https://www.laparoscopyhospital.com/
Laparoscopic Mini Gastric Bypass (MGB) is one of the most commonly performed bariatric surgery and slowly getting popular all over world as obesity surgery. This video demonstrate step by step technique of performing mini gastric bypass surgery by Dr R K Mishra at World Laparoscopy Hospital for a female suffering from Morbid Obesity. Mini Gastric Bypass has Restrictive, Malabsorptive and Hormonal component.

Restrictive:
A small stomach pouch is created restricting the amount of food you can eat.

Malabsorptive:
A portion of the small intestine is bypassed. Since the small intestine is responsible for absorbing the calories from the food you eat, bypassing a portion of the small intestine results in fewer calories being absorbed, thus creating additional weight loss.

Hormonal:
The hormone ghrelin has been nicknamed the “Hunger Hormone” by researchers because of its significant effect on appetite. Gastric Bypass results in a fall in ghrelin levels resulting in a reduced appetite.

This video demonstrate Total Laparoscopic Hysterectomy (TLH) with Infrared Ureteral Stent by Dr R K Mishra at World Laparoscopy Hospital. IRIS U-Kits of stryker has Lighted ureteral stents which can be used in gynecological procedures. This Visualization technology built into the L10 Light Source is designed to help identify the ureters in lower pelvic procedures and reduce the risk of ureteral injury.

This video demonstrate Laparoscopic Cholecystectomy with Real-time Near-Infrared Fluorescent Cholangiography by Dr R K Mishra at World Laparoscopy Hospital. Indocyanine green (icg) fluorescent cholangiography also called Fluorescent cholangiography can be considered as a useful tool for intra-operative visualization of the biliary tree during laparoscopic cholecystectomies. Bile duct injury remains the most feared complication of laparoscopic cholecystectomy. Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging and may reduce injury, but is not widely used. Near Infrared Fluorescence Cholangiography (NIRF-C) is a novel non-invasive method for real-time, radiation free, intra-operative biliary mapping. NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during laparoscopic cholecystectomy. Significantly less time was required to perform NIRF-C than IOC and it is significantly cheaper to use compared to IOC. NIRF-C has the potential to decrease bile duct injury at a significantly lower cost than the use of routine IOC during laparoscopic cholecystectomy.

This Video Demonstrate Sleeve Gastrectomy Fully Explained by Dr R K Mishra at World Laparoscopy Hospital. Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach along the greater curvature. For more information https://www.laparoscopyhospital.com

Published on 11 Jun 2017
Robotic assisted tubal reversal surgery is a surgical procedure in which the Fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system. The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.

Robotic tubal ligation reversal uses the same small incisions as a traditional laparotomy tubal reversal surgery. Smaller incisions generally result in less pain and quicker return to work when compared to traditional tubal ligation reversal using larger abdominal incisions. The robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal, but not as much dexterity as with an open procedure using a 2 to 3 inch incision. The disadvantages to robotic surgery are longer operating times and much higher costs than even traditional laparoscopic surgery.

https://www.laparoscopyhospital.com

This video demonstrate laparoscopic myomectomy performed by Dr R K Mishra at World Laparoscopy Hospital. 80% of women between 30 and 50 years of age have uterine fibroids. Depending on their size and location, fibroids can be completely asymptomatic or can cause pelvic pain, dyspareunia, pressure, urinary problems, and recurrent menorrhagia. In general, the larger the fibroid, the more severe the symptoms. Abnormal bleeding is usually caused by fibroids adjacent to the uterine cavity. Patients who have smaller serosal fibroids may be completely asymptomatic or report only one symptom. Less than 1% of fibroids are malignant, and, unless they affect the patient's quality of life, there's no need for treatment.

The vision of Dr. R. K. Mishra for World Laparoscopy Hospital is to be the world leader in patient experience, clinical outcomes, research and education. We believe in diverse specialists working and thinking as a unit. This kind of cooperation, efficiency and shared vision has fostered excellence in patient care, research and education in laparoscopic, endoscopic and robotic surgery. These principles endure today at WLH, as a nonprofit super specialty institute involve in group practice.

Read More https://www.wlh.ae

This video demonstrate Laparoscopic meckel's diverticulectomy performed by Dr R K Mishra at World Laparoscopy Hospital. Meckel's diverticulum was first described about 400 years ago and continues to be a rare congenital disorder of small intestine. Laparoscopic surgery for Meckel's diverticulum has been described as a safe and effective procedure. We present our this video of patient with symptomatic Meckel's diverticulum. The incidence of Meckel's diverticulum at our institution is 0.3%. The majority of patients were male children. There were no staple-line leaks in any case.

Laparoscopy is useful in both diagnosis and treatment. Laparoscopic resection of Meckel's diverticulum is feasible and ideal, especially when performed in specialized centers.

For more videos https://www.laparoscopyhospital.com/DOWNLOADS.HTM

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World Congress of Laparoscopic Surgeons on 10th and 11th of February 2018

Register for WALS 2018

World Congress of Laparoscopic Surgeons on 10th and 11th of February 2018

India Habitat Center, New Delhi

Unite For 6th International Conference of World Association of Laparoscopic Surgeons. This conference of Minimal Access Surgery will convene hundreds of Surgeons, Gynecologists, Urologists and Pediatric Surgeon from every corner of the world. We look forward to getting to know you as, together, we lead the way in shaping the future of minimally invasive surgery.

This video demonstrate Pediatric Laparoscopic Cholecystectomy and Appendectomy in same patient by Two Port by Dr R K Mishra at World Laparoscopy Hospital. The laparoscopic appendicectomy can be performed using one to several ports. We present our experience of two port laparoscopic cholecystectomy and appendectomy in pediatric patient. The objective was to assess the results retrospectively in terms of complications and its limitations. From our experience, laparoscopic cholecystectomy and appendicectomy using two reusable ports had good visualization, decreased rate of misdiagnosis and a short hospital stay. Contrary to the general belief, the incidence of port site wound infection was minimal.
https://www.laparoscopyhospital.com/

This video demonstrate Bilateral Transabdominal Preperitonial Laparoscopic Inguinal Hernia Surgery Performed by Dr R K Mishra at World Laparoscopy Hospital. Laparoscopic inguinal hernia repair originated in the early 1990s as laparoscopy gained a foothold in general surgery. Inguinal hernias account for 75% of all abdominal wall hernias, and with a lifetime risk of 27% in men and 3% in women. Repair of these hernias is one of the most commonly performed surgical procedures in the world. In the United States, approximately 800,000 inguinal herniorrhaphies are performed annually. https://www.laparoscopyhospital.com

Laparoscopic inguinal hernia repair "IPOM" with Dual-Mesh is an ideal technique for small inguinal hernia. It is easy technique and in our experience has an excellent result. Intraperitoneal Onlay mesh repair is already Worldwide accepted technique foe ventral hernia but its use in direct and indirect inguinal hernia is limited. We have started this surgery first time in 2005. Previously we were performing it with fibrin glue. Bur recently Dr R K Mishra at World Laparoscopy Hospital has started performing IPOM inguinal hernia surgery with the help of tacker and suturing technique.

The IPOM technique focused on the placement of an intra-abdominal piece of a prosthetic biomaterial usually a polypropylene or expanded polytetrafluoroethylene fixed with some type of stapling device which may be tacker or suture; the repair did not involve any dissection of the peritoneum, triangle of DOOM or triangle of PAIN. The advantages of this intraperitoneal onlay mesh repair were the lack of significant dissection of the peritoneal space and the rapid placement of the prosthesis. The recurrence rate, however, was somewhat less than that of the more widely adopted repairs developed later. IPOM technique follow the principle Hydrostatic Pascal law.

The results of this study performed at World Laparoscopy Hospital as well as the meta-analysis of the series presented in the various literature from all over World, indicate that the IPOM (Intra Peritoneal Onlay Mesh) is a feasible, safe and effective procedure in the treatment of recurrent and bilateral hernias.

This an excellent option when a hernia repair is performed by laparoscopic procedures. Surgeon should have good suturing skill. The IPOM has in fact been shown to be faster and easier than the other more commonly performed laparoscopic hernioplasties (TAPP and TEP). It has less chances of faster recovery minimal hospital stay and much earlier return to work.

The preliminary data may also suggest to utilize IPOM laparoscopic inguinal hernia surgery technique in particular cases of inguinal hernia such as very active young males or heavy duty workers. However, the limited series and the short follow-up ask for randomized prospective long term studies to definitely ascertain the true incidence of recurrence and therefore the effectiveness of this attractive procedure.

This surgical video demostrate da Vinci Robotic surgery for severe intra abdominal adhesion in a patient who has undergone multiple laparostomies in the past. She was suffering from severe pain abdomen. The da Vinci Robotic Surgical System speaks to the most recent in surgical and apply autonomy in minimal access surgical advancements. Surgeon has 100% control of the da Vinci System at all circumstances and this is the surgeon who is actually doing the surgery. da Vinci innovation interprets surgeons hand developments into littler, exact developments of modest instruments inside patient body.

In case of severe abdominal adhesion it has great advantage and it can be used as an important tool to perform adhesiolysis. In da Vinci robotic surgery precision of the surgery is better but complication is also possible. Serious complications may occur in any minimal access surgery, including da Vinci robotic Surgery, up to and including death. Individual surgical results and outcome may vary. While doing da Vinci robotic surgery minimal access surgeon should review all available information on non-surgical and surgical options in order to make an informed decision.

Due to small incisions, 3D high definition viseon, less trauma to the body and greater surgeon precision, da Vinci robotic surgery in severe abdominal adhesion provides the following benefits over traditional open procedures including:

Shorter hospital stay
Less blood loss
Less pain
Fewer complications, including less risk of infection
Faster return to normal activities

For minimal access surgeons, da vinci robotic surgery is more precise then conventional laparoscopic surgery due to better visualization of the operative surgical field, correction for tremors in human hand movements and greater maneuverability of instruments because of wrist articulation.

In robotic surgery one arm is a camera, two to go about as the specialist's hands and a fourth arm might be utilized to move hindrances off the surgical path. Patients are encompassed by a total surgical group, while the specialist is situated at a close-by surgeons console. The specialist utilizes a viewfinder which gives a three dimensional picture of the surgical field, and the specialist's hands are set in extraordinary gadgets that direct the instruments. The automated arms sift through any tremors in the surgeon's hands and expands the surgeons's scope of movement. This improved accuracy is particularly useful to the specialist amid particularly sensitive bits of methods during the surgery of severe abdominal adhesion.

With advancement in laparoscopic surgery a number of surgical procedures can be performed combined with laparoscopic cholecystectomy in a single surgery. We evaluate the safety & efficacy of such surgeries. A retrospective review of all patients who had undergone combined procedures with laparoscopic cholecystectomy and hysterectomy. In addition to the benefits of minimal access, patient gets the additional advantage of single hospital stay and single anaesthesia exposure. Thus it is more convenient for the patient and also more cost effective to do cholecystectomy and hysterectomy together if required.
https://www.laparoscopyhospital.com/research/preview.php

https://www.laparoscopyhospital.com/hindi/preview.php
This video demonstrate laparoscopic salpingectomy for right sided ruptured ectopic pregnancy. A ruptured ectopic pregnancy is a medical emergency in which a fertilized egg implants itself outside the uterus where a normal pregnancy gestates. Usually, an ectopic pregnancy is situated in one of the fallopian tubes, and as it grows, it can cause the tube gets to tear or burst.

Laparoscopy is endoscopic visualization of the peritoneal cavity usually assisted by a pneumoperitoneum that distends and separates the abdominal wall from its contents. Visual clarity, space to perform diagnostic and therapeutic procedures and maintenance of a normal physiologic state is required for safe effective surgery. To perform laparoscopic procedures the abdominal cavity is inflated with gas to create the pneumoperitoneum.

Factors that determine the most appropriate gas for pneumoperitoneum are type of anesthesia, physiologic compatibility, toxicity, ease of use, safety, delivery method, cost, and non-combustibility. Gases used for pneumoperitoneum include carbon dioxide (CO2), air, oxygen, nitrous oxide (N2O), argon, helium and mixtures of these gases.

CO2 gas insufflation is preferred by most laparoscopists because it has a high diffusion coefficient and is a normal metabolic end product rapidly cleared from the body. Also, CO2 is highly soluble in blood and tissues and does not support combustion. The risk of gas embolism is lowest with CO2. Cardiac arrhythmias can occur with CO2 pneumoperitoneum. Because of possible CO2 induced hypercarbia, N2O may be preferred in patients with cardiac disease. With prolonged procedures, CO2 retention is possible as evidenced by tachycardia and acidosis.

Pneumoperitoneum is usually initiated by use of a needle or trocar device to transverse the abdominal wall and distend the peritoneal cavity. Another method of access is with an open incision and entering by direct vision through the peritoneum. Caution is required with any method of abdominal entrance or distention. Abdominal penetration complications and incorrect gas placement may result in bleeding or gas dissection within the abdominal wall. Bowel injury, puncture of intra-abdominal vessels, dissection of the fascia or omentum can occur.

After peritoneal access, a gas delivery system is used to inflate and maintain the abdominal distention. Preset pressures of 15 mm Hg or less are safest to maintain pneumoperitoneum and allow performance of laparoscopic techniques. Intra-abdominal pressures in excess of 25 mm Hg are associated with increased airway pressure, increased intrathoracic pressure, increased femoral venous pressure and signs of cardiovascular stimulation with tachycardia and hypertension. Large patients and those who have had multiple abdominal surgeries present a challenge to establish a pneumoperitoneum. Patient selection for laparoscopic procedures and surgical judgment concerning the appropriateness of laparoscopic versus open surgery should be individualized for each circumstance.

Gas delivery systems are composed of a containment cylinder, insufflator (gas throttling down pressure regulating unit), tubing, filter and abdominal entry device or port. The gases used for medical purposes have their production regulated by the Food and Drug Administration. Acceptable limits of contamination are listed in The U.S. Pharmacopoeia. Gas cylinders are made of ferrous alloy that meets Department of Transportation specifications which ensure safe transport. The cylinders contain the gas as a liquid under pressure. Over time, the cylinders build up inorganic and organic contamination. This occurrence requires filtration of the gas prior to insufflation of a patient’s abdomen. The pressure change from the containment cylinder to insufflator and into the patient’s abdomen causes cooling by the Jewel-Thompson effect.
The temperature of carbon dioxide gas is about 20.1° C as it enters the abdomen. The cool gas causes hypothermia if the gas is not pre-conditioned. Gas flow also contributes to hypothermia by convection effects. There is enhanced evaporation from the bowel surface due to gas turbulence from pressurized delivery. Additionally, general anesthesia causes patients to be unable to maintain thermal stability. The net effect is a loss of 0.3 degree C per 60 liters of gas insufflated. In addition, hypothermia may cause decreased gastrointestinal motility and lead to increased potential for ileus.

When the laparoscope is first introduced into the abdominal cavity lens fogging often occurs. This phenomenon is due to the relatively cold dry lens being introduced into a warm moist environment causing the dew point to be reached. This results in condensation forming on the internal lens surface. When the insufflation gas is heated and hydrated or a surface wetting agent is used, no lens fogging occurs and the visual field is clear.

The gases used for pneumoperitoneum have low water content. CO2 has less than 200 parts per million of water. Dry insufflation gases cause drying of the peritoneum and result in intact mesothelial cells being lost or desiccated from the peritoneum surface. To preserve peritoneal surface integrity and decrease the tendency to adhesion formation continuous or intermittent moistening should be performed.

All mechanical systems have inherent weaknesses. Insufflators require proper calibration and maintenance. Insufflator pressure accuracy depends on the quality of the gauges used in the insufflator. Wide ranges of variation are seen due to gauge inaccuracy. Pressure testing should be done regularly to assure proper readings.

Over time, insufflators become contaminated on their internal and external surfaces. Germicidal cleaning of external ports is important. Gas filtration to 0.3 microns prior to abdominal entry assures reduction of quantitative exposure of the peritoneal cavity from these organic and inorganic materials.

Initial abdominal entry pressure readings should be low—less than 2-3 mm Hg. Elevated initial pressures indicate improper placement. Increased intra-abdominal pressures after proper access can impede venous return and result in potential anesthesia complications. Pressure on intra-abdominal surfaces due to the pneumoperitoneum can inhibit bleeding giving a false sense of security regarding hemostasis. Prior to concluding any procedure, surgical sites need to be observed with reduced pressure to assure appropriate hemostasis.

During laparoscopic procedures the abdominal cavity can become contaminated with smoke from the lasers or electrosurgical device used. On a toxicologic basis, tissue combustion within the closed abdomen at laparoscopy is an iatrogenic smoke poisoning incident. Toxic chemicals produced by pyrolysis of human tissue. These chemicals effect peritoneal cells and other cellular components (i.e. activation of macrophages and increased production of tumor necrosis factor). Absorption of these chemicals occurs via the peritoneum. Combustion processes that occur in low oxygen environments cause elevated CO emissions and are common in the laparoscopic situation. Peritoneal absorption of CO causes carboxyhemoglobin formation. Carbon monoxide has 200-240 times greater affinity for hemoglobin than oxygen. The half-life of CO is 5.33 hours in room air. Depending on the amount of smoke produced, anesthetic oxygen concentration and whether smoke evacuation was performed during the procedure, determines the postoperative effects of CO and how much time is required to return to preoperative levels. Carbon monoxide (CO) is known to cause cardiac arrhythmias and can initiate or exacerbate many intra- and postoperative complications. For these reasons smoke within the pneumoperitoneum should be continuously or intermittently evacuated.

Methemoglobinemia may occur during laparoscopic procedures when abdominal tissue combustion occurs. Methemoglobin is the oxidative product of hemoglobin causing the reduced ferrous (Fe2+) to be converted to the ferric (Fe3+) form. The difference between methemoglobin and oxyhemoglobin in the ferric state is that methemoglobin is formed from unoxygenated hemoglobin and is not capable of carrying oxygen or carbon dioxide. This property shifts the oxyhemoglobin dissociation curve to the left, inhibiting oxygen delivery to tissues, and may lead to anoxia. The eventual concentration of smoke and subsequent physiologic changes that occur depend on the amount tissue pyrolized, duration of smoke exposure and effectiveness of smoke evacuation. It must be noted that pulse oximetry does not give a proper evaluation of oxygen saturation in the presence of dyshemoglobinemias (carboxyhemoglobin and methemoglobinemia).
Peritoneal defenses are also effected by irrigation and suction. Irrigation serves to separate tissue surfaces and remove debris and clotted material. However, irrigation also causes dilution washout of resident peritoneal macrophages. Macrophages direct host defense mechanisms that result in recognition, phagocytosis and destruction of foreign substances.

As a result of irrigating the peritoneal cavity with 1 liter of fluid, 60-80% of the original number of macrophages are washed out. It has been shown in the murine model and in patients undergoing peritoneal dialysis that restoration of 90% of the original complement of macrophages requires 72-84 hours. Postoperatively, macrophages are intimately involved in protecting the peritoneum and abdominal cavity from foreign material, bacteria and foreign bodies. They are also involved with the initiation of reperitonealization.

Tissue combustion generates 284 mg of particulates from each gram of tissue pyrolized or 0.3-3.0 x 109 particles per gram of tissue vaporized. These particles range from 0.1-1.0 microns in size clustering between 0.2-0.5 microns. This material is phagocytosed by macrophages, chemically digested, and causes macrophage activation, alteration in chemotaxis and increased cytokine production.

The seemingly inactive invisible pneumoperitoneum is not a static condition and must not be ignored in laparoscopic surgery. The pneumoperitoneum is a dynamic space that affects the patient’s general well being, and specific physiologic cellular processes. The insufflation gas needs to be filtered to reduce contamination, heated to reduce hypothermia and hydrated to preserve cellular integrity and reduce adhesion formation. It is important to recognize the affects of intra-abdominal therapy and the consequences of surgical devices. This includes tissue particles, aerosol production, the by-products of combustion, and their effect on peritoneal tissues locally and the body chemistry and metabolism as a whole.

Conclusion

The pneumoperitoneum creates a complex dynamic set of changing conditions having pathophysiologic consequences during laparoscopy. The effects of unseen tissue touching due to gas flow, cellular stress and inflammation caused by lack of water in the gas combined with increased intra-abdominal pressure can be minimized and corrected. Maintaining intra-abdominal pressure below 12 mmHg, using humidified warmed gas, and adhering to microsurgical principles of tissue handling can be controlled and result in improved clinical outcomes.
https://www.laparoscopyhospital.com/worldlaparoscopyhospital/index.php?id=165&p=&search=

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This video demonstrate Total Laparoscopic Hysterectomy with ligation of Uterine Artery by Dr R K Mishra at World Laparoscopy Hospital. In this surgery for ligation of uterine artery Mishra's knot is used and for the vault closure Weson knot is used. The patient was suffering from severe DUB and surgical removal of the uterus can be lifesaving for those suffering from gynecological cancers or the severe pain and heavy bleeding due to fibroids or endometriosis. Today, there are several surgical approaches that are far less invasive than a total abdominal hysterectomy, which is still widely performed.

The total laparoscopic hysterectomy (TLH) offers women an option that is far less invasive than other surgical approaches. The need for a hysterectomy is an important and difficult decision.

https://www.laparoscopyhospital.com/SERV01.HTM
This video demonstrate Laparoscopic Repair of Recurrent Incisional Hernia by Two Port by Dr R K Mishra at World Laparoscopy Hospital. In 1993, LeBlanc reported the first case of laparoscopic incisional hernia repair with the use of synthetic mesh. The procedure involves the placement of a mesh inside the abdomen without abdominal wall reconstruction. The mesh is fixed with sutures, staples, or tacker.

https://www.laparoscopyhospital.com/
This video demonstrate experimental Ipom Inguinal Hernia Surgery by Suturing - Personnel Technique of Dr R K Mishra. So far we have perform 36 cases of IPOM inguinal hernia surgery with two year followup and the results are encouraging. Any long term randomized control trial is required to see the feasibility of this technique. he IPOM repair has largely fallen from favor, and currently, the most commonly performed laparoscopic techniques are the TEP and TAPP repairs. Although many facets of laparoscopic inguinal hernia repair continue to be debated—such as the possible superiority of one laparoscopic approach to another but IPOM technique we are trying to redefine in our study..

https://www.laparoscopyhospital.com/g...
Laparoscopic myomectomy is an ideal procedure for fibroid uterus and it is safe in the hand of experienced surgeon with good suturing skill. During myomectomy, surgeons take extra steps to avoid excessive bleeding, including blocking flow from the uterine arteries and injecting medications around fibroids to cause blood vessels to clamp down. Nowadays an increasing number of patients with fibroids wish to retain their uterus without improving fertility. Laparoscopic myomectomy can be offered to all women as a safe procedure. Myoma in also called as Rasoli in Hindi language.