAMS
stent
Fig. 8 Necrotic debris in

cavity seen on an
endoscope passed through
the stent
Fig. 9 Cavity with

necrotic debris and
mucopurulent fluid
irrigating fluid
• Endoscopic single or multiple stent transmural drainage with nasocystic irrigation

• Endoscopic transmural drainage with PEG/PEJ irrigation
• Endoscopic transmural drainage with percutaneous irrigation
• Endoscopic transmural drainage with direct endoscopic necrosectomy
• Percutaneous endoscopic drainage and necrosectomy
• [29].
Open necrosectomy for pancreatic necrosis is reported to have very high morbid-
ity (34%–95%), and mortality ranging from 6% to 25% [30]. It also causes long-
term complications like pancreatic exocrine insufficiency. Novel endoscopic
approaches have revolutionized the treatment of infected pancreatic necrosis
[29–32]. Nevertheless, risk of serious complications exist and it is important to

address issues of pancreatic ductal pathology (disruptions/stricture/stones) to mini-
mize recurrence [32].
Indications and Factors Deciding the Timing of Necrosectomy
• Sterile acute pancreatic necrosis does not require intervention neither early nor
delayed unless symptomatic
• Infected early pancreatic necrosis seldom require early intervention and it is pru-
dent to delay interventions by 4–6 weeks.
• If it is necessary to intervene in early pancreatic necrosis because of clinical
deterioration with signs of sepsis, radiological or endoscopic approach should be
preferred over surgery
• Only symptomatic WON with discrete encapsulation should undergo interven-
tion after 4–6 weeks
• Asymptomatic WON irrespective of size and duration does not require interven-
tion [30].
Direct Endoscopic Necrosectomy (DEN)
The procedure is performed under general anaesthesia with C02 insufflation. The
initial steps of Direct Endoscopic Necrosectomy (DEN) is similar to EUS guided
endoscopic transmural drainage but involves dilatation of the cysto-gastric tract
with a balloon of larger size upto 20 mm and placement of LAMS which can allow
subsequent multiple sessions of DEN without need for repeated dilatation. After the
initial establishment of cystogastric tract, the echoendoscope is replaced with a
larger single channel or double channel endoscope which is advanced into the cavity
of WON for direct necrosectomy. The cavity is lavaged with normal saline and
necrotic debris is removed under direct vision using forceps, snares or baskets
(Fig. 9) [33]. Diluted Hydrogen peroxide irrigation can also be used to help in loos-
ening up of necrotic tissue. Newer stents have wider lumen which allow multiple
sessions of DEN without need for repeated dilatations. Multiple sessions may be
required for completing the procedure which is regarded as a distinct disadvantage
of the DEN procedure.
Waterjet necrosectomy device (WAND): Previously there was no device
designed exactly for endoscopic necrosectomy and retrieval of necrotic material
was done with all available snares, forceps or baskets which appeared to be subop-
timal. Bulky or adherent necrotic slough may pose difficulty during removal A
recent innovation is the waterjet necrosectomy device (WAND) which has been
tested in preclinical series (Fig. 10). It can be introduced through a 2.8-mm working
channel of a standard adult upper GI endoscope. (Fig. 11) The principle of WAND
Fig. 10 Waterjet
necrosectomy device
(WAND) (Image courtesy
Dr. Patrick Stephen
Yachimski, Nashville, TN,
USA. Published with his
permission)
Fig. 11 (a): WANDPTFE

catheter fitted through the a
working channel of an UGI
Endoscope. (b): Waterjet
noozle & Handle body
(Image courtesy Dr Patrick
Stephen Yachimski,
Nashville, TN,
USA. Published with his
permission)
b
is necrosectomy by irrigation with water under controlled pressure rather than

mechanical debridement. WAND is designed to provide irrigation pressures which
are capable of fragmenting nonviable necrotic tissue, and at same time avoiding
injury to healthy tissue [34].
Complications
DEN is associated with significant complications and should not be performed

unless indicated despite the high quoted clinical success rate (75–91%). A high
morbidity (14–33%) has been reported with mortality in up to 11% patients.
Bleeding and perforation are the commonly reported complications. Air embolism
been described with DEN, which can be circumvented by using CO2 for insuffla-
tion during the procedure [35–38].
Complications are higher with WON as compared to PPC [39].
Factors directly influencing success rates after endoscopic intervention or drain-
age of PPC/WON are:
1. Endoscopic vs EUS guided drainage.

2. Nature of collections (PPC or WON)
3. Direct Endoscopic Necrosectomy performed or not.
4. Type of stent used (Plastic vs Metal).
Conclusion
The management of PFCs has evolved from primarily open surgical drainage to
endoscopic/radiological based minimally invasive approach. Only symptomatic
PFCs need intervention preferably after 4 weeks. Endoscopic procedures with
endoprosthesis insertion can manage most PFCs that require intervention. EUS
guidance whenever available should be used with endoscopic procedures to decrease
complications. Whereas PPC often resolve with drainage procedures like endo-
scopic transmural drainage or endoscopic transpapillary drainage, necrosectomy
may be necessary in addition to drainage in WON a complication of necrotizing
pancreatitis. Lately patients with WON have safely undergone endoscopic necro-
sectomy, obviating the need for surgical exploration. If PD disruption is suspected,
ERCP with PD stenting should be done to prevent recurrence of PFCs after drain-
age. An individualized patient centric team approach comprising of gastroenterolo-
gist, endoscopists, interventional radiologists, intensivists and the surgeon is
desirable.
Key Clinical Points
1. PFCs are classified based on duration and type of collection i.e. necrotic versus
clear into APFC, ANC, PPC and WON.
2. Intervention for drainage is usually not required in APFC and ANC as they
often improve with conservative management.
3. Only a proportion of symptomatic Walled of Necrosis (WON) and Pseudocysts
(PPC) require intervention.
4. Asymptomatic PFCs do not require interventions irrespective of size and
duration
5. Interventions in symptomatic PFCs are best delayed until after 4 weeks unless
there are compelling evidence for early intervention like sepsis
6. PFCs can be drained surgically, percutaneously under radiologic guidance or
endoscopically
7. Minimally invasive approaches have less morbidity than open surgical proce-
dures for drainage of PFCs
8. Pre procedure radiological investigations, CT scan, MRI, MRCP can provide
information regarding the maturity of cyst wall, necrosis, location i.e. proximity
to bowel, complications like pseudoaneurysm and status of the pancreatic duct
which are important determinants of the route and mode of intervention
9. Anatomic relationship of the PFC to the stomach and duodenum (distance from
gastric or duodenal wall) helps in decision making regarding the choice of
lumen for drainage
10. Endoscopic drainage of PFCs can be done either transmurally or through trans-
papillary route with or without EUS
11. Only EGD based transmural approach requires presence of a luminal compres-
sion visible as endoluminal bulge of the cyst during endoscopy
12. In non-bulging PFCs EUS along with EGD is required for transmural drainage
13. Transpapillary approach has decreased risk of bleeding or perforation com-
pared to transmural drainage.
14. Added advantage of transpapillary approach is that concomitant ductal pathol-
ogy can be addressed viz. intraductal pancreatic stones and pancreatic duct
strictures, ductal disruptions, thus promoting early cyst resolution and decreas-
ing recurrence
15. Endoscopic drainage of the cyst can be achieved with plastic DPS or metallic
fully covered SEMS/ LAMS.
16. WON may require necrosectomy along with drainage
17. Necrosectomy can be performed as a step up procedure with repeated irrigation
and drainage or direct endoscopic necrosectomy
18. Direct Endoscopic Necrosectomy (DEN) involves advancement of the endo-
scope into the cavity of WON through the tract and removal of necrotic material
through, snares, baskets and forceps
19. A large, 15 mm, LAMS can facilitate passage of conventional upper GI endo-
scope into the cyst to enable necrosectomy
20. DEN has significant complications therefore it should not be performed unless
indicated and should be done by experts
21. Waterjet necrosectomy device (WAND) is a recent innovative aid devised for
necrosectomy which has been evaluated in preclinical studies and may prove
promising in future.
Editor’s Note1
The three common approaches in management of peripancreatic fluid collec-

tions are:
1. Percutaneous drainage
2. Endoscopic drainage
3. Surgical drainage (laparoscopic/open).
In a recently published meta-analysis on the three approaches the endoscopic

and surgical drainage were found to be better as regards success rates than percuta-
neous drainage. Moreover, the endoscopic drainage group enjoyed the added bene-
fits of a shorter hospital stay [1].
Endoscopic Versus Percutaneous Drainage
Meta-analysis comparing endoscopic and percutaneous drainage noted a trend for

higher success rate, lower reintervention and need for open drainage as also reduced
hospital stay in the endoscopic group [2, 3] (Table EN1).
Table EN1 Endoscopic versus percutaneous drainage of pancreatic fluid collection

Study author (first), year Result
Endoscopic and surgical drainage for Endoscopic versus percutaneous drainage:
pancreatic fluid collections are better than endoscopic intervention was better for all types
percutaneous drainage: Meta-analysis. of PFCs
Szakó L, 2020 [1] • Success rates
(OR = 3.36; 95% CI 1.48, 7.63;
p = 0.004).
• Recurrence
(OR = 0.23; 95% CI 0.08, 0.66;
p = 0.006).
• Postoperative length of hospital stay
(WMD (days) = −4.61; 95%, CI −7.89,
−1.33; p = 0.006)
Is endoscopic drainage better than Endoscopic versus percutaneous drainage:
percutaneous drainage for patients with Endoscopic group had lower:
pancreatic fluid collections? A comparative • Reintervention rate (or, 0.19; ci,
meta-analysis. 0.08–0.45)
Cai Q, 2020 [2] • Need for surgical intervention (or, 0.08; ci,
0.02–0.39)
Nonsignificant differences in:
• Technical success
• Clinical success
• Adverse events
• Mortality
• Recurrence
• Length of post-intervention hospital stay
1
Endoscopic versus percutaneous management Endoscopic versus percutaneous drainage:
for symptomatic pancreatic fluid collections: Results in favor of endoscopy for:
a systematic review and meta-analysis. • Clinical success
Khan MA, 2018 [3] RR 0.40 (0.26, 0.61), i2 = 42%.
• Technical success: Pooled RR 1.50
(0.52, 4.37).
• Adverse event: Pooled RR 0.77 (0.46,
1.28)
• Rate of recurrence Pooled RR 0.60
(0.29, 1.24)
• Hospital stay Pooled MD − 8.97
(−12.88, −5.07)
• Rate of re-intervention Pooled md
−0.66 (−0.93, −0.38)
PD percutaneous drainage, RR risk ratio, MD mean difference, WMD weighted mean difference,
OR odds ratio, LOH length of hospital stay
Laparoscopic Versus Endoscopic Drainage
PPC: A randomized controlled trial comparing endoscopic and laparoscopic drain-

age of pancreatic fluid collections noted equivalent outcome with a trend for higher
success rates after laparoscopic group though the difference was not statistically
significant; 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7)
after the index intervention and 93.3% and 90% in the laparoscopic and endoscopic
groups respectively (p = 1.0) [4].
WON: Table EN2, summarizes the results of meta-analysis of endoscopic versus
surgical necrosectomy for walled off pancreatic necrosis particularly minimally
invasive surgical necrosectomy. Most studies observed a higher incidence of com-
plications such as multiorgan failure, pancreatic and enterocutaneous fistulae in sur-
gical as opposed to endoscopic group. A lower length of hospital stay was also
noted in the endoscopic group but the endoscopic group required a higher number
of interventions increasing the cost [5–8].
Transphincteric Stenting in Transmural Drainage
The other contentious issue in endoscopic drainage is need for transsphincteric

stenting in transmural drainage and also the choice of stents metallic versus plastic.
No advantage was observed of transpapillary stenting for patients who undergo
transmural drainage of pseudocysts in a recent metaanalysis [9].
Plastic Versus Metallic Stents
Table EN3 enumerates various meta-analyses published on use of metallic versus

plastic stents [10–16]. Most studies conclude that metallic stents are preferable over
plastic stents as they have a higher clinical success rate and lower adverse event.
The commonly reported adverse events being stent migration, bleeding, perforation,
infection and stent occlusion. However metallic stents may erode into an adjacent
vasculature.
Table EN2 Meta-analyses comparing endoscopic versus surgical/minimally invasive method of

treatment in pancreatic necrosectomy
Endoscopic versus surgical treatment for infected Endoscopic versus surgical procedure:
necrotizing pancreatitis: a systematic review and Endoscopic group significant lower
meta-analysis of randomized controlled trials. • New onset multiple organ failure
Haney CM, 2020 [5] • Visceral perforation/enterocutaneous
fistulae
• Pancreatic fistulae
• Hospital stay
No differences in
• Major bleeding
• Post procedure hernia
• Exocrine or endocrine pancreatic
insufficiency
• ICU stay
Superiority of endoscopic interventions over Endoscopic drainage ed versus mis
minimally invasive surgery for infected necrotizing minimally invasive surgery:
pancreatitis: Meta-analysis of randomized trials. Significantly lower in endoscopy
Bang JY, 2020 [6] group:
• New onset MOF
(5.2% vs. 19.7%, RR = 0.34,
p = 0.045)
• Enterocutaneous fistula/perforation
(3.6% vs. 17.9%, RR = 0.34,
p = 0.034)
• Pancreatic fistula
(4.2% vs. 38.2%, RR = 0.13,
p < 0.001)
• Hospital stay
(standardized mean difference,
−0.41, p = 0.010).
No significant difference in:
• Mortality
• Intraabdominal bleeding,
• Endocrine or exocrine pancreatic
insufficiency
Time for a changing of guard: From minimally Endoscopic drainage (ED) versus
invasive surgery to endoscopic drainage for minimally invasive surgical
management of pancreatic walled-off necrosis. necrosectomy (MISN)
Khan MA, 2019 [7] Significantly lower in ED group:
• Mortality
(8.5% and 14.2%, for ED and
MISN POR 0.59; 0.35–0.98),
• New onset MOF
12% and 54% for ED and MISN,
POR 0.12 (0.06–0.31),
• Adverse events: Pooled or was
0.25 (0.10–0.67),
• Pancreatic fistula rate
[OR, 0.20 (0.11–0.37)],
• Length of stay
MD −21.07 (−36.97 to −5.18) days
No difference in:
• Risk of bleeding
Interventions for necrotising pancreatitis. MISN vs ED:
Gurusamy KS, 2016 [8] • Higher adverse events in MISN
(rate ratio 11.70, 95% CI 1.52 to
89.87; 22 participants; 1 study),
• Lower number of interventions per
patient with MIS
Inconsistent results on
• Number of serious adverse events,
• Organ failure rate,
• Hospital stay,
• Intensive therapy unit stay
ED endoscopic drainage, MISN minimally invasive surgical necrosectomy, RR risk ratio, MD mean
difference, WMD weighted mean difference, OR odds ratio, POR Pooled odds ratio, LOH length
of hospital stay, MOF multiorgan failure
Table EN3 Meta-analyses on use of metallic versus plastic stent for drainage of pancreatic fluid
collection
Metal versus plastic stents for drainage of pancreatic Higher clinical success rate with
fluid collection: A meta-analysis. Yoon SB, 2018 [10] metallic stent and lower adverse
event
Metal stents vs plastic stent:
• Clinical success rate
(OR) 3.39, (95% ci) 2.05–5.60)
• Adverse event rate
(OR 0.37, 95% ci 0.21–0.66)
The results were seen in subgroup
analysis both for pseudocyst and
walled-off necrosis.
(continued)
Lumen apposing metal stents in drainage of Higher clinical success rate with
pancreatic walled-off necrosis, are they any better metallic stent and lower adverse
than plastic stents? A systematic review and event
meta-analysis of studies published since the revised Metal vs plastic stent:
Atlanta classification of pancreatic fluid collections. • Clinical-success rate
Mohan BP, 2019 [11] 88.5% (95% CI 82.5–92.6,
I2 = 71.7) and 88.1% (95% CI
80.5–93.0, I2 = 78.1) P = 0.93.
• Adverse-event
11.2% vs 15.9% P = 0.38.
Efficacy and safety of lumen-apposing metal stents Higher clinical success rate with
in management of pancreatic fluid collections: Are metallic stent and lower adverse
they better than plastic stents? A systematic review event
and meta-analysis. Metal versus plastic stent
Hammad T, 2018 [12] • Clinical success rate
0.37 (0.20, 0.67)
• Adverse events rate
0.39 (0.18, 0.84)
A systematic review and meta-analysis of metal Higher clinical success rate, lower
versus plastic stents for drainage of pancreatic fluid adverse event, lower additional
collections: Metal stents are advantageous. intervention with metallic stent
Saunders R, 2018 [13] Metal versus plastic stent
• Clinical success
93.8% versus 86.2% RR 1.08
[95% CI 1.02–1.14]; p = 0.009.
• Adverse events
(10.2% vs. 25.0%), RR 0.42 [95%
CI 0.22–0.81]; p = 0.010.
Metal stent usage
• Reduced bleeding
(2.8% vs. 7.9%), RR 0.37; [95%
CI 0.18–0.75]; p = 0.006.
• Lower number of intervention
12.4% versus 26.7%, RR 0.54;
[95% CI 0.22–1.29]; p = 0.165.
Efficacy and safety of metallic stents in comparison Higher clinical success rate, lower
to plastic stents for endoscopic drainage of adverse event and lesser need for
peripancreatic fluid collections: a meta-analysis and additional intervention with metallic
trial sequential analysis. stent
Panwar R, 2017 [14] Metal versus plastic stent
OR 3.22; 95% CI 1.87–5.54;
P < 0.001.
• Adverse events
OR 0.40; 95% CI 0.24–0.65;
P < 0.001
• Need for additional salvage
procedures lower with metallic
stents.
OR 0.31; 95% CI 0.13–0.70;
P = 0.01
Metal versus plastic stents for pancreatic fluid Higher clinical success rate, lower
collection drainage: A systematic review and adverse event and lower recurrence
meta-analysis. with metallic stent
Zhou X, 2021 [15] Metal versus plastic stent
92% versus 82% (P < 0.01)
• Adverse event rate
20% versus 31% (P < 0.01)
• Recurrence rate
3% versus 10% (P < 0.01)
Comparison between lumen-apposing metal stents Higher clinical success rate, lower
and plastic stents in endoscopic ultrasound-guided recurrence and fewer additional
drainage of pancreatic fluid collection: A meta- intervention with metallic stent
analysis and systematic review. Metal versus plastic stent
Lyu Y, 2021 [16] • Clinical success
(90.01% vs 82.56%) (odds ratio
[OR], 2.44; [CI], 1.79–3.33;
P < 0.00001),
• Less recurrence
(OR, 0.44; 95% CI, 0.29–0.68;
P = 0.0002), and
• Fewer additional interventions
(OR, 0.34; 95% CI, 0.211–0.55;
P < 0.001).
Adverse event: Lumen-apposing metal
stents have slightly more perforations
(OR, 7.10; 95% CI, 1.22–41.30;
P = 0.03) in studies of walled-off
necrosis.
RR risk ratio, MD mean difference, OR Odds Ratio, CI Confidence interval
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Management of Solitary Pulmonary
Nodule
Kamran Ali and Sabyasachi Bal
Introduction
Solitary pulmonary nodule (SPN) is defined as a “focal, rounded opacity ≤3 cm

in diameter, mostly surrounded by an aerated lung, including contact with the
pleura, but without potentially related abnormalities in the thorax”. (potentially
related abnormalities include: pleural effusion, mediastinal lymphadenopathy,
atelectasis) [1].
Widespread use of multi-detector computed tomography (CT) has increased the
incidental detection of such nodules. A clinician however would mainly encounter
a SPN in practice during the following situations:
• Patients being investigated with chest radiology for respiratory symptoms

• Incidental detection on chest imaging done for other purposes
• During screening studies for lung cancer
• Patients with a known cancer undergoing imaging for:
–– staging
–– during surveillance scans
–– post treatment follow-up imaging
Solid and Subsolid Nodules
Apart from knowing what a SPN is, it is also important to understand the concept of
Solid and Subsolid nodules (SSN).
K. Ali · S. Bal (*)

Institute of Chest Surgery, Chest Surgical Oncology and Lung Transplant, Sir Ganga Ram
https://doi.org/10.1007/978-981-16-5473-2_18
402 K. Ali and S. Bal
Fig. 1 Cross sectional CT

scan image of a Solid SPN
in the right lung
Solid nodule, the most common type of SPN, is characterised by homogenous

soft tissue attenuation on CT (Fig. 1).
Subsolid nodule present as two types of focal opacities: part-solid nodule or a
pure ground glass nodule.
• Part-solid nodule (PSN): has both solid and ground glass component ≤3 cm in
diameter.
• Pure ground-glass nodule (PGGN): ground glass opacity ≤3 cm in diameter.
Solid component: the term is used to describe part of a nodule that obscures the
underlying broncho-vascular structure.
Ground-glass component: it refers to opacification, which is more than the
background, but visibility of underlying vascular structure is not hampered [1].
Approach to a SPN
Common societies/groups formulating guidelines and algorithms for management

of lung nodules:
• British Thoracic Society (BTS) [1].

• Fleischner Society [2].
• American College of Chest Physicians (ACCP) [3].
• National Comprehensive Cancer Network [4].
Despite minor discrepancies, all proposed approaches take into consideration the
following factors:
• clinical risk factors for lung cancer

• imaging features of the nodules
• comparison with previous imaging studies
• most appropriate management.
Management of Solitary Pulmonary Nodule 403
The approach in this chapter would be largely based on the recommendations of

the British Thoracic Society (BTS) [1].
The approach consists of
1. Risk assessment for malignancy

2. Surveillance
3. Management
isk Assessment for Malignancy Based

R
on Clinicoradiological Parameters
Assessment of a SPN in terms of ‘risk of malignancy’ is very important to guide

further management, lower the risk less invasive is the adopted approach and
vice versa.
The BTS guidelines published in 2015 identified risk factors consistently associ-
ated with malignancy [1]. The initial assessment is used to identify and differentiate
nodules having a sufficiently low chance of malignancy which can be managed by
only follow up imaging from those which need further assessment.
Clinical and radiological risk factors consistently associated with malignancy in
solid nodules are summarised in Table 1.
A possible benign aetiology is predicted by the presence of a diffuse, central,
laminated, or popcorn pattern of calcification and peri-fissural location. The BTS
came up with an initial assessment algorithm for solid nodules on CT (Fig. 2), and
as per the guidelines patients with nodules with aforementioned benign features can
be discharged [1].
Table 2 highlights the risk of malignancy in a solitary pulmonary nodule based
upon the size (Dutch-Belgian CT screening trial, NELSON trial) [5]. It revealed that
subjects with nodules <5 mm in the maximum transverse diameter or <100 mm3 in
volume had no increased risk of developing lung cancer after 2 years than those
without nodules. Based on the findings mentioned above they recommended CT
surveillance for nodules <8 mm in diameter or <300 mm3 in volume.
Table 1 Clinical and radiological risk factors associated with malignancy

Clinical Radiological
• Age • Nodule diameter
• Current or former smoking status • Spiculation
• Pack—Years of smoking • Upper lobe location
• Previous history of extra—pulmonary cancer • Pleural indentation
• Volume doubling time <400 days
Solid non-calcified nodule(s) on CT
clear features of benign disease*, or nodule <5mm Yes

diameter (or <80mm3) or patient unfit for any treatment? Discharge
No
Yes Assess risk of lung cancer according
Previous imaging?
to survillance algorithm 2
No
Yes
Nodule <8mm diameter or <300mm3 volume?
No
Assess risk using Brock model
<10% risk of malignancy$ ≥10% risk of malignancy
PET-CT with risk assessment using Herder model

(provided size is greater than local PET CT threshold)
<10% risk of 10-70% risk of >70% risk of

malignancy malignancy malignancy
CT survelliance Consider image-guided biopsy; other options Consider excision or non-

(algorithm 2) are excision biopsy or CT surveillance guided surgical treatment (+/-
by individual risk and patient preference. image-guided biopsy)
*e.g. hamartoma, typical peri-fissural nodule

$Consider PET-CT larger nodules in young patients with low risk by Brock score as this score was
developed in screeing cohort (50-75 years) so performance in younger patients unproven.
Fig. 2 BTS algorithm for solid nodules on CT scan [1] (published with permission from British
Thoracic Society)
Table 2 Correlation between nodule size and risk of malignancy

Maximum transverse diameter 2-year risk of Lung Volume of 2-year risk of Lung
of nodule cancer nodule cancer
<5 mm – <100 mm3 –
5–8 mm 1% 100–300 mm3 2.4%
>8 mm 9.7% >300 mm3 16.9%
isk Prediction Models: Brock University Model

R
and Herder Model
The BTS guidelines recommend the use of two risk prediction models (Brock
University model and Herder model) for nodules >300 mm3 volume or >8 mm
diameter [1]. These models are readily available for anyone to use in the form of a
calculator-app on all smartphones (“BTS Pulmonary Nodule Risk Calculator” on
App Store or Google Play Store). The examples of malignancy risk prediction by
Brock model and Herder model can be seen in Fig. 3 and Fig. 4 respectively.
Whereas the Brock model is primarily based on clinical parameters supple-
mented with CT findings, PET CT is an additional modality of assessment in the
Herder model. CT surveillance is recommended for patients with nodules that have
<10% risk of malignancy as assessed by the Brock University model, whereas PET
CT is advisable for patients with higher risk who are further re-evaluated with the
Herder model [6]. The Herder model further classifies FDG (fluorodeoxyglucose)
uptake in PET as absent, faint, moderate or intense [7].
Brock Calculator
Nodule Characteristics Patient Characteristics
Nodule Size (1-30mm) Age (18-100)
26 65
Nodule Count Gender
1 Male Female
Nodule Type Family History of Lung Cancer
Pure Ground Glass Part Soild Yes No
Emphysema
Solid
Yes No
Nodule in Upper Lobe
Brock Model Probability
Yes No
67.7%
Spiculation
Yes No Calculate
Fig. 3 Example of Brock University Model in a 65-year Male with a 26 mm solid nodule
Herder Calculator
Patient Characteristics Nodule Characteristics

Age (18-100) Nodule Size (1-30mm)
65 26
Current or Former Smoker Nodule in Upper Lope
Smoker/former smoker Yes No
Spiculation
Never Smoked
Yes No
Previous History of Extra-Thoracic Ca
PET-CT Avidity Findings i
Yes No
NO FDG Faint FDG
Moderate FDG Intense FDG
Herder Model Probability
10.4%
Calculate
Fig. 4 Example of Herder Model in a 65 year with a non FDG avid 26 mm nodule
Following reassessment with the Herder model consider the following:
• Risk of malignancy <10%—CT surveillance

• Risk is 10–70%—Image guided biopsy
• Risk is >70%—Surgical resection (or nonsurgical treatment for those who are
not fit)
Surviellance of Solid SPN
The aim during surveillance is to assess nodule growth to discriminate between

benign and malignant nodules. Assessment of a nodule size has traditionally been
done by measuring the largest transverse cross-sectional diameter. However, over
the last decade volumetric analysis (manual or semiautomated/automated) has been
increasingly reported as an alternative and better tool to assess nodule growth.
The volume-doubling time (VDT) of a nodule utilizes a simple exponential
growth model that assumes uniform 3-dimensional tumour growth and is calculated
based upon estimate of the difference in the diameter at baseline and follow-up CT
and the time interval between the two scans [8–10]. Using automated volumetry,
growth of nodule, defined as increase in volume >25%, can be reliably predicted at
a 3 month interval CT. Another advantage of a 3-month CT is that most nodules
which resolve do so in 3 months interval. On the other hand, for small nodules,
5–6 mm size, the CT surveillance interval may be extended to 12 months to detect
appreciable growth. Stable disease at 1 year is indicative of benign aetiology [8].
Key BTS Recommendations on Surveillance [1, 8]
1. If initial risk stratification assigns a nodule a chance of malignancy of <10%,

assess growth rate using automated volumetric analysis.
2. Assess growth for nodules of ≥80 mm3 in volume (or ≥6 mm in diameter) by
calculating VDT using CT scan at 3 months and 1 year.
3. Significant growth is defined as ≥25% change in volume
4. For nodules showing clear growth or a VDT <400 days, offer further diagnostic
workup (biopsy, imaging, or resection)
5. For nodules that have a VDT of 400–600 days, consider ongoing yearly surveil-
lance or biopsy as per the patient’s preference.
6. Discharge patients with solid nodules that show stability (<25% volume change)
on CT at 1 year.
7. If 2-dimensional nodule diameter parameters are used to assess growth, follow
up with CT for a total of 2 years.
Management of Subsolid Nodules (SSNs)
SSNs are often benign, preinvasive or early invasive malignant lesions with an indo-
lent disease which carry a better prognosis and calls for a different management
strategy than solid nodules (Fig. 5). The pathological correlates [11–13] of a SSN
are tabulated in Table 3:
Thus, SSNs may represent both preinvasive and invasive lesions. Clinical and
morphological variables that are more likely to be associated with malignancy in
SSNs are:
• advanced age,
• prior history of lung cancer,
• size,
• part-solid nature (independent predictor of malignancy)
• pleural retraction
• indentation
• bubble-like appearance in a pGGN
Approximately 25% of SSNs resolve after 3 months.

Figure 5 highlights the BTS algorithm for management of SSN.
Sub-solid nodule(s) on CT
Yes
Nodule <5mm, patient unfit for any treatment or stable over 4 years?
No
Yes Assess interval change, If stable over less than
Previous imaging?
4 years, assess risk of malignancy as below.
No
Repeat thin section CT at 3 months
Resolved Stable Growth/altered morphology*
Assess risk of malignancy (Brock model£/morophology$),

patient fitness and patient preference.
Low risk of mailgnancy Higher risk of malignancy (approximately

(approximately <10%) >10%) or concering morphology$ -
discuss options with patient)
Discharge Thin section CT at 1, 2, 4 Image-guided Favour resection/

years from baseline biopsy non-surgical treatment
* Change in mass/new solid component

£
Brock model may understimate risk of malignancy in SSN that persist at 3 months
$
Size of the solid component in PSN, pleural indentation and bubble-like apperance
Fig. 5 The BTS algorithm for sub solid nodules on CT scan (reproduced with permission from
British Thoracic Society)
Table 3 Pathological correlates of SSN

Atypical adenomatous hyperplasia Small pure ground glass nodule (pGGN)
(AAH)
Adenocarcinoma in situ (AIS) Larger pGGN
Minimally invasive adenocarcinoma Part solid nodule (PSN) with a smaller solid
(MIA) component
Invasive adenocarcinoma Larger PSN
Key BTS Recommendations for Management of SSNs [1, 8]
1. All SSNs should be revaluated with a repeat thin-section CT at 3 months.

2. For SSNs of ≥5 mm in diameter that is stable at 3 months, use the Brock predic-
tion model to calculate the risk of malignancy
3. Other characteristics such as morphological features (size of solid component,
bubble- -like appearance, and pleural indentation), smoking status, peripheral
eosinophilia, history of lung cancer etc. should be considered in estimation of
risk of malignancy
4. Consider resection/nonsurgical treatment or observation for pGGN that increase

in size ≥2 mm in the maximum diameter and if observation is planned then
repeat CT after a maximum of 6 months.
5. PSN that show enlargement of the solid component or for pGGN which develop
a solid component, consider resection / nonsurgical treatment over observation
the options being considered based upon the patient’s choice, age, comorbidities,
and risk of surgery.
Biopsy Techniques
It is important to establish tissue diagnosis of a solitary pulmonary nodule for fur-

ther management when there is diagnostic uncertainty. There are two approaches of
performing a biopsy:
• Nonsurgical
• Surgical
Nonsurgical biopsy: Preferred when there is sufficient ambiguity pertaining to

the diagnosis which precludes a definitive management and can be either CT or
bronchoscopic aided.
CT-guided percutaneous transthoracic biopsy: It is the preferred technique of
minimally invasive biopsy. The reported yields are high (pooled estimate of 91%)
with limitations of a high incidence of pneumothorax (6.6% requiring chest drain in
the largest series) with the procedure [14–17].
Bronchoscopic aided biopsy: The yield of standard bronchoscopy is low but
can be augmented with innovative techniques such as
• fluoroscopy
• EBUS, radial endobronchial ultrasound
• ENB, electromagnetic navigation bronchoscopy.
A 65%–84% yield with ENB and 46%–77% with radial EBUS has been
reported [18].
The relative draw backs of bronchoscopic guided technique are:
• access limitations of small lesions <2 cm located in peripheral third of the lung
• time consuming
• lack of wide availability (particularly EBUS AND ENB)
Surgical biopsy: Excision biopsy for SPN may be performed in the following
situations:
• high clinical suspicion of malignancy despite histological indications of benign

or indeterminate pathological characteristics
• risk of malignancy is high enough to warrant excision without preoperative biopsy
Thoracoscopic wedge resection remains the gold standard for surgical lung
biopsy (Figs. 6 and 7). The morbidity and mortality of the surgical procedure should
be weighed in contrast to the possibility of progression during radiological surveil-
lance when considering surgical resection as an option. A 0.4% mortality for wedge
resection/ segmentectomy has been reported by the UK and Ireland Society of
Cardio-Thoracic Surgeons. A 30-day mortality of 2.1% and a 90-day mortality of
4.2% has been reported in patients undergoing wedge resection or segmentectomy
(The English National Lung Cancer Audit) [19].
picture of a thoracoscopic
wedge resection using an
endostapler
Fig. 7 Wedge resection

specimen showing a SPN
Surgical and Non-Surgical Treatment
Once a decision to resect a SPN has been taken, few issues regarding the optimal
surgical treatment need to be addressed. The two major considerations are the
approach and the extent of resection.
Surgical Approach: Thoracotomy Vs Thoracoscopy Vs Robotics
Before the advent of Video assisted thoracoscopic surgery (VATS), a thoracotomy

was the gold standard procedure for lung resection of any form. Over the years
VATS has proven to be an excellent alternative approach for pulmonary resections.
Traditional multi-port VATS as well as single port VATS is being widely performed
across the globe. It is better than traditional thoracotomy in terms of better cosme-
sis, less pain and early recovery. The long-term oncological equality or superiority
still needs to be proven however.
Robotic assisted thoracoscopic surgery (RATS) is another new entrant. The
excellent dexterity, 7-degrees freedom of movement, true 3-dimensional binocular
vision and filtering of tremors makes it an excellent choice. However, cost concerns
and availability are important limitations.
Extent of Resection- Lobar Vs Sub-Lobar Resection
Issues in consideration for extent of resection
• location of the nodule

• need for lung sparing surgery
• sub-lobar versus lobar resection
• non-anatomical resection (wedge resection) versus an anatomical
segmentectomy.
Lobectomy has been found to be superior to sub-lobar resection (segmentec-

tomy/wedge resection) as regards local recurrence in early lung cancer in a prospec-
tive randomized trial [20, 21]. However, sub lobar resections may be equivalent to
lobar resections in small tumor size <2 cm, elderly or those who may not tolerate a
lobectomy [8, 20, 22, 23].
Key BTS Recommendations on Surgery (Fig. 8) [1, 8]
1. VATS rather than an open surgery should be the preferred surgical approach in SPN
2. In the context of a pulmonary nodule biopsy confirmed as lung cancer preopera-
tively or following a wedge resection with intraoperative frozen section analysis,
lobectomy should be offered as definitive management which may be attempted
at the same anaesthetic setting.
3. In a patient where preservation of functioning lung tissue is desirable, anatomi-

cal segmentectomy can minimize operative risk as also improve physiologi-
cal outcome
4. For nodules less than 2 cm in diameter without evidence of nodal disease a diag-
nostic anatomical segmentectomy may be considered if no pathological confir-
mation and frozen section is possible
Localization Techniques for Nodules (Table 4)
Bi-digital palpation in thoracotomy makes it easy to localize and resect even deep-
seated small lesions, if a limited resection is planned. Certain characteristics of the
nodules make it difficult to locate in thoracoscopy viz.: small size, located deep to
the visceral pleura and nodules exhibiting a ground-glass morphology.
Several preoperative marking techniques have been developed to facilitate local-
ization of these nodules, their use is subject to availability of the facility and exper-
tise (Table 4) [24–29].
Excision or non-surgical treatment considered
PET-CT scan for staging (if not already performed)
Yes No
Fit for surgery?
Yes Image-guided lung biopsy

Choose between
possible and safe
Image-guided Image-guided No
lung biopsy lung biopsy
Yes Maliganancy Maliganancy Yes

Wedge resection Or
confirmed? confirmed?
with on-table
frozen section No No
Proceed to Anatomical Lobectomy Consider repeat biopsy or

completion segmentectomy proceeding to excision/non- SABR, RFA or
lobectomy during if unfit for surgical treatment if concern Conventional Radical
same anaesthetic lobectomy about false-negative biopsy Radiotherapy
Fig. 8 The BTS protocol for excision of a SPN (reproduced with permission from British Thoracic
Society) (RFA radiofrequency ablation, SABR stereotactic ablative body radiotherapy)
Table 4 Preoperative localization techniques for solitary pulmonary nodules [24–29]

CT guided hook wire/needle/microcoil insertion
Lipoidal injection
Methylene blue injection
Indocyanine green injection and infra-red localization
Radiotracer injection
Bronchoscopic techniques of localization: Electromagnetic navigation/virtual bronchoscopic
navigation
Virtual 3D assisted CT localization
Nonsurgical Treatment Without Pathological Confirmation
Patients with SPN who are deemed unfit for surgical treatment and patients who
choose to opt out of surgical treatment can be offered non-surgical treatment options.
An attempt should be made to obtain a histological confirmation, however if such is
not possible, treatment may proceed without biopsy, provided the risk of malig-
nancy is higher than 70%. The main alternatives to surgery are:
• Stereotactic body radiotherapy (SABR)

• Radiofrequency ablation (RFA)
• Radical radiotherapy
Key BTS Recommendations for Non-surgical Treatment [1, 8]
1. Stereotactic body radiotherapy or Radiofrequency ablation is a viable option for

patients who are unfit for surgery, with pulmonary nodule(s) which are at a high
risk of malignancy, and where biopsy is nondiagnostic or not possible.
2. Conventional radical radiotherapy can be considered for patients who have pul-
monary nodule(s) with high probability of malignancy, who are unfit for surgery,
and in whom SABR or RFA is not feasible
Key Clinical Points

1. SPN are classified into two types: Solid and Subsolid nodules, subsolid nodules
are further categorized as PSN and PGGN types
2. Management of solitary pulmonary nodules should be carried out by a multidis-
ciplinary team (surgeon, oncologist, pulmonologist, radiologist, pathologist,
radiation oncologist)
3. Initial assessment is used to identify and differentiate nodules having a suffi-
ciently low chance of malignancy which can be managed by only follow up
imaging from those which need further assessment.
4. CECT of the thorax and PET CT are useful diagnostic imaging modalities for
characterization of SPN
5. There is enough evidence to support the use of two malignancy prediction calcu-
lators (Brock & Herder) for better characterization of the risk of malignancy, and
a higher nodule size threshold for follow-up (≥5 mm or ≥80 mm3) of solid pul-
monary nodules.
6. For management of nodules with extended volume-doubling times CT based
volumetry should be preferred
7. The BTS algorithms can guide the diagnostic and management strategies of SPN
8. Subsolid nodules have a good prognosis and therefore a less aggressive approach
may be adopted in their treatment.
Editor’s Note1
Preoperative localization of solitary pulmonary nodules is crucial for excision by

minimally invasive techniques. Indications for preoperative assisted localization
include: (1) solitary or multiple small nodules i.e. <15 mm or nodules located in
depth >10 mm from visceral pleura, (2) pure ground-glass or subsolid nodule, and
(3) difficult to localize nodules via palpation intraoperative.
The localization techniques can be (a) CT guided (b) bronchoscopic guided (c)
Virtual 3D assisted CT localization. The techniques employed in CT guided preop-
erative localization include: (1) percutaneous hookwire localization (2) percutane-
ous coil localization and (3) localization by percutaneous liquid material injection
(lipoidal, methylene blue, indocyanine green etc).
Hookwire localization is the most commonly performed technique in which a hook-
wire trocar is inserted in a target area near the lesion under radiologic guidance with care
taken to avoid puncturing the lesion. The recommended distance between the target area
and nodule should be <1 cm. A post localization CT is done to confirm position of the
hookwire and look for complications like pneumothorax. The percutaneous coil local-
ization is similar to the hookwire localization, but entails use of coil instead of hookwire.
Unlike the hookwire localization where the end of the hook is fixed to the skin, percuta-
neous coil localization is of two types in one type the percutaneous coil is positioned in
the lung and the other the tail is positioned outside the visceral pleura.
Localization by liquid material injection such as lipoidal, methylene blue and
indocyanine green have been used as alternative to hookwire and coil localization.
In lipoidal injection the site turns into a mass and this enables identification in sub-
sequent surgery. An inherent advantage with percutaneous lipoidal injection for
localization is that surgery need not be immediately undertaken and can be done
after 1–2 days as opposed to 1–2 h for percutaneous hook wire localization.
Localization with methylene blue has limitations in a pigmented lung and also
because of early diffusion thus calls for early operative intervention preferably in
1–2 h after injection. Indocyanine green injection and localization with use of intra-
operative near infra-red technology is a promising approach and can also be used
with preoperative 3D assisted printing localization technology.
The two main techniques employed for bronchoscopic localization are: (1)
Localization under electromagnetic navigation bronchoscopy (2) virtual broncho-
scopic navigation localization technology. In electromagnetic navigation bronchos-
copy a probe with a sensor is guided into position with the help of an extracorporeal
magnetic positioning plate. In virtual bronchoscopic navigation technology fluores-
cent dye is injected into the nodule aided by bronchoscope and subsequent com-
puter based 3D mapping is used.
The operation for resection of the nodule entails excision of puncture site and
tract as also area in which liquid material is injected in addition to ensuring a clear
resection margin. Therefore. a site on visceral pleura as close to the nodule as
possible should be selected for the puncture site. Some limitations of percutaneous
1
localization techniques enlisted are: (1) tumor to visceral pleura distance >4 cm
results in increased complications (2) location of tumor close to heart/ great vessel
(3) accessibility of localization hampered by scapula or ribs. There are less chances
of complications like pneumothorax and bleeding in bronchoscopic localization
however the procedure is complex and has higher costs as well as limited accuracy.
References for Editor’s note
1. Liu B, Gu C. Expert consensus workshop report: guidelines for preoperative

assisted localization of small pulmonary nodules. J Can Res Ther. 2020;16:967–73.
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Minimally Invasive Thymectomy
Aloy J. Mukherjee, Mohsin Khan, and Charu Gauba
Introduction
Myasthenia Gravis (MG) and Thymoma share a common treatment in terms of

surgery wherein a repertoire of approaches have been described [1]. Vast experi-
ences have been garnered over the years on video-assisted thoracic surgery (VATS)
approaches for thymus which has also modernised over years. VATS is superior in
terms of less postoperative pain, better preserved pulmonary function, and improved
cosmesis [2, 3] Results of VATS thymectomy are comparable as regards achieve-
ment of complete stable remission from MG and symptomatic improvement, as
well as safety wherein VATS has proven to be at par and above other conventional
surgical techniques [4]. A wider acceptance of VATS by MG patients and their neu-
rologists for early stage thymectomies is being witnessed consequent to the
improved attributes and outcomes.
The earliest report on thymectomy, published by Sauerbruch dates way back to
1913 [5]. Blalock performed this procedure in 1936 and popularized it [6–8].
Sugarbaker from Boston [9] first described thoracosopic thymectomy which was
furthered by the Belgium group in 1993 [10].
Variants in approach that has evolved in VATS thymectomy include: video-
assisted thoracic surgery (VATS) unilateral—right sided/left sided [11] and video
assisted thoracoscopic extended thymectomy (VETET) which is a bilateral thoraco-
scopic approach combined with a cervical incision [12]. Endoscopic robot-assisted
thymectomy appears to have promising outcomes; however, long-term data is pend-
ing [13]. Minimally invasive techniques have proved advantageous over
A. J. Mukherjee (*) · M. Khan

Minimal Access, GI, Bariatric and Robotic Surgery, Indraprastha Apollo Hospitals,
New Delhi, India
C. Gauba
Dept of Neurology and Neurophysiology, Indraprastha Apollo Hospitals, New Delhi, India
https://doi.org/10.1007/978-981-16-5473-2_19
420 A. J. Mukherjee et al.
conventional techniques due to their better outcome in terms of less postoperative

pain morbidity and mortality, better cosmesis. Optimum surgical approach is still
awaiting a universal consensus peeping into the available data. Various factors
including a number of classifications, patient demographics, disease spectrum etc.
along with various practice guidelines are responsible for variable outcomes in thy-
mectomy patients. The various considerations as to use of VATS thymectomy,
salient points on patient selection, specific perioperative management strategies,
operative technique and recent outcomes is discussed in this chapter.
Indications
These may be considered as absolute or relative depending upon the degree of

severity of the disease, age of patients, medical treatment response. Thymectomy
has a clear role in achieving good control in many patients of MG but in those with
purely ocular symptoms though its role is doubtful still data and experience suggest
that thymectomy might be beneficial in disabled patients particularly those who are
in early stages of disease or in patients with disease refractory to conservative ther-
apy [14]. Also those with late severe generalised disease have poor response, as well
as a high morbidity and mortality rate, and therefore are poor surgical candidates.
Ambiguity exists regarding the role of thymectomy for those in the middle of the
disease spectrum. Papatesat as et al. advocated early surgical intervention in all MG
patients as thymectomy reduces the risk of development of extra thymic neoplasms
in MG [15]. Practically, the need for thymectomy in MG patients are the views of
the different specialities: physicians to last extent favour medical management,
waiting for surgery till their final push, while surgeons advocate early surgery.
Indications of Thymectomy
1. Thymoma
(a) Small (<2 cm) intra thymic thymoma
(b) Large well encapsulated thymoma (preferably <5 cm)
(c) Minimally invasive thymoma
2. Generalized MG unresponsive to medical treatment
3. MG with ocular disease refractory to treatment
Classification of Thymectomy
1. T1 Transcervical thymectomy
(a) Basic
(b) Extended
2. T2 Videoscopic thymectomy
(a) Classic VATS
Minimally Invasive Thymectomy 421
(i) unilateral
(ii) bilateral
(iii) subxiphoid
(b) VATET
(i) Extended-bilateral thoracoscopy + open cervical exploration
3. T3 Transsternal thymectomy
(a) Standard
(b) Extended
4. T4 Transcervical and transsternal thymectomy
Preoperative Evaluation
Computed tomography (CT) with contrast enhancement is necessary to rule out

vascular invasion, its relation with innominate veins and superior vena cava and it
allows for better delineation of the mediastinal masses. Alternatively, MRI may be
used. Patient with anterior mediastinal mass which are suspicious for thymoma are
candidates for resection subject to ruling out of vascular lesions or abnormalities.
Transthoracic needle aspiration might help in diagnosis of thymoma but not popu-
larised due to various controversies. Preoperative evaluation should also include
investigations for detection of associated MG.
Preoperative Preparation
Involvement of anaesthesia, neurology and the surgical team is mandatory from

preoperative planning, through intra-operative management and ultimately up to the
postoperative period. Evaluation for symptoms like diplopia, ptosis, dysarthria, dif-
ficulty chewing, slurred speech, dysphagia, dyspnoea and fatigability should be
made. Cardiac stress evaluation and optimization of pulmonary function is of para-
mount importance.
Preoperative plasmapheresis may be helpful in patients who are poor responder
for medical management. Surgery has no role during myasthenia crisis and medical
management should be continued till it is resolved and MG patients can undergo
surgery only if their medical condition is optimized. The risk of myasthenic crisis
after thymectomy can be considerably reduced by appropriate patient selection and
taking up for surgery only after the myasthenic symptoms are well controlled. Many
thymoma patients have only subtle myasthenic symptoms hence steroids and immu-
nosuppressants may be initiated after surgery in these patients, particularly to reduce
the risk of post-operative infection.
Plasma exchange (PLEX) or Intravenous Immunoglobulin (IVIG) therapy may
be given prior to thymectomy. This helps to reduce the pre-operative steroid dose,
reduces the chances of post-operative worsening and reduces hospital stay. Seggia
and colleagues demonstrated that hospital stay and lower cost can be achieved by
plasmapheresis which led to significantly improved respiratory function and muscle
strength in MG patients undergoing thymectomy [16]. Preoperative anaesthetic

medication is minimal, usually consisting only of atropine and a mild sedative.
Preoperative anticholinergic medications are avoided. Myasthenic patients pose no
particular anaesthetic problems, although long-acting muscle relaxants should be
avoided. Deep anaesthesia is maintained by an inhalational agent and short-acting
narcotic. A single-lumen endotracheal tube suffices for airway control and
ventilation.
Operative Technique
Basic Laparoscopic Instruments required:
• 5 mm 30 Degree Telescope

• Two 5 mm Maryland dissectors/Micro dissectors
• 5 mm Endoscopic suction cannula
• 5 mm Endoscopic energy source (Ultrasonic shears)
• 5 mm Electrocautery hook
• 5 mm Clip applicators and endoclips
• 10 mm Endoscopic retrieval bag
Patient and Port Position: The patient is placed in a 30-degree semi recumbent
supine position, with ipsilateral arm abducted and a bag placed under the shoulder.
Right-side approach is more commonly preferred for non thymomatous myasthenia
gravis, as it provides greater manipulation workspace with the heart out of the way
(Fig. 1). A left sided approach is usually reserved for a left sided thymoma.
Pneumothorax is created by inserting 10 mm trocar by open technique into the
thoracic cavity at fourth/fifth ICS in mid-axillary line (Fig. 1) similar way like inser-
tion of chest drainage tube and connecting it to gas insufflation setting pressures to
Fig. 1 Patient positioning

and initial port placement.
Supine with right up 30°,
arm outstretched or rested
on L-arm rest
6–8 mmHg. This results in compression of lung thus providing space for surgical
manoeuvrings. Lung exclusion can also be done with a double lumen endotracheal
tube supplemented with insufflation of carbon dioxide (5–8 mmHg pressure at 4 L/
min flow rate). Once the lung is adequately deflated the carbon dioxide insufflation
is discontinued. Carbon dioxide insufflation alone can be used for lung collapse
keeping the pressures to 6–8 mmHg throughout the surgery which alleviates the
need of a double lumen tube. A 5 mm 30-degree camera makes it easy to change
camera position among all the ports. The surgeon and camera man stand on the
same side while the scrub nurse and second assistant positioned on the contalateral
side (Fig. 2).
The 3-port technique is commonly used. The initial 10 mm port incision should
always be directed in front of the tip of the scapula along the mid/posterior axillary
line. The second and third 5-mm instrument ports should be inserted guided under
direct thoracoscopic vision at the 2nd/3rd intercostal space and sixth/seventh inter-
costal space respectively in midaxillary line/anterior axillary line (Fig. 1). A sub
mammary fold approach for port placement can be adopted in females for cosmetic
reasons. The initial/first 10 mm port is used for specimen removal and after the end
of procedure a chest drain with water seal is placed through it.
Dissection of the gland: Dissection begins just anterior to the phrenic nerve, by
incising the mediastinal pleura with hook electrocautery/ultrasonic shears. The thy-
mus and pericardial fat are carefully mobilized from the right phrenic nerve. Care
should be exercised to prevent thermal or stretch injury to the nerve (Figs. 3 and 4).
Fig. 2 Operative room

set up
anesthesiologist
monitor
assisting
doctor
scrub
nurse
surgeon
Fig. 3 Thymus gland

bounded on either side by
phrenic nerve, inferiorly by
pericardium and superiorly
by innominate vein
Fig. 4 Dissection begins

just anterior to the phrenic
nerve (Blue arrow),
incising the mediastinal
pleura with ultrasonic
shears
The pleural incision is extended along the length of the nerve toward the dia-
phragm, and all thymic tissue and pericardial fat are swept from the pericardium,
starting near the diaphragm (Fig. 5). Dissection is achieved via combination of blunt
and sharp dissection. Additionally, the thymus is mobilized superiorly by incising
the mediastinal pleura along the medial border of the internal mammary vessels.
This dissection is carried superiorly, freeing all soft tissue from the retro sternum
and eventually the thymus from the innominate vein. Gentle traction of the thymus
is initiated, which facilitates the identification of all vein branches draining into the
innominate vein. All thymic veins and attachments are controlled with endoclips
along the innominate vein (Figs. 6 and 7).
Complete gland removal: Once all thymic veins and attachments are dissected,
the superior poles can be identified with gentle downward traction of the gland.
Care should be taken as number and position of thymic veins are not definite and at
times may be incongruous. Using careful countertraction, the cephalad attachments
of the superior poles can be freed under direct visualization. All arterial connections
with the internal mammary arteries in this region are clipped and ligated. Also, care
is to be taken to identify the inferior thyroid vein while dissecting the superior horns
of the thymus in the thyro-thymic tract as it can be a source of torrential bleed.
Following mobilization of the superior poles, medial dissection can continue toward
the left chest, taking all thymic tissue and fat from the pericardium (Fig. 8).
Fig. 5 Thymic tissue and

pericardial fat are swept
from the pericardium
Fig. 6 Superior horn

division. The superior
horns are gently retracted
caudally and exposed using
countertraction. Once
retracted and visualized,
the superior horns are
divided with the ultrasonic
shears
Fig. 7 Clipping and

division of a thymic vein.
The innominate vein is
skeletonized, and all
thymic veins and
attachments are clipped
and divided
Dissection from left side: Left side can be part of thoracoscopic unilateral or in
general thoracoscopic bilateral approach. A 5-mm port is inserted into the left chest
for dissection of left thymus. Before this, right lung ventilation is started again and
maintained till the end of surgery. A 30-degree thoracoscope is inserted into the left
chest and is controlled by the surgical assistant. Output from this scope is displayed
separate from the primary surgeon’s scope/monitor, allowing simultaneous bilateral
mediastinal visualization. For more dissection from left side two additional ports
can be inserted under direct visualisation on the left side as done in right sided
approach.
Fig. 8 Medial dissection

continued toward the left
chest, taking all thymic
tissue and fat from the
pericardium
a b
Fig. 9 (a) Bare area after complete en bloc dissection, phrenic-to-phrenic resection of all thymic
tissue and anterior mediastinal fat. (b) Final view from the right side in c/o bilateral approach
The advantages and disadvantages of the various approaches of VATS thymec-

tomy with respect to working space, approach to nerve and vessel identification,
tumor resection and anatomical problem encountered is enumerated.
The left cardio-phrenic angle is identified which serves as starting point of dis-
section, by grasping the thymus and the fat pad anterior to the left phrenic nerve.
The thymus gland is lifted by dissecting off the pericardial layer. Opening up the
retrosternal plane, the dissection is continued upwards along the left phrenic nerve,
to join the thoracic inlet superiorly. The surgical assistant maintains view of the left
phrenic nerve and mammary vessels throughout the left thymic dissection. The dis-
section is carried to the level of the left phrenic, ensuring complete en bloc, phrenic-
to-phrenic resection of all thymic tissue and anterior mediastinal fat (Fig. 9a, b). The
completely mobilized specimen can then be removed through one of the 10-mm
port sites using an endoscopic bag (Fig. 10).
Following specimen removal (Fig. 11), the anterior mediastinum is inspected,
ensuring complete removal of all thymus, fat, and soft tissue. It is important to look
for extrathymic tissue elsewhere in thoracic cavity as they remain the cause of resid-
ual disease (Fig. 12).
Fig. 10 The completely

mobilized specimen can
then be removed through
one of the 10-mm port
sites using an
endoscopic bag
Fig. 11 Complete thymus

gland showing right and
left thymic horns with
adenoma in body along
with peri thymic fat
extending along the
phrenic nerve course till
diaphragm
Chest drainage: If only right sided approach was adopted a single chest
drain suffices. However, in cases where the left pleura is also opened or when
left thoracoscopic dissection is added (Bilateral VATS), a chest drain can be
passed trans-mediastinal under direct visualization as it is a single cavity.
Adequate lung expansion is directly visualized before closing all port sites
sequentially in layers with absorbable sutures and skin with glue/sutures
(Fig. 13).
Fig. 12 Extrathymic nest

in a patient with thymic
carcinoma
Fig. 13 Final outcome of

minimally invasive
technique (VATS). Two
small scars and third port
converted to Chest tube
drain
Robot Assisted VATS Thymectomy
Some of the drawbacks of conventional minimal access surgery include: having to

instruct an assistant to drive the endoscope, amplification of physiologic tremor
with long instruments, limited mobility in angles due to rigid instruments and an
fulcrum effect. Most of the endoscopes have two dimensional images with loss of
depth perception and limited magnification possibilities. Many of these concerns
with laparoscopic surgery are alleviated with the advent of the robotic surgical sys-
tem as any patient who can virtually undergo thymectomy by open technique can
undergo thymectomy using the robotic technique. The only relative contraindica-
tions of robotic thymectomy is large vessel invasion and very large >12 cm tumour.
Operative Setup
The patient is placed in supine position and induced under general anaesthesia
with a dual lumen endotracheal tube. In most thymic lesions a semi right lateral
decubitus position is helpful particularly for non-thymomatous myasthenia
Anesthesiologist 30° up or
a b
new port placement
Monitor 30° up 30° up

or down or down
Target
Surgical
Target assistant 30° down or
new port placement
Robot
Monitor
Scrub
nurse
Monitor
Instrument
Robotic
table
console
Fig. 14 The robotic platform can be docked from either side of the patient depending on surgical
approach and/or operating room layout
gravis, however one may choose a right/left sided approach depending on location
of the disease. The patient’s chest and hip are elevated, and the position is secured
with a de-sufflated bean bag with proper padding of pressure points. The upper
arm (side of approach) is outstretched, and the lower arm is secured at the patient’s
side. The robotic platform can be docked from either side of the patient depending
on surgical approach and/or operating room layout (Fig. 14). It is regarded that the
left sided approach is possible easily with robotic surgery in spite of less space,
leads to more complete removal of all thymic tissue thus preventing myasthenia
gravis from developing post-operatively even in patients only presenting with
thymoma.
Operative Technique (Left Side Approach)
Once the patient has been positioned, prepped, and draped, the left lung is collapsed
and single right lung ventilation is initiated. A Veress needle is inserted into the
chest and intrathoracic placement is confirmed with a saline column drop test. The
left chest is then insufflated with CO2 to expedite and augment lung collapse and
depression of the diaphragm and ventricle from the chest wall and sternum. This is
typically well tolerated at a pressure of 8 mmHg on high flow. Alternately 8 mm
port can be introduced into thoracic cavity under direct vision by open technique
when patient is on single lumen tube and gas insufflation at 8 mmHg works very
well in collapsing the lung.
Port position: An 8-mm camera port is inserted into the fifth intercostal space
within the inframammary fold at the anterior to mid-axillary line. Rest three trocars
are placed under direct vision.
An 8-mm port is placed in the third intercostal space on the anterior axillary line.
The next 8-mm port is placed in the fifth intercostal space, just lateral to the sternum
(left robotic working arm). Lastly, a 12-mm assistant port is placed caudally in the
midaxillary line, typically in the seventh intercostal space for suctioning.
The robotic console is then brought in proximity to the bedside with the central
column positioned over the patient’s contralateral shoulder. Appropriate instrumen-
tation is then inserted though the trocars under direct visualization and docked to the
robot; In general, an ultrasonic shears is preferred energy source in the right work-
ing robotic arm port and a bipolar grasper in the left robotic arm port.
Dissection of the gland: Once all instrumentation is docked to the robotic con-
sole, direct visualization of the left phrenic nerve is achieved. En bloc resection is
initiated through incision of the mediastinal pleura, just medial to the left
phrenic nerve.
Careful mobilization of the phrenic nerve is performed, preserving the nerve if
adequate oncologic margins are feasible. Pleural incision is carried along the length
of the nerve, taking care to prevent stretch injury to the nerve or damage to the adja-
cent perineural vessels. Dissection is continued medially, using a combination of
sharp and blunt dissection. All thymic tissue and pericardial fat are taken off from
the pericardium in all directions medially, caudally and cephalad towards the
innominate vein.
Upwards, the pleural incision goes anteriorly adjacent to the internal mammary
artery and phrenic nerve junction. This dissection is extended downwards to the
diaphragm, running medial to the internal mammary vessels. All tissue is then
excised from the retro sternum with blunt and sharp dissection to the level of the
innominate vein superiorly, and medial to the contralateral internal mammary ves-
sels (better visualized after contralateral pleural incision). The left and right thymic
horns are identified at the top which are fully mobilized, and resected en bloc with
the specimen.
Following division of the thymic horns, dissection is carried toward the right
pleura. At this point in the operation, risk of injury to the contralateral phrenic
nerves and/or mammary vessels can be high if adequate visualization is not obtained.
It is found that identification of the contralateral nerve and/or internal mammary
vessels can be difficult in certain cases and therefore two strategies have been iden-
tified to facilitate this. One method is through utilization of simultaneous bilateral
visualization of the mediastinum. In this method, we insert a 5-mm thoracoscopic
port into the contralateral chest at the level of the infra mammary crease.
Thoracoscopic video output from this port, is controlled by the bed side assistant
surgeon, can be directly linked to existing robotic platforms, allowing bilateral and
simultaneous mediastinal visualization while sitting at the robotic console. The bed-
side assistant maintains visualization of vital contralateral structures as the primary
surgeon operates from the left side.
Additionally, a technique of phrenic nerve visualization described by Wagneret

al. through use of near infrared fluorescence imaging can be used [17]. This technol-
ogy, commercially available in robotic and nonrobotic platforms, utilizes the laser-
induced fluorescence of indocyanine green (ICG) imaging contrast to highlight the
phrenic nerves and other key vascular structures. ICG solution, 5–10 mg, is given
intraoperatively and intravenously, and can be visualized within seconds. The laser-
induced fluorescence of ICG is then superimposed onto the surgeon’s video display,
allowing easy differentiation of phrenic nerves and adjacent pericardiophrenic ves-
sels from surrounding tissues.
Once adequate visualization of the contralateral phrenic nerve and mammary
vessels is obtained, the right pleura is incised from the left side. The bedside assis-
tant follows the primary surgeon with the contralateral thoracoscope, ensuring full
dissection of thymic tissue is accomplished between both nerves, while preventing
injury. Thymic veins are identified and ligated with care to avoid undue traction
from the tumour during dissection. Smaller vessels can typically be ligated with the
ultrasonic shears, but it is advised to clip larger vessels with a standard handheld or
robotic clip applier. The full en-bloc specimen is removed via a 15-mm endoscopic
specimen bag. Areas of minor bleeding are controlled with electrocautery, bipolar,
or clips. A multilevel intercostal nerve block with 0.25% Bupivacaine solution for
postoperative analgesia helps in reducing postoperative pain. A 28-French chest
tube or 24-French Blake drain is inserted into the left chest under direct visualiza-
tion and passed across the mediastinum. The chest tube is secured with sutures and
all port sites are closed.
Pearls and Technical Aspects of VATS
• The completeness of dissection is confirmed by anatomical inspection of the

resected gland and also the thymic bed for any left-over peri thymic fat or ectopic
thymic tissue. Also, care is to be taken to look for accessory horns especially
below the innominate vein, where they can be missed easily.
• Safe thymectomy is possible after identification of both phrenic nerves. A safe
energy source should be used to minimise any thermal injury to the nerves.
Energy sources like harmonic decreases dissection time and allows safe control
of the thymic vessels [18].
• It is preferable to dissect first the superior horns from the innominate vein before
mobilizing the, body, or the inferior horns to prevent the gland from obscuring
the surgical field of visionduring the crucial step of innominate vein dissection.
Further the dissected horns can be used as traction for manipulation and dissec-
tion thus avoiding injury to the tumour capsule.
• Although thymectomy doesn’t require more than three ports, nevertheless rou-
tine retraction through the additional medial fourth 5 mm port increases exposure
thus making surgery feasible for large hyperplastic glands with abundant peri-
thymic fat [19].
• A semi supine position is preferred as it allows, for an emergency quick ster-

notomy if the need arises.
• A single chest tube suffices when both pleural cavities are connected
• Final inspection and anatomical completeness should be ensured at the end [19].
• The junction forming the superior vena cava should be clearly visualized after
brachiocephalic vein has been skeletonised.
Post-Operative Care
With advent of modern anaestheisa and minimally invasive surgeries early extu-
bation add further to the advocated better outcomes of minimally invasive thy-
mectomy. Normal diet is given, unless there is bulbar weakness due to MG. Chest
physiotherapy as well as incentive spirometry is mandated for speedy recovery
along with chest x-ray monitoring. It is imperative to monitor Spo2 and bedside
spirometry serves well in the early postoperative period to detect early respira-
tory muscle weakness. A volume of <15 mL/kg, or continuous fall in forced vital
capacity should raise an alarm towards respiratory failure. Preoperative medica-
tions should be resumed in early postop for the control of MG In the absence of
air leak or bleeding intercostal chest drainage tube can be removed after postop-
erative day 1. Steroids and immune suppressants should also be resumed after
surgery and should be gradually tapered over several months. In non-thymoma-
tous MG, there is improvement in 85% of patients of whom 35% of achieve drug-
free remission [20]. However, the effect of thymectomy may be observed only
after 1–2 years. Remission rate increases with time and reaches 40–60% after
7–10 years.
Advantages of VATS
The relative advantages of VATS are:
1. The VATS and Robotics approaches minimize chest wall trauma which results in
lower morbidity, enabling early discharges, and improved patient acceptability
for surgery.
2. Conversion from VATS to sternotomy is low ranging from 2.6 to 5.5% [21].
3. The VATS approach is preferred for many reasons.
(a) Excellent vision: A panoramic vision of thorax and wide angle manipulation
is major advantage of VATS
(b) Handling bleeding: As the thymus, is more an anterior mediastinal structure,
chest offers direct approach than the neck and it is easy to handle any
bleeding.
(c) Completion thymectomy: Residual thymic tissue can be taken with ease, in
cases where transcervical approach had failed.
(d) Cosmesis: VATS offers better cosmesis which although not arguable to jus-
tify a particular approach yet serves better to larger young female population
with the disease.
(e) Pulmonary function: A randomized prospective study has clearly attributed
an advantage of VATS over open approach in terms of better pulmonary
function and a faster recovery for MG [22]. This adds to earlier extubation
and thus significant reduction in postoperative pulmonary infections.
Limitations/Contraindications of VATS Thymectomy
Some of the cited limitations of VATS are [21]:
1. Severe coagulopathy
2. Pleural symphysis.
3. Patients with poor lung function, COPD, ILD or other severe underlying lung
disease in whom single lung ventilation may be difficult to manage.
4. Young children may not be suitable candidates due to smaller airways which are
not amenable to the smallest double-lumen tube andone-lung ventilation with
other methods can be more hazardous.
5. Previous surgery in the ipsilateral chest is a relative contraindication
VATS Variants and Future
Single Incision Minimally Invasive Thoracic Surgery
A single port approach is a currently investigational technique in minimally invasive

thoracic surgery. This approach requires instruments that articulate and is more
challenging than traditional VATS approaches. The operative approach is similar to
that in traditional VATS surgery, with the patient placed in the lateral decubitus posi-
tion. A 2–3 cm incision is created over the desired rib space (typically the fifth),
over the anterior axillary line, and a single port accommodating camera in middle
and working instruments on its sides. The potential benefit of single incision may
include decreased pain and more rapid recovery, but this technique requires further
study to prove its superiority.
Future
The uniportal technique could be described as a way of performing surgery with the
least number of devices possible, reducing this way a possible compression over the
intercostal space when multiple instruments are introduced through a single inci-
sion. The use of two specific instruments: a long curved stainless-steel Dennis suc-
tion device on the left hand and an energy device on the right hand is the key. The
coordination enables a fast and effective dissection and coagulation and exposure in
addition, the use of an external articulated camera support allows for a firm and
stable handling without an assistant. Future experience gained with the uniportal
approach will favour this type of surgery, therefore enabling the optimization of
hospital resources [23].
Non-intubated Uniportal VATS Thymectomy
Non-intubated thoracic surgery (NITS) has been the hot topic in past decade. It
offers potential advantages over general anaesthesia of avoiding side effects of
endotracheal intubation, mechanical ventilation, and general anaesthetic drugs.
Thoracic centres are enthusiastic about NITS, although the criteria for patient selec-
tion and the standard anaesthetic care for NITS are yet to be established.
The rationale here is to avoid muscle relaxants, which would lower the risk of
postoperative muscle weakness and respiratory insufficiency, thus improving patient
recovery. Awake endoscopic thymectomy has been reported which allows the
patient to eat, drink, and walk in immediate postoperative period. With iatrogenic
opening of the pleurae, continuous suction through a nasogastric tube to the pleural
hole would help to expand the lung passively [24].
Outcomes of VATS Versus Open Thymectomy
A systematic review of the literature was done comparing open to minimally inva-
sive thymectomy, both nonrobotic and robotic VATS included a total of 20 compara-
tive studies encompassing 2068 patients receiving either open [1230 (59.5%)] or
minimally invasive [838 (40.5%)] thymectomy [25]. There was considerable varia-
tion regarding patient age, sex, and indication for thymectomy across studies, but all
studies were individually well matched between comparison groups. Across stud-
ies, there was a consistent trend of significantly lower mean blood loss (VATS:
20–200 mL; Open 86–466 mL), pleural drainage duration (VATS: 1.3–4.1 days;
open 2.4–5.3 days), and hospital length of stay (VATS: 1.0–10.6 days; Open
4.0–14.6 days) in patients treated with minimally invasive thymectomy. No consis-
tent differences could be found in terms of operative time, rate of R0 resection of
malignancy, or perioperative complications. Long-term outcomes such as remission
of myasthenia gravis and thymoma recurrence were similar in open and minimally
invasive groups, although follow-up time was limited across studies. Friedant et al.
performed a systematic review and meta-analysis of minimally invasive versus open
thymectomy for malignancy [26]. They too reported a lower estimated blood loss
during minimally invasive thymectomy with a standardized mean difference of
−0.78 (95% CI: −1.05, −0.51). Length of hospital stay was also shorter for mini-
mally invasive groups (standardized mean difference −0.88; 95% CI: −1.52, −0.24).
There were no significant differences in operative time, rates of R0 resection, com-
plications, or locoregional cancer recurrence.
Outcomes of Robotic Versus Nonrobotic VATS Thymectomy
Few studies have directly compared outcomes for robotic and nonrobotic VATS
thymectomy. Ye et al. reported a series of 25 unilateral VATS procedures compared
to 21 unilateral robotic VATS procedures for Masaoka stage I thymoma. No signifi-
cant differences was noted in operating time or estimated blood loss, but a shorter
pleural drainage time (1.1 days vs. 3.6 days; P < 0.01) and length of hospital stay
(3.7 vs. 6.7; P < 0.01) was seen in the robotic VATS group. There were similar con-
versions to open surgery (VATS-1; robotic VATS-0) and incidence of postoperative
complications (VATS-1; robotic VATS-1). Robotic VATS as anticipated incurred a
significantly higher mean hospitalization cost ($8662 vs. $6097; P < 0.01) [27].
Ruckert et al. conducted a cohort study of 79 VATS versus 74 robotic VATS thymec-
tomies for myasthenia gravis. Both groups were well matched with respect to age,
sex, and disease severity, and there were similar operating times (198 ± 48 vs.
187 ± 48 min), rates of open conversion [1(1.3%) vs. 1(1.4%)], and postoperative
morbidity [2(2.5%) vs. 2(2.7%)] in the VATS and robotic VATS groups, respec-
tively [28].
Marulli and colleagues reported a series of 100 patients undergoing robotic thy-
mectomy for myasthenia gravis. Postoperative complications occurred in 6 (6%) of
patients, and median hospital stay was 3 days (range 2 to 14 days) [29]. Ruckert
et al. reported a series of 106 consecutive robotic thymectomies for myasthenia
gravis, with a 1% rate of open conversion and 2% rate of postoperative morbid-
ity [30].
The purported benefits of a robotic approach are related to its narrow nature and
the rigid chest wall. With the use of CO2 this space is widened, resulting in improved
visualization and operability. In comparison to VATS, the complications are similar.
With regard to clinical outcomes, there appears to be no significant difference,
although some suggest that there is a quicker improvement in quality of life and
shorter hospital stay.
Conclusion
Various modes of thymectomy have been established in the treatment of thymic

pathologies. VATS and robotic-assisted VATS thymectomy have proven to be safe
alternatives to open techniques and clearly improve outcome, based on blood loss,
hospital length of stay, healing time, and cosmetic appearance. Long-term outcomes
such as remission of myasthenia gravis and thymoma recurrence also appear to be
comparable. Although the current studies do not provide sufficient evidence estab-
lishing superiority in terms of resection but definitely give an edge over decreasing
morbidity postoperatively and also improving quality of life. Additionally, numer-
ous techniques have been developed and described using these robotic and nonro-
botic VATS technologies, each with their own inherent advantages and challenges.
As experience with these minimally invasive techniques continues to grow, clear
guidelines can be formulated.
Key Clinical Points
1. Myasthenia Gravis (MG) and Thymoma share a common surgical treatment

where in numerous approaches have been described.
2. VATS results in better pain tolerance, preserved pulmonary function and
increased cosmetic acceptance.
3. VATS clearly takes an edge over and above open surgery in complete stable
remission from MG and symptomatic improvement, without compromis-
ing safety.
4. VATS thymectomy may be performed with a unilateral thoracoscopic, bilateral
thoracoscopic or infrasternal/subxiphoid approach using the conventional three
port or the more recent uniport method.
5. The risk of myasthenic crisis after thymectomy can be considerably reduced by
appropriate patient selection and planning surgery only after the myasthenic
symptoms are well controlled.
6. Myasthenic patients pose no particular anaesthetic problems, although long-
acting muscle relaxants should be avoided. Deep anaesthesia is maintained by
an inhalational agent and short-acting narcotic.
7. A preoperative MDCT with 3D reconstruction of thymic veins has been cited to
be additionally useful step in ensuring operative safety during thymectomy.
8. In thoracoscopy, the right-side approach is common for any non-thymomatous
myasthenia gravis, as it serves with ample manipulation space with the heart
safely kept away.
9. Left sided thymoma is better taken from left side.
10. Lung exclusion is usually obtained by using double lumen endotracheal tube in
conjunction with carbon dioxide insufflation (5–8 mmHg pressure at 4 L/min
flow rate). Carbon dioxide insufflation alone can be used for lung collapse
keeping the pressures to 6–8 mmHg throughout the surgery which alleviates the
need of a double lumen tube.
11. All concerns with laparoscopic surgery are also alleviated by robotic surgery as
any patient who can virtually undergo thymectomy by open technique can
undergo thymectomy using the robotic technique.
12. Left sided approach is possible easily with robotic surgery in spite of less space,
which leads to more complete removal of all thymic tissue preventing myasthe-
nia gravis developing post-operatively even in patients only presenting with
thymoma.
13. A single chest tube suffices when both pleural cavities are open and connected.
14. Completeness of the thymus specimen along with the thymic bed should always
be inspected for complete removal.
Editor’s Note1
VATS thymectomy approach: Thymectomy was traditionally performed using a

median sternotomy or cervical incision using the open approach. With the advent of
minimally invasive procedures like video assisted thymectomy (VATS) and robotic
thymectomy (RVATS) the need to perform more morbid open operations have
decreased especially in early disease. The limited space in the anterior mediastinum
and need for bilateral approach were the initial problems envisaged in use of VATS
approach for thymectomy. The use of laprolift to lift the sternum, CO2 insufflation
and bilateral approach when needed has to a large extent circumvented these prob-
lems. VATS thymectomy may be performed with a unilateral thoracoscopic, bilat-
eral thoracoscopic or infrasternal/subxiphoid approach using the conventional three
port or the more recent uniport method.
Subxiphoid approach: The proponents of the subxiphoid approach for thymec-
tomy propose a lower postoperative pain with the approach as the risk of intercostal
nerve injury is minimized as compared to the lateral VATS approach. Additionally,
the mediastinal anatomy using this approach is similar to open sternotomy approach.
A better aesthetic outcome has also been suggested. Nevertheless, the risk for bleed-
ing from major veins like the innominate vein, maybe difficult to control [1]. A
preoperative MDCT with 3D reconstruction of thymic veins has been cited to be
additionally useful step in ensuring operative safety during thymectomy.
Outcome -open/ VATS/robotic: A lower intraoperative blood loss, shorter hos-
pital stay, lower complication rates, lesser pulmonary complications, similar mean
specimen weight and remission rates have been noted in the VATS approach in
meta-analyses comparing open and VATS thymectomy for myasthenia gravis [2, 3].
The results of VATS approach have been encouraging for selected early stage thy-
momas. When compared with open sternotomy approach lower blood loss, chest
drainage, hospital stay has been cited with no difference in R0 resection rates or
postoperative recurrence [4–6]. In two systemic review and meta-analysis compar-
ing the VATS with RVATS approach, the two procedures were found to have similar
outcomes other than a longer operative time with RVATS (Table EN1) [7, 8].
1
Table EN1 Comparison of various approaches for VATS thymectomy - advantages and disadvantages [31]
438
Vessel Nerves
Intrathoracic Thymic Recurrent
Working Brachiocephalic vein and vein and Phrenic nerve Anatomical
Approach space vein artery artery nerve (left) Lung Pericardium Tumor resection problem
Trans- Limited Possible Possible Possible Difficult Good Impossible Difficult Limited to Impossible to
cervical and small tumor resect large
partially tumor;
difficult Impossible to
approach lower
portion of
thymus
One-sided Limited Possible and Same side: Possible Same Impossible Good Good Needed Impossible to
Trans- but partially Good and side: intercostal resect cervical
intrathoracic same difficult Other side: partially Good thoracotomy; portion;
side: Difficult difficult Other postoperative difficult to
Good side: pain approach
Other Difficult another part of
side: thymus
Limited
Bilateral Good Possible Good Good Good Impossible Good Good Needed Difficult to
trans- intercostal resect cervical
intrathoracic thoracotomy; portion
postoperative
pain
(continued)
A. J. Mukherjee et al.
Table 1 (continued)
Vessel Nerves
Intrathoracic Thymic Recurrent
Working Brachiocephalic vein and vein and Phrenic nerve Anatomical
Approach space vein artery artery nerve (left) Lung Pericardium Tumor resection problem
Trans- Limited Possible and Possible Possible Possible Impossible Possible Possible No need for Difficult to
subxiphoid partially and and and thoracotomy resect cervical
difficult partially partially partially fat portion
difficult difficult difficult completely;
difficult to
Minimally Invasive Thymectomy
approach the
upper portion
of left
innominate
vein
439
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Retroperitoneoscopic Minimally
Invasive Adrenalectomy
Sameer Rege
Introduction
Surgical excision for adrenal pathologies was conventionally done with open
method and required large abdominal incisions to reach these small glands. The
vasculature being small and lean in these glands, there was a propensity for easy
damage to these structures during open surgery with resultant bleeding and added
morbidity for the patient. Further the deep position of these small friable glands
makes access in open surgery difficult, often requiring large incisions to retrieve the
small gland. Minimal access surgery with magnification and pinpoint precision
have not only made adrenal surgery more meticulous, but long reach of laparo-
scopic instruments through small ports also have reduced the morbidity of abdomi-
nal incision leading to less hospital stay, postoperative pain and additionally offers
better cosmesis.
Adrenalectomies with minimal access techniques have been described with
transperitoneal and retroperitoneal approaches which can be via posterior or lateral
approach. We in this chapter describe the retroperitoneal (RP) technique of minimal
access surgery for removing a diseased adrenal.
Anatomy and Physiology
Adrenal or suprarenal glands are situated in deep retroperitoneum just at the upper
pole of the kidneys. These are in close proximity to inferior vena cava, liver and the
kidney on right side while aorta, tail of the pancreas, spleen, duodenojejunal flexure
and hilum of the kidney on left side.
S. Rege (*)
Seth GS Medical College and KEM Hospital, Mumbai, India
https://doi.org/10.1007/978-981-16-5473-2_20
444 S. Rege
These endocrine glands are responsible for secretion of various hormones which
regulate the blood pressure, electrolytes and hormones for stress response.
Anatomically, adrenal gland has a peripheral cortex and central medulla and disor-
ders vary with pathological affection of these areas.
History
Higashihara from Japan and Gagner from Canada are credited with first laparo-
scopic adrenalectomy in 1992 [1]. Gaur et al from India in 1992, initiated work in
retroperitoneum for renal procedures such as laparoscopic ureterolithotomy and
paraaortic lymph node biopsies [2] and in1993, endoscopic model for retroperito-
neal adrenalectomy was demonstrated by Brunt et al. [3] with CO2 insufflation and
retroperitoneoscopy, which laid the foundation for retroperitoneal surgeries. Mercan
et al. [4] are credited for posterior retroperitoneal approach described in 1995 for 11
cases which was modified and popularized by Walz et al. [5].
Minimal Access Adrenalectomy
Adrenalectomies with minimal access techniques have been described with trans-
peritoneal and retroperitoneal approaches which can be via posterior or lateral
approach.
There are advantages and disadvantages of either approach. Transperitoneal
approach offers better visibility and working space. The surgeons are usually famil-
iar with landmark and structures however one has to mobilize few organs and struc-
tures to reach the adrenal and hence they are liable for damage. Tumors more than
5 cms were better amenable with transperitoneal approach but recently retroperito-
neal approach has also proved to be safe for them. Previous abdominal surgery may
pose a difficulty in reaching adrenal gland via transperitoneal approach due to adhe-
sions. In obese patients with friable hepatomegaly one may have difficulty in access-
ing the right adrenal vein. Bilateral lesions would entail change of positions and
hence longer operative times in the transperitoneal approach.
Retroperitoneal approach is direct and does not interfere with the intraabdominal
organs, hence damage to them is rare. It may also be a preferred approach with a
scarred abdomen with prior history of abdominal surgery. The incisions are on the
back leading to less postoperative pain so that the patients can be mobilized early
requiring shorter hospital stay. However, the smaller space in the retroperitoneum,
crowding of instruments and unfamiliar anatomy with unclear landmarks at the
beginning of procedure requires specialized training at high volume centers and still
has a long learning curve [1].
Lateral retroperitoneal approach familiarized by Zhang et al has been shown to
be effective in the management of larger tumors (more than 5 cms) and has impro-
vised dissection so as to shorten the intra operative time as compared to transperito-
neal approach. However bilateral lesions require change of position and hence a
longer operative time [6–8].
Retroperitoneoscopic Minimally Invasive Adrenalectomy 445
Posterior approach developed and popularized by Walz et al could deal with
bilateral lesion in same prone position of the patient or even simultaneous surgery
with two specialized teams decreasing the operative time [5]. The standardized
operative steps allow management of large adrenal lesion with minimized blood
loss and pain. Training is a must to work in the small retroperitoneal space with
decreased freedom of movement of instruments below the ribs. The principle of the
retroperitoneal surgery is based on adrenal being enclosed in loose Gerota’s fascia
and can directly be accessed from posterior aspect after opening the deep thoraco-
lumbar fascia, the same approach being followed in conventional lumbotomy
approach for renal surgeries.
All patients need an extensive workup with hormonal assay, computerized
tomography with special cuts at the level above kidney to delineate the vascular
supply, drainage and relations with adjoining structures. Endocrinology and cardiac
opinions are usually sought for. It is imperative that the surgical team should be well
versed with the radiology of the patient to plan the surgery. Sestambi and MIBG
scan should be done if indicated. Tables 1 and 2 enumerates the various common
approaches adopted and indications for minimally invasive adrenalectomy.
Posterior Retro-Peritoneal Approach
The surgery is conducted under general anaesthesia with endotracheal intubation.

Nasogastric tubes and urinary catheter are inserted. In patients with pheochromocy-
toma, a central venous access and arterial line is secured.
Operating Room Lay out: The dissection in the posterior approach is in a
smaller space with lot of loose areolar tissue, hence it is preferable to have a high-
definition system with two monitors placed at the shoulder of the table.
Patient Position: After anesthesia induction in supine position, patient is placed
in prone jack knife position. The abdomen and the chest of the patient rest on a
special rectangular pillow with hollow centre allowing the abdomen to get
Table 1 Approaches in minimally invasive adrenalectomy

I. Laparoscopic Transperitoneal, Lateral Transabdominal
II. Laparoscopic Transperitoneal, Anterior Transabdominal approach/Trans mesocolic
approach
III. Laparoscopic lateral retroperitoneal
IV. Laparoscopic posterior retroperitoneal
V. Robotic transperitoneal
VI. Robotic retroperitoneal
Table 2 Indications for minimally invasive adrenalectomies
Functional adrenal tumors

Early-stage malignancies of adrenal gland
Isolated adrenal metastasis
Non-Functional adrenal tumors/Incidentalomas
446 S. Rege
Monitor
Laparoscopic
Cart
Fig. 1 Patient position posterior approach
accommodated in between (Fig. 1). This special pillow placed also suspends the
upper torso allowing about 90 degrees flexion of the hips which ensures the flatness
of the spine opening up the retroperitoneal space between diaphragm and the
pelvis [5].
The knees can be flexed at right angle and are supported with adequate padding.
The legs are separated providing space for the assistant. The operating surgeon usu-
ally stands on the side to be operated (patient being prone it’s the opposite side of
the table) with the camera monitor on the opposite head end side and another moni-
tor for assistant on the operating surgeon’s side. For unilateral lesions, the lateral
edge of the patient coincides with the lateral edge of the table allowing a better
mobility of instruments, however for bilateral lesions; the patient is placed in the
centre of the table. The scrub assistant stands on the opposite side of the lesion.
Instruments: A 10 mm 30-degree telescope is preferred; however, a 5 mm tele-
scope may be helpful for retrieving the specimen and also if single port surgery is
being planned with posterior approach. The carbon dioxide insufflators should be
able to maintain pressure of minimum of 20 mmHg and higher. Special energy
device such as bipolar or ultrasonic scissors are preferable as adrenal veins can be
sealed and tackled with them, however hemoclips and harmonic scalpel can also be
used. Disposable blunt trocar with inflatable balloon and adjustable sleeve is prefer-
able as the first port. Conventional laparoscopic instruments can be used; however,
a clamp which can hold a peanut of gauze piece may be useful for blunt dissection.
TECHNIQUE: Posterior Approach
The entire back is scrubbed and draped to keep the lumbar area open with lateral
drapes placed below the anterior axillary line. First landmark to identify is the tip of
the 12th rib on the side and transverse 1.5 cm incision is taken just below the tip. A
straight scissors is pushed vertically inside to pierce the thoracolumbar fascia
Fig. 2 Intra-operative
image of straight scissor
being used to create the
first port
noticed with a sudden give-way feel and the tract is adequately dilated to allow the
surgeons finger to go in (Fig. 2).
Index finger of left hand is inserted for right adrenalectomy and vice versa. This
dissection is done laterally closer to the abdominal wall to dissect the Gerota’s down
from the abdominal wall. First working port, a 5 mm port (preferably spiral/ ringed)
is introduced laterally in the space created by the tip of index finger through the
midaxillary line pointing towards the spine which should ideally be more than
10–12 cm lateral from the first trocar. A 10 mm blunt trocar with inflatable balloon
with adjustable sleeve is introduced through the first incision. This optical port is
self- retaining and being transparent allows vision through port at the near site also.
The space in insufflated with carbon dioxide and a pressure of 20 mmHg is kept
which allows to open up spaces between the abdominal wall and the areolar tissue.
A 30- degree telescope is introduced with vision facing the spine. Blunt dissection
is done to take all areolar tissue down from the abdominal wall so that the kidney
falls down. Third 10 mm port is introduced in oblique direction towards the apex of
the space from the midpoint of the first port and the spine at the same level to avoid
torque at the abdominal wall. This port is also used for the optics to provide a sec-
toral vision, when the first two ports are used as working ports (Fig. 3).
On either side, the initial aim is to dissect all retroperitoneal loose areolar tissue
from the posterior abdominal wall so that the working space is developed (Fig. 4).
The dissection is deemed complete when the inferior vena cava is seen bare till apex
on the right side and the entire apex is seen on either side (Figs. 5 and 6).
On right side, the upper pole of the kidney is cleared from inferior vena cava
medially to lateral abdominal wall (9 to 3 ‘0’clock) to identify the peritoneum seen
as a shiny glistening layer and the bare area of the liver. Accidental fenestration of
the peritoneum and Toldt’s membrane should be prevented, however the pneumo-
peritoneum always does not interfere with retroperitoneal dissection. The adrenal
gland with the loose areolar tissue is never grasped but only retracted with the pea-
nut grasper or blunt grasper, which prevents fragmentation of the gland irrespective
of the pathology.
The retrocaval arteries traverse medially and are coagulated during dissection to
lift the adrenal from the lateral border of the inferior vena cava. The dissection
gradually moves cranially to identify the adrenal vein, which is coagulated and
448 S. Rege
Fig. 3 Port Position in

bilateral posterior
adrenalectomy
Fig. 4 Working space

being created by taking
down the loose fatty
areolar tissue from the
abdominal wall. (Cobweb
appearance of the right
retroperitoneum)
Fig. 5 Image showing

identification of the
Inferior vena cava on
right side
transected with an energy device or clipped and cut (Figs. 7, 8 and 9). In general,
ultrasonic shears are used and after identifying the adrenal vein is clipped. One has
to be very sure to clip the specimen side of the vein first and also ensure complete
clipping.
On the left side the adrenal lies at an upper level than right side and also
extends more medially and till the hilum of left kidney. Hence the left kidney is
additionally dissected on posterior aspect till the hilum and bared medially and
the left kidney is lowered so as have access to the left adrenal vein which joins
Fig. 6 Schematic diagram showing venous drainage of both adrenals as viewed from the posterior
approach

right adrenal vein (Yellow
arrow)
450 S. Rege
Fig. 8 Right adrenal vein

looped and clipped first
near the specimen
Fig. 9 Double clipping of

the adrenal vein near IVC
the renal vein (Fig. 10). Attempts are made to preserve the inferior phrenic vein
which travels on posterior abdominal wall lateral to aorta and joins the adrenal
vein to drain into the left renal vein (Fig. 11). The adrenal vein is secured and
then the adrenal gland is than dissected from caudal to cranial along with the
areolar tissue.
The resected gland is placed in endobag (Fig. 12) and retrieved. Occasional sur-
geon has mentioned morcellating the specimen in the endobag prior to removal [5].
The fascia and the ports are sutured and drains are seldom required.

left adrenal (A) from the
upper pole of the
kidney (K)

left adrenal (A) from the
lateral abdominal wall
(Yellow Arrow)
Fig. 12 The adrenal

specimen bagged for
extraction
452 S. Rege
Special Concerns of Posterior Approach
Intra-operative bleeding: There is a concern about tackling of bleeding from infe-

rior vena cava, other smaller veins and the aorta on the left side especially in the
smaller space. It is important that the surgeon dissects precisely and achieves hemo-
stasis at the same instance. However, if one encounters bleeding, introduction of a
gauze piece and compression of the same should ideally help. Compression achieves
hemostasis or helps in localizing the bleeder. Rarely venous bleeding from inferior
vena cava can be managed by increasing the pressure in the dissected space from 20
to 30 mmHg temporarily (higher retroperitoneal pressure than intravenous pressure
which allows compression of smaller veins).
Prone position: Concerns raised by anaesthesiologist are about any sudden
event requiring resuscitation in prone position. These patients can have events due
to hormonal release especially with phaeochromocytomas and are usually preopera-
tively prepared and blocked with alpha and beta blocker medications. Walz et al
promoted posterior approach without blocking these phaeochromocytomas and
insisted on minimal handling of the gland to reduce secretions and aim at securing
the venous drainage first [9].
Other complications: There is also a concern of decreased venous return due to
increased retroperitoneal pressure compressing the inferior vena cava. Increase in
intraabdominal pressure intraperitoneally has shown decreased venous return, the
same hasn’t yet been proved or documented in prone position with high retroperito-
neal pressures [1]. Surgical emphysema, pneumomediastinum or pneumothoraces
are often thought off than seen in these patients.
Learning curve: This posterior approach has a long learning curve as the train-
ing starts with understanding the posterior and retroperitoneal anatomy, appropriate
positioning of the patient and dissection in the right plane with complete hemosta-
sis. Beginners should select cases with BMI less than 35, tumors smaller than 6cm
and preferably nonfunctioning lesions [10].
TECHNIQUE: Lateral Approach
In the lateral approach, the dissection is again in a smaller space like the posterior
retroperitoneoscopic approach and is more difficult in males as compared to females
because of more muscle mass.
The patient is operated in total lateral decubitus position with elevation of the
kidney/lumbar bridge of the table and straightening the ipsilateral lower limb to
maximize the distance between iliac crest and the 12th rib. All pressure points over
the hips, legs, and bony prominences are well padded and care should be taken not
to over extend the axilla to prevent brachial plexus injuries. The operating surgeon
stands on the contralateral side of the patient (the right-side adrenal operated from
left side of the table meaning facing the abdomen of the patient) along with the
camera assistant. The second assistant stands towards the back of the patient. The
position is similar to that for lateral transperitoneal laparoscopic adrenalectomy and
nephrectomy.
Scrubbing is done from nipple to knee in anterior and lateral aspect and posteri-
orly entire back on the operating side till below the iliac crest. The first incision is a
longitudinal 2 cm incision taken below the tip of 12th rib in posterior axillary line.
A straight scissors as described earlier is inserted through the thoracolumbar fascia
and the muscles are separated by blunt dissection. Retroperitoneal space is identi-
fied by a sudden give way and the once the space is confirmed, finger dissection to
push the Gerota’s fascia upwards and the peritoneum downwards is done blindly
with the index finger. A 10 mm balloon trocar with adjustable sleeve is then inserted
in this space and inflated and the space is created with about 600–800 mL balloon
distension. Then a 10 mm optical trocar is inserted about 2 fingerbreadths above the
iliac crest in the mid-axillary line and used as the camera port. Second trocar of
5 mm as a working port is inserted under vision below the costal margin in the ante-
rior axillary line. The site of balloon trocar insertion is used as the third port or as
the second working port in the posterior axillary line. Digitally controlled place-
ment of trocars is essential to avoid inadvertent injury to the peritoneum and the
Gerota’s fascia. CO2 insufflation pressure is maintained above 20 mmHg. Some
surgeons prefer a 12 mm working trocar instead 10 mm for using endo-GI sealing
devices usually on the dominant hand side [6–8].
Mobilization of retroperitoneal adipose tissue from Gerota’s fascia is done.
Gerota’s fascia is incised longitudinally just posterior to the peritoneal reflection;
superiorly from the indentation that is the meeting point of peritoneal reflection and
psoas muscle to the iliac fossa inferiorly. Dissection is carried out in the avascular
plane between perirenal fat capsule and anterior layer of prerenal fascia. The dissec-
tion is then done medially to reach the anterior surface of adrenal gland and identi-
fication of the vascular structures.
In creating the retroperitoneal space, the important aspect is orientation of the
vascular structures—IVC on the right side and the renal vein on the left. For the
right side the adrenal vein is usually located postero-laterally to the vena-cava and
for the left side, the left adrenal vein is usually located on the upper surface of the
renal vein. If the surgery is being done for pheochromocytoma, it is essential that
the adrenal gland is retracted with blunt instruments and not grasped to prevent
inadvertent tumor rupture [6, 7]. Also, it is necessary to identify the adrenal vein
first to secure and clip the vein. On the right side the adrenal vein drains into the
IVC, so identification of vena cava is essential whereas on the left dissection of
renal hilum is to be done first as left adrenal vein drains into the left renal vein. One
needs to be cautious about the variant anatomy of right adrenal vein.
In this approach it is better to use blunt dissectors because of proximity of vascu-
lar structures especially on the right because troublesome bleeding will make the
surgery difficult and may need conversion to open. Care should be taken to avoid
inadvertently touching the IVC with heated vessel sealing devices. Another risk on
the left side is the close proximity of tail of pancreas on the ventral aspect and care-
ful blunt dissection should be done to avoid injury. The lateral approach is better in
the way that no position change will be required if need for open conversion arises.
The inferior and medial aspects of the gland are then dissected and the adrenal
arteries are identified and clipped. Use of hemoclips is preferred for adrenal artery
454 S. Rege
and vein. On the left side the branches of phrenic vein need to be tackled and
clipped. The superior aspect of the gland is dissected followed by lateral aspects
which is poorly vascularised. The specimen is retrieved through the camera port in
an endobag. The fascia of the ports greater than 10 mm are closed followed by skin
closure. Drains are usually not required.
Posterior vs Lateral Approach
The posterior approach seems to have greater incidence of intraoperative risks than
those with a lateral approach owing to following reasons
I. Patients position on the table itself can cause hemodynamic instability

II. Not easy to rapidly convert the procedure into open technique in case of major
bleeding.
III. Patients with high BMI, the adipose tissue raises intraabdominal pressure in the
dorsal position and the retroperitoneal space is highly compressed because of
presence of excess adipose tissue.
In the Lateral approach,
I. A particular drawback seen in the lateral approach is that bilateral tumours are
difficult to operate owing to position change requirement for each side.
II. The inferior vena cava on the right side and the aorta on the left side lie deeper
to the adrenal and the kidney, hence very careful dissection has to be done in the
lateral approach as the weight of the tumor presses on to space between these
vital structures, with minimal space left for retraction and managing the
vasculature.
III. Higher learning curve compared to the posterior approach.
Size of the tumour was initially a limiting factor for the lateral approach. But
with improvement of laparoscopic instruments and better understanding of anat-
omy, size is no longer a limiting factor of lateral retroperitoneal approach versus
transperitoneal approach [7]. Tables 3 and 4 summarizes the quoted advantages and
disadvantages of minimally invasive retroperitoneal approaches for adrenalectomy.
Table 3 Advantages of minimally invasive retroperitoneal approach

I. Avoidance on intrabdominal adhesion
II. Easy direct access to adrenal vein without organ mobilization
III. Lesser area of dissection
IV. Lower chances of injury to abdominal organs
V. Less postoperative pain
VI. Better hemostasis due to higher pressure achieved in limited retroperitoneum without
causing change in hemodynamic stability
VII. Decreased chances of incisional hernia
Table 4 Disadvantages of minimally invasive retroperitoneal approach

I. Smaller space leads to crowding of instruments
II. Unfamiliar anatomy
III. Unclear landmarks in the beginning of the procedure
IV. Difficulty in controlling major vascular catastrophy
V. Disadvantages of a prone position
VI. Longer learning curve
VII. Larger tumors may be difficult to access
VIII. Excessive retroperitoneal and perinephric fat can make dissection difficult in high BMI
patients
IX. Inability to explore the rest of the abdomen for other pathologies/ metastasis,
X. Not suitable for advanced malignancies
Reasons for Conversion
The relative reasons for conversion quoted in literature are surgeons’ inexperience,
bleeding, failure to progress, failure to maintain a working space due to
pneumoperitoneum.
Complications of Retroperitoneal Adrenalectomy
Minor complication rates vary from 0 to 15% for unilateral while increase to 23%
for bilateral surgeries and no significant difference is observed in laparoscopic intra-
peritoneal and retroperitoneal approaches [11]. Splenic, liver and peritoneal injuries
have been documented along with relaxation of abdominal wall especially for pos-
terior approach. Injury to subcostal nerve leading to pain has also been documented
with posterior approach [12] (Table 5).
Comparison of Retroperitoneal with Other Approaches
Zhang et al promoted and standardized the lateral retroperitoneoscopic adrenalec-

tomy and it has been the most common technique in dealing with adrenal tumours
in China [6, 7].
Wei Chen et al. (2017) studied 67 patients with adrenal tumours greater than
5 cms (5.8 cm ± 1.1 cm) of which 41 underwent lateral retroperitoneoscopic adre-
nalectomy and rest were operated by open procedure. They showed lateral retroperi-
toneoscopic adrenalectomy to be superior to open procedure in terms of operative
time, blood loss, complications, time to ambulation and hospital stay [8, 13].
Ho Seok Chung et al (2019) in Korea compared 130 patients operated for lateral
(n = 56) and posterior (n = 74) retroperitoneoscopic adrenalectomy. There was no
significant difference in perioperative outcomes between two groups except for
operative time (lateral approach 105 ± 41.21 mins and posterior approach
71.5 ± 31.51 mins; p = 0.001). Male sex and size >5 cm was associated with
456 S. Rege
Table 5 Complications of retroperitoneal adrenalectomy
I. Bleeding, retroperitoneal haematoma

II. Splenic, Liver, Peritoneal injuries
III. Subcostal nerve injury
increased operative time in the lateral approach [14]. They mentioned the lateral
approach to have all the other advantages of the posterior approach, over transperi-
toneal approach [4].
The retroperitoneal procedures have a steep learning curve, require a thorough
knowledge of retroperitoneal anatomy and should be initially attempted for tumours
less than 6 cm and non-functional or benign cases in patients with normal BMI [10,
15, 16].
Role of ICG in Minimally Invasive Adrenalectomy
ICG in Delineation of Vascular Anatomy
Recently there have been studies on the use of ICG (Indocyanine Green) dye for
delineating the vascular anatomy in laparoscopic transperitoneal and retroperitoneal
adrenal surgeries. ICG is a nontoxic dye that can aid in the identification of vascular
structures and parenchymal tissue planes in real time. It requires a special camera
and monitor system compatible with the fluorescence imaging. The green intraop-
erative fluorescence helps to delineate the margins of resection and guide towards a
more precise operation. The role of ICG is especially important in lateral approach
owing to close proximity of vascular structures at the start of the dissection. ICG
should be given IV (intravenous) after a test dose just after the insertion of ports.
I CG in Adrenal Sparing Surgeries for Bilateral Disease

and Reoperations
In particular, for patients with bilateral adrenal disease or a hereditary syndrome

associated disease with high risk of recurrence (e.g., VHL, MEN2a syndromes), this
may help for subtotal adrenal sparing surgeries reducing the incidence of iatrogenic
adrenal insufficiency and lifelong adrenal hormone supplementation, osteoporosis
and risk of Addisonian crisis [17]. Its role is important in re-operative cases and also
as a useful guide for beginners.
Conclusion
Minimal access surgery for adrenal has many benefits and the posterior retro-
peritoneal approach among them though initially technical difficult can be used
simultaneous for bilateral cases. Retroperitoneal space is small hence needs immac-
ulate dissection of tissue but it hardly causes systemic problem.
Key Clinical Points

1. Minimal access surgery with magnification and pinpoint precision have not only
made adrenal surgery more meticulous, but the long reach of laparoscopic instru-
ments through small ports also have reduced the morbidity of abdominal inci-
sion leading to less hospital stay, postoperative pain and additionally offering a
better cosmesis.
2. Retroperitoneal approach is direct and does not interfere with any intraabdomi-
nal organs, thus feasible in a scarred abdomen. As the incisions are on the back,
pain scores are low and the patients can be mobilized early requiring shorter
hospital stay.
3. Smaller space in the retroperitoneum, crowding of instruments and unfamiliar
anatomy with unclear landmarks at the beginning of procedure requires special-
ized training at high volume centres for performing retroperitoneal adrenalecto-
mies and it still has a long learning curve.
4. Posterior retroperitoneal approach can deal with bilateral lesion in same prone
position or even simultaneous surgery can proceed with two specialized teams
decreasing the total operative time.
5. Anaesthesiologist often have concerns about prone position due to difficulty in
resuscitation particularly in patients of phaechromocytomas who are usually
preoperatively prepared and blocked with alpha and beta blocker medications.
Few experienced authors have also promoted posterior approach without block-
ing these phaeochromocytomas and insisted on minimal handling of the gland to
reduce secretions and aim at securing the venous drainage first.
6. Decreased venous return due to increased retroperitoneal pressure compressing
the inferior vena cava has not been proved or documented in prone position.
7. The retroperitoneal procedures have a steep learning curve, require a thorough
knowledge of retroperitoneal anatomy and should be initially attempted for
tumors less than 6 cm and non-functional or benign cases in patients with
normal BMI.
458 S. Rege
Editor’s Note1
Adrenalectomy
Approach
Adrenalectomy may be performed by minimally invasive or open approach. Both
open and minimally invasive surgery can be performed by transperitoneal or retro-
peritoneal approach. Minimally invasive approach maybe: laparoscopic transab-
dominal, laparoscopic retroperitoneal or laparoscopic robot assisted. Further they
may be multiport or uniport technique. Retroperitoneal approaches can be lateral or
posterior whereas the transabdominal approach is usually a lateral approach with
rare reports of an anterior transmesocolic transabdominal approach.
isk Factors for Complications

R
Besides surgeon’s experience, histological type of tumor, large size of the tumor and
increased BMI are likely independent variables associated with higher complication
rates in laparoscopic adrenalectomy [1].
inimally Invasive Retroperitoneal Adrenalectomy

M
in Phaeochromocytoma
One of the chief hesitations in the use of minimally invasive adrenalectomy for
phaeochromocytoma was due to concerns regarding haemodynamic instability dur-
ing handling. However, a recent meta-analysis has observed a superior outcome of
laparoscopic adrenalectomy over open adrenalectomy in phaeochromocytomas
with respect to: blood loss, transfusion rate, hemodynamic instability, postoperative
complications, return to diet time and length of hospital stay [2]. Conventional
knowledge suggests an approach for early control of the adrenal vein in phaeochro-
mocytomas to prevent haemodynamic crisis. However, with the advent of mini-
mally invasive adrenalectomy authors have reported favourable results of
phaeochromocytoma resection without early control of adrenal vein [3]. Quick
access to the adrenal vein without organ mobilization can be achieved by laparo-
scopic retroperitoneal approach rather than laparoscopic transperitoneal approach.
In a study comparing retroperitoneal laparoscopic approach with open approach to
phaeochromocytoma, the retroperitoneal approach scored better on variables related
to operative time, bowel recovery and hospital stay [4].
inimally Invasive Adrenalectomy in Malignancies

M
Laparoscopic adrenalectomy with excision of periadrenal fat is recommended to
achieve R0 resection in adrenocortical carcinoma and has been deemed suitable in
only stage I and stage II cancers <10 cm [5]. Issues related to port site recurrence,
peritoneal recurrences and R+ resections are chief concerns with use of minimally
invasive techniques in treatment of adrenal malignancies. A recent meta-analysis
comparing minimally invasive adrenalectomy with open adrenalectomy in
1
treatment of adrenocortical carcinomas noted comparable operation time and post-

operative complication. Minimally invasive procedures are associated with less
blood loss and shorter length of stay. Regarding oncological outcome parameters,
minimally invasive approaches were associated with more positive surgical mar-
gins, peritoneal recurrences as also earlier and higher number of local recurrences.
However, the worse outcome in oncological parameters did not translate into a
worse survival and the two groups had similar overall and cancer specific survival
in the study [6]. Nevertheless, it has been suggested that though minimally invasive
approaches may be feasible in treatment of adrenal malignancies without any adja-
cent organ invasion, adrenal malignancies are best treated with the open approach [7].
inimally Invasive Adrenalectomy for Isolated Adrenal Metastases

M
Reports are emerging on the use of laparoscopic adrenalectomy for isolated adrenal
metastasis. Lung and renal carcinomas being the most common primary tumor and
capsular invasion or large size >7.5 cm is quoted as the common adverse factors in
performance of laparoscopic adrenalectomy for metastasis [8–11]. In a multicenter
study comparing laparoscopic and open adrenalectomy for metastatic adrenal
lesions, the authors observed a marginally better survival due to higher R0 resec-
tions in the laparoscopic group which they attributed to be probably due to selection
of less advanced cases in laparoscopic group [11].
inimally Invasive Retroperitoneoscopic Adrenalectomy in Large

M
Adrenal Tumors
Large adrenal tumors were initially considered as contraindications to minimally
invasive surgery, however lately reports are emerging of performance of laparo-
scopic adrenalectomy safely in large benign tumors. In a study comparing differ-
ences between laparoscopic transabdominal versus retroperitoneal approach in
large tumors, significant advantages were noted in the retroperitoneoscopic approach
[12]. Particularly with respect to right sided tumors regarding operation time 113 vs
85 min, pneumoperitoneum time 93 vs 64 min and estimated blood loss 96 vs
23 mL, as noted in transperitoneal approach and retroperitoneal approach, respec-
tively [12]. Another study evaluating different laparoscopic approaches in the man-
agement of large adrenal tumors >5 cm versus smaller tumors < 5 cm noted
favourable outcome in retroperitoneal approach for larger tumors. The authors also
proposed the use of partial resection method to minimize postoperative hormone
supplement [4]. Contrarily surgeons have reported the transperitoneal approach to
be favored technique in larger tumors [13]. The SAGES (Society of American
Gastrointestinal and Endoscopic Surgeons) guidelines for minimally invasive adre-
nalectomy advocates the preference of transperitoneal approach for larger tumors
(>6 cm) [14].
MI and Retroperitoneal Adrenalectomy
B
BMI and increased retroperitoneal fat mass has been shown to be associated with
adverse outcomes related to operative time and complications in retroperitoneal
adrenalectomy [15,16]. Periadrenal fat volume rather than BMI is associated with
460 S. Rege
increased operative time after retroperitoneal adrenalectomy [17]. Contrary notions

propose operation time and adrenal gland size as predictors of outcome and not
BMI in posterior retroperitoneoscopic adrenalectomy [18].
Meta-Analysis Comparing Transperitoneal Versus

Retroperitoneal Adrenalectomy
Table EN1 highlights results of various metanalyses comparing laparoscopic trans-
peritoneal and retroperitoneal approaches. The laparoscopic retroperitoneal
approach scores better on variables related to operative time, blood loss, hospital
stay and time to first ambulation all of which are less in posterior retroperitoneo-
scopic as compared to lateral retroperitoneoscopic approach. Favorable results were
noted even in phaeochromocytomas with retroperitoneoscopic approach there being
no difference in haemodynamic stability. A noted confounder in these analyses
maybe surgeons experience as laparoscopic retroperitoneal approach is preferred
technique of expert surgeons and also tumor characteristics may differ due to differ-
ent approach indications [19–22].
obotic Adrenalectomy: Meta-Analyses Comparing Robotic

R
and Laparoscopic Adrenalectomy
Robotic adrenalectomy has been shown to have equal outcome as regards mortality
and morbidity. Robotic approach has been suggested to decrease conversion rates in
large adrenal tumors and decrease conversion and operative time in patients with
high BMI. Results of robotic and laparoscopic adrenalectomy for malignancies
showed no difference with respect to positive margin, lymphadenectomy, hospital
stay, readmission and mortality [23]. Table EN2 outlines the results of metanalysis
on robotic compared with laparoscopic adrenalectomy [24-27].
I nvestigational Adjuncts and Technique Modifications in Minimal

Access Adrenalectomy
ingle Site Adrenalectomy/Single Incision

S
Retroperitoneal Adrenalectomy
With evolvement of the concept of SILS in laparoscopic surgery, single site laparo-
scopic surgery for adrenal using both transperitoneal and retroperitoneal approach
have been reported [28,29]. In a meta-analysis comparing single port adrenalec-
tomy with multiport adrenalectomy significantly less requirement of pain medica-
tion as well as pain scores was observed in the single site group. A shorter hospital
stay, shorter duration to oral intake and better cosmetic satisfaction was also reported
in the single site group. However single port surgeries had significantly longer oper-
ative time as compared to multiport adrenalectomies [30].
ingle Plane Retroperitoneoscopic Adrenalectomy

S
In this technique the authors propose the use of a single plane to dissect the adrenal
in benign disease. In the classical retroperitoneal approach three blood less planes
are dissected to expose the adrenal i.e. dissection plane between the perirenal fat
and the anterior renal fascia, between the posterior renal fascia and the lateral aspect
Table EN1 Meta-analysis comparing retroperitoneal and transperitoneal adrenalectomy

Study Result
Comparison of the retroperitoneal versus Retroperitoneal laparoscopic adrenalectomy
Transperitoneal laparoscopic associated with:
Adrenalectomy perioperative outcomes • Shorter operative time (WMD: 34.91, 95% ci:
and safety for Pheochromocytoma: a 27.02 to 42.80, i2 = 15%; p < 0.01),
meta-analysis [19]. • Less intraoperative blood loss (WMD: 139.32,
95% ci: 125.38 to 153.26, i2 = 0, p < 0.01)
• Shorter hospital stay (WMD: 2, 95% CI: 1.18
to 2.82, I2 = 82%, p < 0.01)
No significant differences were found in:
• Complication rate
• Incidence of hemodynamic crisis
Meta-analysis of trials comparing No statistically significant differences between
laparoscopic transperitoneal and lateral transperitoneal adrenalectomy and
retroperitoneal adrenalectomy [20]. retroperitoneal adrenalectomy in terms of:
• Operative time
• Blood loss
• Hospital stay
• Time to oral intake
• Overall and major morbidity
• Mortality.
Retroperitoneal versus transperitoneal Retroperitoneal approach was associated with:
laparoscopic adrenalectomy in adrenal • Shorter operative time [WMD = –13.10; 95%
tumor: a meta-analysis [21]. confidence interval (CI), −23.83 to −2.36;
p = 0.02],
• Less intraoperative blood loss
(WMD = −40.60; 95% ci, −79.73 to −1.47;
p = 0.04),
• Shorter duration of hospital stay
(WMD = –1.25; 95% ci, −2.36 to −0.14;
p = 0.03),
• Time to first ambulation (WMD = −0.38; 95%
ci, −0.47 to −0.28; p < 0.001).
No difference in:
• Number of convert to open management
• Time to first oral intake,
• Major postoperative complication rate
Systematic review and meta-analysis of Retroperitoneoscopic adrenalectomy
retroperitoneoscopic versus laparoscopic compared to laparoscopic adrenalectomy had
adrenalectomy [22]. lower hospital stay:
• Posterior Retro Approach: SMD −1.45 (95%
CI –2.76 to −0.14)
• Lateral Retro Approach SMD −1.45 (95%
confidence interval −2.76 to −0.14) and −0.54
(−1.04 to −0.03)
There were no differences in:
• Duration of operation
• Blood loss
• Time to ambulation and oral intake
• Complication rates
PRA posterior retroperitoneal adrenalectomy, LRA lateral retroperitoneal adrenalectomy, WMD
Weighted mean difference, SMD standardized mean difference, CI confidence interval
462 S. Rege
Table EN2 Meta-analysis comparing laparoscopic versus robotic adrenalectomy

Study Result
Comparing the efficacy and safety of RA was associated with a significantly lower:
laparoscopic and robotic • Open conversion rate
adrenalectomy: a meta-analysis and • Length of hospitalization
trial sequential analysis [24]. • Marginal results regarding blood loss
LA and RA were similar in terms of:
• Operative duration
• Positive margin
• Complications
• Mortality rate
Laparoscopic versus robotic Robotic Adrenalectomy (RA) vs Laparoscopic
adrenalectomy: A comprehensive Adrenalectomy (LA)
meta-analysis [25]. RA fared better:
• Shorter hospital stay (WMD: −0.40; 95% CI, −0.64
to −0.17)
RA fared worse:
• Operating time (WMD: 15.60; 95%CI, 2.12 to
29.08).
No significant difference:
• Intraoperative complications,
• Postoperative complications,
• Mortality,
• Conversion to laparotomy,
• Conversion to laparotomy or laparoscopy
• Blood loss.
Robot-assisted versus laparoscopic Robotic Adrenalectomy (RA) vs Laparoscopic
adrenalectomy: a systematic review Adrenalectomy (LA)
and meta-analysis [26]. LA fared better:
• Shorter operating time in LA (WMD = 17.52 min;
95% CI, 3.48−31.56; P = 0.01),
RA fared better:
• Less blood loss (WMD = −19.00 mL; 95% CI,
−34.58 to −3.41; P = 0.02)
• Shorter length of hospital stay (WMD=−0.35 day;
95% CI, −0.51 to −0.19; P < 0.001).
No significant differences:
• Conversion rates
• Overall complications.
Robotic versus laparoscopic Robotic Adrenalectomy (RA) vs Laparoscopic
adrenalectomy: a systematic review Adrenalectomy (LA)
and meta-analysis [27]. RA fared better:
• Hospital stay (WMD: −0.43; 95% CI, −0.56 to
−0.30; p < 0.00001),
• Blood loss (WMD: −18.21; 95% CI, −29.11 to
−7.32; p = 0.001).
No significant difference:
• Conversion rate
• Operative time
• Postoperative complication rate
Most of the postoperative complications were minor
(RA = 80% LA = 68%).
RA robotic adrenalectomy, LA laparoscopic adrenalectomy, WMD weighted mean difference
of the perirenal fat and third plane on the parenchymal surface of the upper renal
pole. In the single plane adrenalectomy the authors approach the anterior aspect of
the adrenal first and dissect between the upper pole of the kidney and capsule of
adrenal gland [31].
and Assisted Retroperitoneal Adrenalectomy

H
Similar to laparoscopic hand assisted approach in other surgeries, reports on laparo-
scopic hand assisted adrenalectomy have been published both using transperitoneal
or retroperitoneal techniques. However, the hand assisted technique is rarely used in
retroperitoneoscopic adrenalectomy due to the small working area. It has been pro-
posed as a rescue procedure in complicated cases [32].
I ntraperinephric Fat Versus Extraperinephric Fat Approach

The conventional method described is the extraperinephric fat approach where the
plane is created outside the Gerotas fascia. An intraperinephric fat approach to the
adrenal between the perinephric fat and renal capsule has been suggested to decrease
chances of peritoneal injury, however it has greater chances of renal capsular injury
and adhesions due to saponification of perinephric fat can pose difficulty [33].
lipless and Suture Less Laparoscopic Adrenalectomy

C
In a total of 251 patients who underwent adrenalectomy for various diseases, the
authors explored the possibility of clipless and sutureless adrenalectomy using
bipolar cautery and found no major bleeding or serious complications intraopera-
tively or postoperatively [34].
464 S. Rege
erioperative Principles of Fast Track Surgery

P
in Retroperitoneal Adrenalectomy
In a study comparing “Fast track” management versus conventional perioperative
management in retroperitoneal laparoscopic adrenalectomy, significant advantages
related to hospital stay, postoperative pain scores, postoperative inflammatory
response and overall general well-being was seen in the “Fast-track” group [35].
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1):S22–7.
Laparoscopic Donor Nephrectomy
Umesh Sharma and Hemant Goel
Introduction
Annually 735,000 deaths are attributed to chronic kidney disease globally and an
equivalent number is also observed in India [1, 2]. End stage renal disease (ESRD)
is best treated with renal transplantation. According to United Network for Organ
Sharing registry data there are many benefits of living donor renal transplantation
such as (1) shorter waiting period (2) better graft (3) improved patient survival (4)
optimization of medical health of the recipient and (5) an overall reduced cost when
compared long term with cadaveric transplantation [3]. However, organ shortage is
a key limiting factor that mars the success of kidney transplantation.
The first laparoscopic nephrectomy was reported by Clayman et al. [4] in 1990.
Following the demonstration of the feasibility of “Laparoscopic donor nephrec-
tomy” (LDN) in the animal models by Gill and colleagues, Ratner et al. [5] per-
formed the first laparoscopic live donor nephrectomy in 1995. Today most centres
performing “Open donor nephrectomy” (ODN) are slowly adopting minimal access
donor nephrectomy like LDN & “Robotic Assisted Donor Nephrectomy” (RADN).
LDN, overcomes some of the inherent disincentives of open organ donation by
making donor nephrectomy less painful, shortening the convalescence period, and
improving the cosmetic outcome thereby exhibiting the potential to increase the
number of living kidney donations. In this chapter we describe different surgical
techniques related to LDN (Table 1).
U. Sharma (*) · H. Goel

Department of Urology and Renal Transplantation, PGIMER and Dr RML Hospital,
New Delhi, India
https://doi.org/10.1007/978-981-16-5473-2_21
470 U. Sharma and H. Goel
Table 1 Minimally invasive Surgical techniques for living donor nephrectomy

Laparoscopic transperitoneal technique
- Laparoscopic donor nephrectomy (LDN)
- Hand-assisted LDN
- Laparo-endoscopic single site donor nephrectomy (LESS DN)/ Single port laparoscopic
donor nephrectomy (SPLDN)
- NOTES (Natural Orifice transluminal endoscopic surgery) donor nephrectomy
- Robotic/ Robot assisted donor nephrectomy (RADN)
Endoscopic retroperitoneal technique
- Endoscopic retroperitoneal donor nephrectomy (ERDN)
- Hand-assisted ERDN
Fig. 1 Patient placed for

left donor nephrectomy.
Port placements are
marked
Strategies Adopted to Increase Organ Donation
Various strategies have been adopted to increase the number of living donors and
organ donation:
(a) ABO-incompatible renal transplant with or without splenectomy

(b) Cross-over transplantation (paired-kidney exchange program)
(c) Emotionally related kidney donation
(d) Genetically unrelated renal donor
(e) Transplantation of abnormal kidneys
(f) Laparoscopic donor nephrectomy (LDN)
Surgical Techniques
Laparoscopic Donor Nephrectomy (LDN): Left Kidney
Position & Port site The operation is commenced with the donor positioned in a
left lateral decubitus position and the operation table flexed (Fig. 1). A 12 mm cam-
era trocar, is inserted two fingerbreadths above and lateral to umbilicus and if the
donor is obese then it can be placed even more laterally at lateral border of rectus.
Pneumoperitoneum is created to maintain an intraabdominal pressure of 12 mmHg
Laparoscopic Donor Nephrectomy 471
so as not to compromise renal perfusion. Additional ports of 12 mm and 5 mm are
inserted under vision at midway between spino-umbilical line and in left subcostal
region in the mid clavicular line. Another 5mm port is inserted in left anterior axil-
lary line for retraction (Fig. 1).
Mobilization of Structures to Reach the Hilum Kidney The colon is mobilised

and displaced medially. Upper pole of kidney is dissected free of spleen by dividing
splenophrenic and lienorenal ligament. Thorough mobilisation of spleen will make
it fall medially along with tail of pancreas, thus preventing inadvertent injury to
spleen and greater curvature of stomach. Gonadal vein and ureter are identified and
dissected up to renal hilum with exposure of the psoas muscle (Fig. 2). Ureteral dis-
section with preservation of periureteral fatty tissue and fat at the inferior pole of the
kidney is recommended to help maintain ureteral vascularity and prevent ureteral
stricture, the area commonly referred to as “the golden triangle”. It needs to be
noted that the entire lateral attachments of the kidney are completely released only
after hilar dissection is completed but before ligation of the pedicle because com-
plete mobilization before hilar dissection will cause the kidney to fall forward and
make hilar dissection difficult.
Peri-Renal and Hilar Dissection Lumbar veins, sometimes multiple, are seen
inferior and posterior to renal vein. The adrenal vein is found medially and superior
to renal vein. The adrenal and lumbar veins are clipped and divided (Fig. 3). The
gonadal vein is left attached to renal vein for vascular reconstruction if required
later; additionally, it is hypothesized to help in preserving vascularity to upper ureter
though the issue is controversial as orchialgia is a perceived complication of the
manoeuvre. Thereafter the renal vein is identified, dissected, and hooked to expose
the renal artery which is traced till its origin (Fig. 4). After dividing the adrenal vein,
Fig. 2 Lower window

showing Gonadal vein
(GV) and ureter (U)
complex
Fig. 3 Hilar dissection

showing tributaries of left
renal vein (LRV) i.e.,
Lumbar vein (LV), Adrenal
vein (AV) and Gonadal
vein (GV)
Fig. 4 Left renal artery

(LRA) is hooked by right
angle forceps after clipping
and dividing lumbar and
adrenal vein. Left Renal
Vein (LRV)
an upper window is created between the adrenal gland and the kidney. The ureter is
dissected down to the point of its crossing of iliac vessels, wherein it is clipped and
divided, one should be careful not to damage the nerves running on the psoas mus-
cle particularly the genitofemoral nerve in the process.
Preparation for Extraction and Ligation of Vascular Pedicle An incomplete

access for extraction of the kidney, to be done later, is made at this stage by a creat-
ing a Pfannenstiel incision or midline incision, with peritoneum kept intact until the
final extraction process is initiated. Low molecular weight heparin sulphate (3000
units) is injected 5 min before ligating the vascular pedicle. Next the renal artery and
vein are separately divided using an EndoGIA vascular stapler or double Hem-o-
lock clips (Fig. 5 a and b). Stapling being preferred over the use of Hemlock clip.
a b
Fig. 5 (a) Clipping of left renal artery; (b) Clipping of left renal vein
Fig. 6 Graft being

harvested from lower
midline/pfannenstiel
incision (Two finger
technique)
Extraction of the Kidney The kidney can be removed with an Endo-Catch bag or
manually, either through a 5-cm periumbilical incision, or alternatively through a
Pfannenstiel incision or muscle-splitting Gibson incision which is prepared in
advance before the division of renal hilum (Fig. 6). In the manual extraction tech-
nique, the perirenal fat lateral to the kidney is held with two fingers inserted into the
abdominal cavity through the small incision, and the graft gently extracted. The
retrieved kidney is immediately flushed with preservation fluid and stored on ice.
The main advantage of the manual extraction technique as compared with
laparoscopic bag technique is that it exhibits a shorter warm ischemia time, without
any significant increase in donor morbidity, also the additional costs of the endobag
is mitigated.
Drawbacks of LDN
The most important drawback of LDN is that it exhibits a steep learning curve. The
transperitoneal approach makes it vulnerable to the associated complications of
bowel injury from trocar insertion or instrumentation and intestinal adhesions.
Shorter operative time, warm ischaemia time and greater vessel lengths are the rela-
tive advantages of open procedure [6]. Other complications reported in laparoscopic
group include injuries to adjacent organs, spleen, vascular injuries, retroperitoneal

haematomas pneumothorax and pneumomediastinum. A conversion rate to open
surgery of 1.8% has been reported with vascular injury accounting for nearly half of
the conversions [7].
LDN vs ODN
Laparoscopic donor nephrectomy displays the well-founded benefits associated

with minimally invasive approach viz: a shorter hospital admission, reduced postop-
erative analgesic requirement, improved cosmetic outcome and a faster return to
work as compared with open donor nephrectomy. Laparoscopic donor nephrectomy
is safe, inflicts a less donor morbidity and achieves similar allograft function, but
with the relative drawback of increased costs and warm ischaemia time as compared
to open donor nephrectomy [8]. A modified open technique also known as the mini-
open technique has been advocated to enjoy the benefits of laparoscopic nephrec-
tomy (faster recovery) as also a shorter operative time, but a higher analgesic
requirement has been noted [9, 10].
Hand-Assisted LDN
Hand-assisted LDN can be used as an intermediary bridge in the learning curve

when venturing into totally laparoscopic donor nephrectomy from open approach.
The procedure is performed transperitoneally using a hand port and other laparo-
scopic ports [11]. The surgeon usually uses his non dominant hand in the hand port.
Various incisions have been described for insertion of hand port such as midline,
periumbilical, lower quadrant vertical and Pfannensteil incision [12, 13]. The
inserted hand provides a tactile feedback, aids in dissection, minimizes traction/tor-
sion of the kidney during dissection, can provide quick compression of an inadver-
tent massive haemorrhage and facilitate fast extraction of the kidney. The other
perceived benefits of using a hand assisted technique are: easy learning curve, less
blood loss, equivalent complication rate, shorter warm ischaemia and operative time
as compared to laparoscopic technique [12, 13]. Hand assisted donor nephrectomy
is also beneficial in obese individuals and those with prior upper abdominal surgery,
where the totally laparoscopic approach may be difficult [14]. A lower pain score,
less analgesic requirement and early return to work are the other benefits of hand
assisted as compared to open technique [15]. Prominent drawbacks of hand assisted
donor nephrectomy include additional costs incurred due to hand port, inefficient
ergonomics due to abnormal body posture and resultant shoulder back and hand
muscle strains, greater traumatic injury to graft due to increased manipulation and
increased incidence of wound infection. Problems due to vascular injury, haemor-
rhage, staple line malfunction, difficulty in exposing the kidney, obesity and adhe-
sions are common reasons for conversion to open [12]. A randomized comparative
trial of laparoscopic donor nephrectomy with and without hand assistance observed
similar outcome, complications and quality of life in both the groups [16].
Right vs Left Kidney for LDN
The right renal vein being shorter and the constraints of space due to the liver over-
lying the right kidney, it is always a technical challenge to laparoscopically harvest
the right kidney for transplant. After transplant, as the right renal artery is long, it
can get kinked while the right vein which is short (particularly in laparoscopic
approach where an additional 1 cm length of the vessel is lost due to stapling),
makes it more prone to compression by the kidney leading to higher incidence of
venous thrombosis in in right kidney grafts making surgeons prefer the left for
LDN. However, the important principle of leaving the better kidney with the donor
needs to be adhered to and experts working particularly in high volume institutions,
take up RLDN in spite of the difficulties [17]. Contrarily it has been reported that
the right kidney is easy to extract and decreases risk of splenic injury [13].
Laparoscopic Donor Nephrectomy (LDN): Right Kidney (Fig. 7)
Due to the inherent anatomical challenges discussed earlier, the right kidney is used
only in approximately 20% cases. To circumvent the drawbacks various modifica-
tions advocated in transperitoneal approach of laparoscopic right donor nephrec-
tomy include 1) dissection of the inter aortocaval space to allow division of the renal
artery at its origin from the aorta, 2). Control of renal vein at its junction with the
vena cava to ensure a maximal possible length 3) inclusion of a cuff of vena cava,
using a laparoscopic vascular clamp which is thereafter repaired by intracorporeal
suturing 4) use of recipient saphenous vein graft supplement to reconstruct the renal
vein in case harvested renal vein is very short. On the right side there is no need to
control the lumbar, gonadal and adrenal vein as they do not drain into the renal vein.
Fig. 7 Right renal hilum

showing (top to bottom)
upper renal artery (RA-U),
renal vein (RV), lower
renal artery (RA-L) and
ureter (U). L Liver
Endoscopic Retroperitoneal Donor Nephrectomy (ERDN)
The advantage of ERDN is that the peritoneal cavity is not breached. ERDN can be
performed with and without hand assistance. The procedure is performed with the
donor in full lateral position. Initially a retroperitoneal workspace is created by
blunt dissection using a balloon or the operator’s hand which is further maintained
at a pressure of 12mm by insufflation of carbon dioxide (CO2). Further dissection
and mobilization of the kidney, ureter and vascular pedicles are performed on prin-
ciples as described for LDN. In limited studies it has been observed that hand
assisted retroperitoneoscopic nephrectomy yields similar intraoperative and postop-
erative outcome both for donors and recipients as compared to laparoscopic
approach [18–20].
ingle-Port Laparoscopic Donor Nephrectomy (SPLDN)/

S
Laparoendoscopic Single Site Donor Nephrectomy (LESS-DN)
Laparoendoscopic single-site surgery and supporting devices are being explored

with an aim to reduce donor morbidity and also improve patient satisfaction [21,
22]. The operation through a concealed incision in the umbilicus can allow the per-
formance of the entire procedure as well as specimen extraction from the single site
and gives the donor a very small residual scar once healed. Multiple instruments can
be inserted through the single-commercially available port devices. The potential
advantages of SPLDN include reduced number of incisions, reduced pain and
shorter hospital stay. Several issues like the steep learning curve and need for spe-
cialized instruments are the impediments of single incision surgery from becoming
the standard of care. The single port natural orifice transumbilical donor nephrec-
tomy has been denoted as E NOTES procedure (embryonic Natural Orifice
Transluminal Endoscopic Surgery) [23].
Robotic Assisted Donor Nephrectomy (RADN)
Initial series of robotic-assisted laparoscopic donor nephrectomies was reported in

the year 2001, by the University of Illinois at Chicago. RADN can be performed
with or without hand assistance. The advantages of the robotic paraphernalia viz: a
magnified 3D vision and better articulating robotic instruments can aid in dissection
and suturing, if necessary, particularly in cases with complex vascular anatomy. The
da Vinci Xi robot has a rotating tower that supports the robotic arms which can be
adjusted to achieve the desired triangulation and is ergonomically advantageous.
The performance of the robotic approach requires multiple robotic/laparoscopic
ports. Manual manoeuvred assistant ports for use of energy devices, staplers, and
for extraction are required. Most authors describe the use of 4–5 robotic ports for
dissection and retraction, a 12 mm camera port at the umbilicus and an infraumbili-
cal 8 cm hand GelPort for extraction. When operating on the right side an additional
port is necessary for liver retraction. The operative steps mirror the laparoscopic
approach described earlier. Though robotic donor nephrectomy is feasible, it does
not appear to have overt advantages over other minimally invasive techniques and
has added costs [24, 25]. There are anecdotal reports of robotic donor nephrectomy
being performed through trans vaginal route (hybrid NOTES) [26].
Complications
The incidence of perioperative complications with minimally invasive live donor

nephrectomy is overall low of around 3%–4%. Intraoperative major complications
(0.6%) includes bleeding (1.5%), rarely endovascular stapler malfunction etc.
Surgeons should keep in note about anecdotal reports of injury to the left common
iliac artery due to Verees needle, infectious complications (2.6%), injury to other
organs, cardiopulmonary complications and thromboembolic events which occur in
less than 1 % cases. Pneumothorax, pneumomediastinum, subcutaneous emphy-
sema are other quoted complications related to insufflation. Conversion to open
donor nephrectomy is required in 1.1% cases and should be considered as a safe
sequlae rather than a complication of the procedure. Rare post-operative complica-
tions are chylous ascites, rhabdomyolysis and other complications like paralytic
ileus, epididymitis, orchalgia, genitofemoral nerve neuropraxia [27, 28].
Conclusion
A variety of techniques both open and laparoscopic have been described for living
donor nephrectomy. Minimally invasive techniques due to its association with
decreased morbidity and improved recovery time should be viewed as the preferred
approach for majority of these patients. The key principle of donor safety is para-
mount in making final decisions regarding donation techniques. Also different cen-
tres and surgeons may have varied approaches that result in good and safe outcomes.
Thus, the experience of the surgeon in a particular approach becomes an important
consideration in determining the best approach for each patient.
Key Clinical Points

1. Renal transplantation is considered the best and complete option for end stage
renal disease.
2. The minimally invasive approaches include laparoscopic, robotic, single port
laparoscopic and natural orifice transluminal endoscopic surgery.
3. Minimally invasive donor nephrectomy reduces postoperative pain, shortens
convalescence, and improves the cosmetic outcome of donor nephrectomy thus
increasing the acceptability and rates of live donor nephrectomy.
4. Minimally invasive approaches in donor nephrectomy may be transperitoneal
or retroperitoneal and with or without use of hand assistance.
5. The hand-assisted technique acts as an intermediary bridge in learning curve of

totally laparoscopic donor nephrectomy and has been projected to have lower
intraoperative and postoperative complication rates.
6. The hand assisted technique has some advantages in that it provides a tactile
feedback, aids in dissection, minimizes traction/torsion of the kidney during
dissection, can provide quick compression of an inadvertent massive haemor-
rhage and facilitate fast extraction of the kidney.
7. Most surgeon prefer the left kidney for transplant as the right renal artery is
long, and can get kinked while the right renal vein which is short (particularly
in laparoscopic approach where an additional 1 cm length of the vessel is lost
due to stapling) may be prone to thrombosis, also there are constraints of space
due to the liver overlying the right kidney.
8. When choosing between the right and left kidney for donor nephrectomy, addi-
tional factors that need to be considered are, vascular anomalies and principle
of leaving behind the better kidney.
9. In laparoscopic donor nephrectomy care is taken to preserve the gonadal ves-
sels on the left, the periureteral and inferior renal polar fat along with the ureter
to prevent devascularization of the ureter and decrease formation of ureteral
strictures (concept of the golden triangle).
10. Extraction of the kidney can be done through various incisions or a GelPort and
an access incision to the effect should be partially made (only peritoneum left
intact) before ligation of the pedicle.
11. Extraction may be done using an EndoCatch bag or manually, it is important to
avoid torsion during the process.
12. The advantages of the robotic approach include a magnified 3D vision and bet-
ter articulating robotic instruments that can aid in dissection and suturing, as
also the rotating tower that supports the robotic arms that can be adjusted to
achieve the desired triangulation.
13. Overall complication rates are low and conversion to open donor nephrectomy
is required in 1.1% cases which should be considered as a safe sequlae rather
than a complication of the procedure.
Editor’s Note1
Live donor nephrectomy has evolved with time from conventional open approaches
to the newer minimally invasive techniques. The initial scepticism of laparoscopic
donor nephrectomy has waned with emerging studies which vouched for its safety
and efficacy as equivalent to open donor nephrectomy. In a recently published meta-
analysis on longterm outcome of laparoscopic versus open donor nephrectomy, the
authors observed, similar 1-year outcomes as compared with open technique with
respect to serum creatinine levels, proteinuria, donation attitude, donor health-
related quality of life and recipient graft survival between the groups [1]. Since
laparoscopic procedures have longer operative times as compared to conventional
open procedures a longer ischaemia time has been noted in laparoscopic donor
nephrectomy which however does not translate into a worse outcome and given the
attractive attributes of less pain shorter hospital stay and better cosmesis it has
gained an overall modest acceptability [2]. Many variations in technique have been
investigated such as use of retroperitoneal versus transperitoneal approach, use of
hand assisted versus total laparoscopic approach, laparoscopic single site technique
as compared to multiport laparoscopic approach, right versus left laparoscopic
donor nephrectomy and recently robotic versus laparoscopic approach. Most stud-
ies show some differences in the short-term end points viz: warm ischaemia time,
operative time blood loss, conversion, postoperative pain/ analgesic requirement
complication and hospital stay in published systematic reviews/metanalysis. Overall
the retroperitoneal approach appeared to have lesser complications than transperito-
neal laparoscopic approach and warm ischaemia time as well as mean operative
time was observed to be less in hand assisted technique as compared to total laparo-
scopic approach. The laparoscopic single site donor nephrectomy appears to be
technically more challenging as evidenced by higher conversion rates and operative
time. Pertinent long term outcome like graft survival and function appears to be
largely independent of these technical modifications (Table EN1) [3–12].
Recently an attempt has been made to classify difficulty of laparoscopic donor
nephrectomy and the following variables were noted to significantly influence dif-
ficulty: gender, BMI, technique (hand assisted versus pure), presence of multiple
renal arteries and veins. Interestingly age and side of operation (left versus right)
was not found to be significant [13].
Other variations reported in literature are in modes of pedicle ligature viz the
vessel sealing devices for renal pedicle for example use of clips versus staplers for
vascular control [12], single stapler technique for pedicle control [14] and routes of
extraction of specimen through extended port site compared to delivering through
Pfannensteilor periumbilical incision (Table EN1) [11].
1
Table EN1 Metanalysis/systemic reviews on technique modifications of laparoscopic donor

nephrectomy
Study, first author name, year Results
Robot-assisted laparoscopic vs laparoscopic donor Laparoscopic donor nephrectomy:
nephrectomy in renal • shorter operative time (P = 0.001)
transplantation: A meta-analysis. • shorter warm ischemia time
Wang H 2019 [3] (P < 0.00001)
• less blood loss (P = 0.002)
Robotic donor nephrectomy:
• lower visual analogue score
• postoperative pain scores
No difference in the following
postoperative parameters:
• duration of hospital stay
• serum creatinine value in donor
• recipient glomerular filtration rate
(eGFR)
• donor complications
Laparoendoscopic single-site donor nephrectomy In the LESS-DN group pain scores at
(LESS-DN) versus standard discharge were significantly less.
laparoscopic donor nephrectomy. No significant differences between
Gupta A, 2016 [4] LESSDN and LDN was observed
regarding the following parameters:
• operative time
• blood loss/ blood transfusions
• complication rates
• hospital stay
• return to normal activities
• conversion to another form of surgery
• warm ischaemia time
• analgesic requirement
• graft loss
Laparoscopic and hand-assisted laparoscopic Hand assisted laparoscopic donor
donor nephrectomy: A systematic review nephrectomy had shorter:
and meta-analysis. • warm ischaemia time (P = 0.006)
Broe MP, 2018 [5] • operative time (P < 0.001)
no differences in:
• conversion
• complications
• length of hospital stay
Right Versus Left, Laparoscopic Living-Donor The right group:
Nephrectomy: A Meta-Analysis. • shorter operative time, (P = 0.005)
Wang K, 2015 [6] • lower operative blood loss (P = 0.003)
• lower donor intraoperative complication
(P = 0.03)
There were no differences as regards:
• hospital stay
• graft function
• graft loss at 1 year
• conversion to open procedure
• donor blood transfusion
• postoperative complications
Study, first author name, year Results
Determining the Superior Technique for Retro-peritoneoscopic approach had the
Living-donor Nephrectomy: the Laparoscopic following advantages as compared to
Intraperitoneal Versus the Retroperitoneoscopic laparoscopic transperitoneal group:
Approach.He B, 2016 [7] • lower blood transfusion
• less delayed graft functions
• less vessel injuries
• less conversion to open surgical
procedure
A comparison of technique modifications in • Retroperitoneoscopic group had less
laparoscopic donor nephrectomy: a systematic complications
review and meta-analysis. • Hand-assisted techniques had shorter
Özdemir-van Brunschot DM, 2015 [8] first warm ischemia and operation times
Laparoendoscopic single-site (LESS) vs Laparoscopic live donor nephrectomy had
laparoscopic living-donor nephrectomy: a the following benefits over LESS LDN:
systematic review and meta-analysis.Autorino R, • shorter operative time P = 0.003
2015 [9] • less likelihood for conversion
No significant difference was observed in:
• warm ischaemia time
• estimated blood loss
• hospital stay
• visual analogue pain score at discharge
• postoperative complication
• postoperative renal function of recepient
analgesic requirement was lower for LESS
LDN (P = 0.04)
Should hand-assisted retroperitoneoscopic Hand assisted retroperitoneoscopic
nephrectomy replace the standard laparoscopic nephrectomy HARP was superior to Total
technique for living donor nephrectomy? A Laparoscopic Nephrectomy with respect to:
meta-analysis. • shorter operative duration
Elmaraezy A, 2017 [10] • shorter warm ischemia time
No significant difference with respect to:
• blood loss
• hospital stay
• graft survival
• intraoperative complications
Laparoscopic nephrectomy - Pfannenstiel or Pfannensteil extraction site had benefits
expanded port site specimen extraction: a of:
systematic review and meta-analysis. • Less in patient stay (p = 0.03)
Amer T, 2015 [11] • Lower blood loss (p = 0.03)
Staplers or clips? A systematic review and Hem-o-Lok clips versus staplers
meta-analysis of vessel controlling devices Disadvantages of Hem-o-Lok clips:
for renal pedicle ligation in laparoscopic live • greater blood loss
donor nephrectomy.Liu Y, 2018 [12] • longer warm ischemia time (WIT)
Advantages of Hem-o-Lok clips:
Longer vascular graft length in clip group
longer as compared to stapler group.
Lower Cost
No difference in outcome as regards:
• device failure rate
• death rate
• severe hemorrhage rate.
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Recent Concepts in Minimal Access Surgery: Deborshi Sharma Priya Hazrah

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Recent Concepts

ISBN 978-981-16-5472-5 ISBN 978-981-16-5473-2 (eBook)

 Prof (Dr.) Vijay Kumar Shukla, MS, MCh

Learning is like rowing upstream, not to advance is to drop back....

New Delhi, India Deborshi Sharma

“it always seems impossible until its done”— Nelson Mandela

Dr Deborshi Sharma and Dr Priya Hazrah, Editors RCMAS

Priya Hazrah graduated from the Institute of Medical Sciences, Banaras Hindu

Deborshi Sharma is presently Director Professor of surgery in the department of

Fundoplication is a surgical technique used as a treatment modality for GERD with

R. Parshad (*) · A. Kumar

studies have shown that probability of developing symptoms needing emergent

1. Barium Esophagogram: Barium studies are losing favour in western literature

Table 1 Montreal Consensus definition of symptoms of GERD

Medical vs Surgical Therapy

Antireflux Barrier Mechanism and Fundoplication

(c) Intact phreno-esophageal membrane.

• Failed medical management (inadequate symptom control, severe regurgitation

Apart from these indications individual evaluation of patients is important for

The Preferred Approach: Open vs Laparoscopic?

Role of Fundoplication in NERD

Non-erosive reflux disease (NERD) is a spectrum of GERD defined as troublesome

Role of Fundoplication in Obesity

 urrent Controversies Related to the Technique

There is some variation in the technique of fundoplication seen amongst different

 he Key Components of Fundoplication as Recommended Are

 he images of the aforementioned steps as performed: (Figs. 1, 2,

 omplete vs Partial Wrap

Fig. 1 Hiatal Dissection

Fig. 2 Mobilization of the

A more recent metanalysis in 2016 compared the Laparoscopic Nissen fundopli-

Fig. 3 Division of Short

Fig. 4 Complete crural

 ivision vs Non-Division of Short Gastric Vessels

Fig. 6 Shoe shine

Six RCT’s have been performed comparing division vs non-division of short

 esh vs Suture Closure of Hiatus Hernia

(16.1%) with no significant difference in complication rates of 5.1% vs 4.6%

 ole of Bougie Dilators

ergonomics, it didn’t take time for surgeons to implement it in performing antireflux

Magnetic Ring Implants (LINX™ Procedure)

Table 2 Manometry changes in magnetic ring implants

Fig. 8 Schematic diagram

Key Clinical Points

5. CT Scan is useful to demonstrate cephalad migration of the GEJ and fundus

Insertion of the Bougie Across the Esophageal Junction

Insertion of a bougie is often recommended in numerous guidelines including

LES Electrical Stimulation

It is a novel technique that has been designed to be a successful, minimally invasive

Laparoscopic Sleeve Fundoplication

Laparoscopic sleeve gastrectomy has been noted to increase gastroesophageal reflux. It

investigated the concept of adding a fundoplication to laparoscopic sleeve gastrectomy

Endoscopic Fundoplication/Transoral Incisionless Fundoplication

TIF (Transoral incisionless fundoplication) is being investigated as a minimally

Stretta is a procedure by which radiofrequency treatment is delivered to the lower

GERD-Health Related Quality of Life Questionnaires convey that heartburn and

Table EN1 Metanalysis on efficacy and safety of endoscopic, transoral incisionless

Table EN2 Meta-analysis comparing magnetic sphincter augmentation versus fundoplica-

Prof (Dr.) Vijay Kumar Shukla, MS, MCh

New Delhi, India Deborshi Sharma

Medical vs Surgical Therapy

Antireflux Barrier Mechanism and Fundoplication

The Preferred Approach: Open vs Laparoscopic?

Role of Fundoplication in NERD

Role of Fundoplication in Obesity

urrent Controversies Related to the Technique

he Key Components of Fundoplication as Recommended Are

he images of the aforementioned steps as performed: (Figs. 1, 2,

omplete vs Partial Wrap

ivision vs Non-Division of Short Gastric Vessels

esh vs Suture Closure of Hiatus Hernia

ole of Bougie Dilators

Magnetic Ring Implants (LINX™ Procedure)

Insertion of the Bougie Across the Esophageal Junction

LES Electrical Stimulation

Laparoscopic Sleeve Fundoplication

Endoscopic Fundoplication/Transoral Incisionless Fundoplication

xtent of Gastrectomy and Different Minimally Invasive

and-Assisted Laparoscopic Gastrectomy (HALG)/LADG

Laparoscopy-Assisted Gastrectomy (LAG)

Totally Laparoscopic Gastrectomy (TLG)

Laparoscopic Function-Preserving Surgery

Single-Incision Distal Gastrectomy (SIDG)

D1 Versus D2 Lymphadenectomy

Comparison of Open Vs Laparoscopic Gastrectomy

atient Position, Trocar Location and Performance

2 Lymphadenectomy and Specimen Resection for Distal

Gastrointestinal Reconstruction after Distal Gastrectomy

Drain Placement and Closure

Laparoscopic Versus Open D2 Gastrectomy

Variations in Extent of Resection

dditional Organ Excision

nastomotic Techniques after Distal Gastrectomy

econstruction after Proximal Gastrectomy

econstruction after Laparoscopic Total Gastrectomy

Emerging Use of Laparoscopic Techniques in Early Gastric Cancer

Sentinel Node Navigation Surgery

References for Editor’s notes