Asian venous thromboembolism guidelines: updated recommendations for the prevention of venous thromboembolism

The Asian venous thromboembolism (VTE) prophylaxis guidelines were first published in 2012. Since its first edition, the Asian Venous Thrombosis Forum (AVTF) working group have updated the Asian VTE epidemiology and reviewed issues that were not addressed in the previous guidelines. The authors noted that the rising incidence of VTE across Asia may be attributable to aging population, dietary changes, and increasing incidence of obesity and diabetes. The new additions in the guideline include role of thrombophilia in VTE, bleeding risk in Asians, individual risk assessment, updates in the prevention of VTE in medically ill, bariatric surgery, cancer, orthopedic and trauma patients. The influence of primary thrombophilia in perioperative VTE is still unclear. The secondary risk factors, however, are similar between Asians and Caucasians. The group found no evidence of increased risk of bleeding while using pharmacological agents, including the use of novel anti-coagulants. At present, Caprini risk assessment model is widely used for individual risk assessment. Further validation of this model is needed in Asia. In medically ill patients, pharmacological agents are preferred if there is no bleeding risk. Intermittent pneumatic compression device (IPC) is recommended in patients with bleeding risk but we do not recommend using graduated compressive stockings. In bariatric patients, data on VTE is lacking in Asia. We recommend following current international guidelines. A high index of suspicion should be maintained during postbariatric surgery to detect and promptly treat portomesenteric venous thrombosis. Different cancer types have different thrombotic risks and the types of surgery influence to a large extent the overall VTE risk. Cancer patients should receive further risk assessment. In patients with higher thrombotic risk, either due to predisposing risk or concomitant surgery, low molecular weight heparin is indicated. Different countries appear to have different incidence of VTE following trauma and major orthopedic surgery. We recommend mechanical prophylaxis using IPC as the main method and additional pharmacological prophylaxis if the thrombotic risk is high. As for obstetric practice, we propose adherence to the UK Greentop guideline that is widely accepted and utilized across Asia. To improve VTE thromboprophylaxis implementation in the region, we propose that there should be better health education, establishment of hospital-based guidelines and multidisciplinary collaboration

Primary laparoscopic cholecystectomy in patients with portal cavernoma and non-obstructive portal biliopathy: Two case reports

A laparoscopic cholecystectomy can be technically challenging with co-existing portal hypertension, as commonly seen with cirrhosis of the liver. Extra hepatic portal vein obstruction (EHPVO) although less common, is a significant cause of portal hypertension in India. EHPVO has a unique clinical profile, which differentiates it from portal hypertension associated with cirrhosis of the liver. This impacts therapy in EHPVO algorithmically and operatively. We report two cases of symptomatic gall stones with portal cavernoma. Further evaluation revealed non-obstructive portal biliopathy. Both underwent a successful laparoscopic cholecystectomy. We highlight the importance of careful operative strategy, diligent haemostasis and the feasibility of performing a laparoscopic cholecystectomy in patients with symptomatic gall stones associated with a portal cavernoma

Portomesenteric venous thrombosis after laparoscopic sleeve gastrectomy: A case report and a call for prevention

Postoperative portomesenteric venous thrombosis (PMVT) is being increasingly reported after bariatric surgery. It is variable and often a nonspecific presentation along with its potential for life-threatening and life-altering outcomes makes it imperative that it is prevented, detected early and treated optimally. We report the case of a 50-year-old morbidly obese man undergoing a laparoscopic sleeve gastrectomy who developed symptomatic PMVT two weeks postsurgery, which was successfully treated by anticoagulant therapy. We provide postulates to the etiopathological mechanism for this thrombotic entity. The growing recognition that obesity and bariatric surgery create a procoagulant state regionally and systemically provides impetus for designing the ideal protocol for PMVT prophylaxis, which could be more common than currently believed. We support the early screening for PMVT in the postbariatric surgical patient with unexplainable or intractable abdominal symptoms. The role of routine surveillance and the ideal duration of post-PMVT anticoagulation is yet to be elucidated

Double rolling and center hitch technique for laparoscopic ventral hernia repair

Background: Intraperitoneal onlay mesh repair is an established modality to treat large ventral hernias. Various techniques of laying the mesh are utilized. We present the Double Rolling and Center Hitch technique to lay a large intraperitoneal onlay mesh. Objective: The aim of the study is to devise and adopt a method to reduce the difficulty in manoeuvring a large mesh inside the peritoneal cavity. It should also help in correct placement of mesh and decrease the operative time. Materials and Methods: The DRACH technique was used in eighteen patients with large ventral hernias between May 2010 and September 2011. The Mesh size used was 15x20cm and more (considered to be large mesh). Results: All the procedures were completed successfully. Mesh handling was significantly easier with the DRACH technique. The average mesh deployment time (MDT) was 15mins. In all cases the mesh was adequately centred with a margin of 3-5cm from the defect. Conclusion: The DRACH technique can be employed to lay large intraperitoneal meshes in order to reduce the handling difficulties associated with large meshes, and to aid in better placement of meshes so as to centered over the defect

Single-incision multi-port laparoscopic appendectomy: How I do it

<b>Introduction</b> : Single-incision laparoscopic surgery (SILS) appendectomy seeks to further minimise the trauma of parietal access of laparoscopic appendectomy. <b>Methods:</b> We present our initial experience of 17 cases of SILS appendectomy which were completed using conventional laparoscopic instruments. We utiliesd a single-incision multi-port laparoscopic appendectomy (SIMPLA) technique. <b>Results:</b> The operative time was 63 &#177; 20 min, blood loss 6.5 &#177; 5 mL, bowel movement (passing stool) occurred in 2.6 &#177; 0.6 days. Most patients were discharged on the first operative day on oral diet. The analgesic usage and pain scores were similar to multi-port laparoscopic appendectomy. No complications were noted at follow-up till 4 weeks and the surgical wound healed in all patients with an inconspicuous scar. <b>Conclusion:</b> Our initial experience with SILS appendectomy demonstrates its feasibility and supports the promise of minimising further the access of laparoscopic surgery. The clear advantage is its cosmetic benefit

Single-incision multi-port laparoscopic appendectomy: How I do it

Introduction : Single-incision laparoscopic surgery (SILS) appendectomy seeks to further minimise the trauma of parietal access of laparoscopic appendectomy. Methods: We present our initial experience of 17 cases of SILS appendectomy which were completed using conventional laparoscopic instruments. We utiliesd a single-incision multi-port laparoscopic appendectomy (SIMPLA) technique. Results: The operative time was 63 ± 20 min, blood loss 6.5 ± 5 mL, bowel movement (passing stool) occurred in 2.6 ± 0.6 days. Most patients were discharged on the first operative day on oral diet. The analgesic usage and pain scores were similar to multi-port laparoscopic appendectomy. No complications were noted at follow-up till 4 weeks and the surgical wound healed in all patients with an inconspicuous scar. Conclusion: Our initial experience with SILS appendectomy demonstrates its feasibility and supports the promise of minimising further the access of laparoscopic surgery. The clear advantage is its cosmetic benefit

Review of contemporary role of robotics in bariatric surgery

With the rise in a number of bariatric procedures, surgeons are facing more complex and technically demanding surgical situations. Robotic digital platforms potentially provide a solution to better address these challenges. This review examines the published literature on the outcomes and complications of bariatric surgery using a robotic platform. Use of robotics to perform adjustable gastric banding, sleeve gastrectomy, roux-en-y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch and revisional bariatric procedures (RBP) is assessed. A search on PubMed was performed for the most relevant articles in robotic bariatric surgery. A total of 23 articles was selected and reviewed in this article. The review showed that the use of robotics led to similar or lower complication rate in bariatric surgery when compared with laparoscopy. Two studies found a significantly lower leak rate for robotic gastric bypass when compared to laparoscopic method. The learning curve for RYGB seems to be shorter for robotic technique. Three studies revealed a significantly shorter operative time, while four studies found a longer operative time for robotic technique of gastric bypass. As for the outcomes of RBP, one study found a lower complication rate in robotic arm versus laparoscopic and open arms. Most authors stated that the use of robotics provides superior visualisation, more degrees of freedom and better ergonomics. The application of robotics in bariatric surgery seems to be a safe and feasible option. Use of robotics may provide specific advantages in some situations, and overcome limitations of laparoscopic surgery. Large and well-designed randomised clinical trials with long follow-up are needed to further define the role of digital platforms in bariatric surgery