Inguinal hernia surgery  is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the  inguinal canal  in the groin region.


There are two different clusters of hernia: groin and ventral (abdominal) wall. Groin hernia includes femoral, obturator, and inguinal. [ 1 ]  Inguinal hernia is the most common type of hernia and consist of about 75% of all hernia surgery cases in the US. Inguinal hernia, which results from lower abdominal wall weakness or defect, [ 2 ]  is more common among men with about 90% of total cases. [ 3 ] [ 4 ]  In the inguinal hernia, fatty tissue or a part of the small intestine gets inserted into the inguinal canal. [ 5 ]  Other structures that are uncommon but may get stuck in inguinal hernia can be the appendix, caecum, and transverse colon. [ 6 ]  Hernias can be asymptomatic, incarcerated, or strangled. [ 3 ]  Incarcerated hernia leads to impairment of intestinal flow, and strangled hernia obstructs blood flow in addition to intestinal flow. [ 1 ]


Inguinal hernia can make a small lump in the groin region which can be detected during a physical exam and verified by imaging techniques such as computed tomography (CT). This lump can disappear by lying down and reappear through physical activities, laughing, crying, or forceful bowel movement. Other symptoms can include pain around the groin, an increase in the size of bulge over the time, pain while lifting, and a dull aching sensation. [ 5 ]  In occult (hidden) hernia, the bulge cannot be detected by physical examination and magnetic resonance imaging (MRI) can be more helpful in this situation. [ 7 ]  Males who have asymptomatic inguinal hernia and pregnant women with uncomplicated inguinal hernia can be observed, but the definitive treatment is mostly surgery. [ 8 ]


Surgery remains the ultimate treatment for all types of  hernias  as they will not get better on their own, however not all require immediate repair. [ 9 ] [ 10 ]   Elective surgery  is offered to most patients taking into account their level of pain, discomfort, degree of disruption in normal activity, as well as their overall level of health. [ 9 ]  Emergency surgery is typically reserved for patients with life-threatening complications of inguinal hernias such as incarceration and strangulation. Incarceration occurs when  intra-abdominal fat  or small intestine becomes stuck within the canal and cannot slide back into the abdominal cavity either on its own or with manual maneuvers. Left untreated, incarceration may progress to bowel strangulation as a result of restricted blood supply to the trapped segment of small intestine causing that portion to die. [ 11 ]  Successful outcomes of repair are usually measured via rates of hernia recurrence, pain and subsequent quality of life. [ 12 ]


Surgical repair of inguinal hernias is one of the most commonly performed operations worldwide and the most commonly performed surgery within the United States. A combined 20 million cases of both inguinal and  femoral hernia  repair are performed every year around the world with 800,000 cases in the US as of 2003. The UK reports around 70,000 cases performed every year. [ 13 ]  Groin hernias account for almost 75% of all abdominal wall hernias with the lifetime risk of an inguinal hernia in men and women being 27% and 3% respectively. Men account for nearly 90% of all repairs performed and have a  bimodal incidence  of inguinal hernias peaking at 1 year of age and again in those over the age of 40. Although women account for roughly 70% of femoral hernia repairs, indirect inguinal hernias are still the most common subtype of groin hernia in both males and females. [ 14 ]


Inguinal hernia surgery is also one of the most common surgical procedures, with an estimated incidence of 0.8-2% and increasing up to 20% in preterm children. [ 15 ] [ 16 ]


Surgical intervention for hernias is guided by various factors, including the severity of symptoms, hernia type, medical history, hernia size, bowel incarceration (bowel can no longer return to the abdomen) and the overall general health of the person. [ 12 ] [ 9 ] [ 17 ] [ 18 ]


Elective surgery  is planned in order to help relieve symptoms, respect the person's preference, and prevent future complications that may require emergency surgery. [ 19 ] [ 20 ]


Surgery is offered to the majority of people who:


Symptomatic hernias tend to cause pain or discomfort within the groin region that may increase with exertion and improve with rest. A swollen scrotum within males may coincide with persistent feelings of heaviness or generalized lower abdominal discomfort. The sensation of groin pressure tends to be most prominent at the end of the day as well as after strenuous activities. Changes in sensation may be experienced along the scrotum and inner thigh. [ 21 ]


A hernia in which the small intestine has become incarcerated or strangulated constitutes a surgical emergency. Symptoms include: [ 19 ] [ 11 ] [ 21 ]


Surgical repair within 6 hours of the above symptoms may be able to save the strangulated portion of the intestine. [ 10 ]


Although pediatric inguinal hernias sometimes present asymptomatically, surgical repair is still the standard of care to prevent hernia incarceration, which for children who are born with hernias has a risk of 12% in full-term children and 39% in preterm children. [ 22 ]  In preterm neonates, the timing for intervention appears to be of utter importance as surgical  hernia repair after neonatal intensive care unit (NICU) discharge might decrease recurrence and anesthesia-induced respiratory difficulties compared to surgery before NICU discharge. [ 23 ]


The person with the hernia should be given an opportunity to participate in the  shared decision-making  with their physicians as almost all procedures carry significant risks. The benefits of inguinal hernia repair can become overshadowed by risks such that elective repair is no longer in a person's best interest. Such cases include: [ 21 ] [ 10 ] [ 12 ]


Additionally, certain medical conditions can prevent people from being candidates for laparoscopic approaches to repair. Examples of such include: [ 19 ] [ 10 ] [ 12 ]


Techniques to repair inguinal hernias fall into two broad categories termed "open" and " laparoscopic ". Surgeons tailor their approach by taking into account factors such as their own experience with either techniques, the features of the hernia itself, and the person's anesthetic needs. [ 19 ] [ 21 ]


The cost associated with either approach varies widely across regions, but updated guidelines published by the International Endohernia Society (IES) cast doubt on the comprehensiveness of cost comparison studies due in part to the complexity inherent in calculating costs across institutions. [ citation needed ]  The IES asserts that hospital and societal costs are lower for laparoscopic repairs as compared to open approaches. They recommend the routine use of reusable instruments as well as improving the proficiency of surgeons to help further decrease costs as well as time spent in the OR. [ 24 ]  However, as an example, the  UK 's  National Health Service  spends £56 million a year in repairing inguinal hernias, 96% of which were repaired via the open mesh approach while only 4% were done laparoscopically. [ 13 ]


All techniques involve an approximate 10-cm incision in the groin. Once exposed, the hernia sac is returned to the abdominal cavity  or excised and the abdominal wall is very often reinforced with  mesh . [ 11 ]  There are many techniques that do not utilize mesh and have their own situations where they are preferable. [ 25 ] [ 17 ]


Open repairs are classified via whether prosthetic mesh is utilized or whether the patient's own tissue is used to repair the weakness. Prosthetic repairs enable surgeons to repair a hernia without causing undue tension in the surrounding tissues while reinforcing the abdominal wall. Repairs with undue tension have been shown to increase the likelihood that the hernia will recur. Repairs not using prosthetic mesh are preferable options in patients with an above-average risk of infection such as cases where the bowel has become strangulated (blood supply lost due to constriction). [ 21 ]


One large benefit of this approach lies in its ability to tailor anesthesia to a person's needs. People can be administered  local anesthesia , a  spinal block , as well as  general anesthesia . [ 19 ]  Local anesthesia has been shown to cause less pain after surgery, shorten operating times, shorten recovery times as well as decrease the need to return to the hospital. However, people who undergo general anesthesia tend to be able to go home faster and experience fewer complications. [ 26 ] [ 27 ] [ 10 ]  The European Hernia Society recommends the use of local anesthesia particularly for people with ongoing medical conditions. [ 12 ]


Repairs that utilize mesh are usually the first recommendation for the vast majority of patients including those that undergo laparoscopic repair. [ 12 ]  Procedures that employ mesh are the most commonly performed as they have been able to demonstrate better results compared to non-mesh repairs. [ 21 ]  Approaches utilizing mesh have been able to demonstrate faster return to usual activity, lower rates of persistent pain, shorter hospital stays, and a lower likelihood that the hernia will recur. [ 29 ] [ 12 ] [ 30 ] [ 31 ] [ 32 ] [ 33 ] [ excessive citations ]


Options for mesh include either  synthetic  or  biologic . Synthetic mesh provides the option of using "heavyweight" as well as "lightweight" variations according to the diameter and number of mesh fibers. [ 34 ]  Lightweight mesh has been shown to have fewer complications related to the mesh itself than its heavyweight counterparts. [ 35 ]  It was additionally correlated with lower rates of chronic pain while sharing the same rates of hernia recurrence as compared to heavyweight options. [ 36 ] [ 37 ] [ 38 ]  This has led to the adoption of lightweight mesh for minimizing the chance of chronic pain after surgery. [ 21 ]  Biologic mesh is indicated in cases where the risk of infection is a major concern such as cases in which the bowel has become strangulated. They tend to have lower  tensile strength  than their synthetic counterparts lending them to higher rates of mesh rupture. [ 39 ]


Biomeshes are increasingly popular since their first use in 1999 [ 40 ]  and their subsequent introduction to the market in 2003. Some have a similar price to high end synthetic meshes. They can be produced from absorbable, animal-sourced  extra cellular matrix , or by other means. Synthetic absorbable meshes are also available.


Meshes made of  mosquito net  cloth, in  copolymer  of  polyethylene  and  polypropylene  have been used for low-income patients in rural  India  and  Ghana . [ 41 ]  Each piece costs $0.01, 3700 times cheaper than an equivalent commercial mesh. [ 42 ] [ 43 ]  They give results identical to commercial meshes in terms of infection and recurrence rate at 5 years. [ 42 ]


The Lichtenstein tension-free repair has persisted as one of the most commonly performed procedures in the world. The European Hernia Society recommends that in cases where an open approach is indicated, the Lichtenstein technique be utilized as the preferred method. [ 12 ]  Recent studies have indicated that mesh attachment with the use of  adhesive glue  is faster and less likely to cause post-op pain as compared to attachment via suture material. [ 44 ] [ 45 ] [ 46 ]


The plug and patch tension-free technique has fallen out of favor due to higher rates of mesh shift along with its tendency to irritate surrounding tissue. This has led to the European Hernia Society recommending that the technique not be used in most cases. [ 12 ]


A variety of other tension-free techniques have been developed and include: [ 19 ] [ 21 ]


Techniques in which mesh is not used are referred to as tissue repair technique, suture technique, and tension technique. All involve bringing together the tissue with sutures and are a viable alternative when mesh placement is contraindicated. [ 19 ]  Such situations are most commonly due to concerns of contamination in cases where there are infections of the groin, strangulation or perforation of the bowel. [ 21 ] [ 10 ]


The Shouldice technique is the most effective non-mesh repair thus making it one of the most commonly utilized methods. [ 29 ]  Numerous studies have been able to validate the conclusion that patients have lower rates of hernia recurrence with the Shouldice technique as compared to other non-mesh repair techniques. [ 48 ]  However this method frequently experiences longer procedure times and length of hospital stay. Despite being the superior non-mesh technique, the Shouldice method results much higher rates of hernia recurrence in patients when compared to repairs that utilize mesh. [ 12 ] [ 48 ]


The Bassini technique, described by  Edoardo Bassini  in the 1880s, was the first efficient inguinal hernia repair. [ 49 ] [ 50 ]  In this technique, the  conjoint tendon  (formed by the distal ends of the  transversus abdominis  and  internal oblique  muscles) is approximated to the  inguinal ligament  and closed. [ 51 ]


The Shouldice technique was itself an evolution of prior techniques that had greatly advanced the field of inguinal hernia surgery. Such classic open non-mesh repairs include: [ 21 ] [ 19 ]


There are two main methods of laparoscopic repair:  transabdominal preperitoneal  ( TAPP ) and  totally extra-peritoneal  ( TEP ) repair. When performed by a surgeon experienced in hernia repair,  laparoscopic  repair causes fewer complications than Lichtenstein, particularly less  chronic pain . However, if the surgeon is experienced in general laparoscopic surgery but not in the specific subject of laparoscopic hernia surgery, laparoscopic repair is not advised as it causes more recurrence risk than Lichtenstein while also presenting risks of serious complications, as organ injury. All that said, many surgeons are shifting to using laparoscopic techniques as they require smaller incisions, and result in less bleeding, lower infection rates, faster recovery, shorter hospitalization periods, and reduced chronic pain. [ 65 ] [ 66 ]


Recurrence rates are identical when laparoscopy is performed by an experienced surgeon. [ 66 ]  When performed by a surgeon less experienced in inguinal hernia lap repair, recurrence is larger than after Lichtenstein. [ 68 ]


Robot assisted repair of inguinal hernias has demonstrated safety and efficacy in surgeries repairing inguinal hernias that present on both sides of the pubic bone (bilateral) as well as inguinal hernias that present on one side (unilateral). [ 69 ]  In comparing robot assisted repair of inguinal hernias to traditional laparoscopic techniques, robot assisted surgeries repairing inguinal hernias have longer operating times and can be more costly. However, measures of safety, complication rates, and readmission rates did not significantly differ between robot assisted repair and traditional laparoscopic repair. [ 70 ] [ 71 ]


Studies have demonstrated that men whose hernias cause little to no symptoms can safely continue to delay surgery until a time that is most convenient for patients and their healthcare team. Research shows that the risk of inguinal hernia complications remains under 1% within the population. [ 81 ] [ 20 ] [ 9 ] [ 21 ]  Watchful waiting requires that patients maintain a close follow-up schedule with providers to monitor the course of their hernia for any changes in symptoms and can be safely offered for up to 2 years. [ 82 ] [ 11 ]


Patients who do elect watchful waiting eventually undergo repair within five years as 25% will experience a progression of symptoms such as worsening of pain. Elective repair discussions should be revisited if patients begin to avoid aspects of their normal routine due to their hernia. [ 12 ] [ 83 ] [ 10 ]  After 1 year it is estimated that 16% of patients who initially opted for watchful waiting will eventually undergo surgery. Furthermore, 54% and 72% will undergo repair at 5-year and 7.5-year marks respectively. [ 84 ] [ 17 ]


The use of a  truss  is an additional non-surgical option for men. It resembles a jock-strap that utilizes a pad to exert pressure at the site of the hernia in order prevent excursion of the hernia sack. It has little evidence to support its routine use and has not been shown to prevent complications such as incarceration (bowel can no longer slide back into abdomen) or strangulation of bowel (constriction causing loss of blood supply). However some patients do report a soothing of symptoms when utilized. [ citation needed ]


Inguinal hernia repair complications are unusual, and the procedure as a whole proves to be relatively safe for the majority of patients. Risks inherent in almost all surgical procedures include: [ 9 ]


Risks that are specific to inguinal hernia repairs include such things as: [ 9 ] [ 17 ] [ 21 ]


Post-herniorrhaphy inguinodynia  is a condition where 10-12% of patients experience severe pain after inguinal hernia repair, due to a complex combination of different  forms of pain signals . [ 87 ] [ 88 ] [ 12 ]  It can occur with any inguinal hernia repair technique, and if unresponsive to pain medications, further surgical intervention is often required. [ 89 ]  Removal of the implanted mesh, in combination with  bisection of regional nerves , is commonly performed to address such cases. [ 90 ] [ 91 ] [ 92 ]  There remains ongoing discussion amongst surgeons regarding the utility of planned resections of regional nerves as an attempt to prevent its occurrence. [ 92 ] [ 93 ]


Mortality rates for non-urgent, elective procedures was demonstrated as 0.1%, and around 3% for procedures performed urgently. [ 94 ] [ 10 ]  Other than urgent repair, risk factors that were also associated with increased mortality included being female, requiring a femoral hernia repair, and older age. [ 95 ] [ 96 ] [ 97 ]


Upon awakening from anesthesia, patients are monitored for their ability to drink fluids, produce urine, as well as their ability to walk after surgery. Most patients are then able to return home once those conditions are met. [ 17 ]  It is not uncommon for patients to experience residual soreness for a couple of days after surgery. [ 98 ] [ 25 ]  Patients are encouraged to make strong efforts in getting up and walking around the day after surgery. [ 12 ]  Most patients can resume their normal routine of daily living within the week such as driving, showering, light lifting, as well as sexual activity. [ 9 ]  Long work absences are rarely necessary and length of sick days tend to be dictated by respective employment policies. [ 12 ] [ 10 ]


In general, it is not recommended to administer antibiotics as prophylaxis after elective inguinal hernia repair. However, the rate of wound infection determines the appropriate use of the antibiotics. [ 99 ]


Post-op development of any of the following should warrant timely reporting via phone: [ 25 ] [ 17 ]


Most indirect inguinal hernias in the abdominal wall are not preventable. Direct inguinal hernias may be prevented by maintaining a healthy weight, refraining from smoking, preventing straining during bowel movements, and maintaining proper lifting techniques when heavy lifting. [ 17 ] [ 9 ]  There is no evidence that indicates physicians should routinely  screen  for asymptomatic inguinal hernias during patient visits. [ 100 ]


Intestine transplantation  ( intestinal transplantation,  or  small bowel transplantation ) is the  surgical   replacement  of the  small intestine  for  chronic  and  acute  cases of intestinal  failure . While intestinal failure can oftentimes be treated with alternative therapies such as  parenteral nutrition  (PN), complications such as PN-associated  liver disease  and  short bowel syndrome  may make transplantation the only viable option. One of the rarest type of  organ  transplantation performed, intestine transplantation is becoming increasingly prevalent as a therapeutic option due to improvements in  immunosuppressive regimens , surgical technique, PN, and the clinical management of pre and post-transplant patients. [ citation needed ]


Intestine transplantation dates back to 1959, when a team of surgeons at the  University of Minnesota  led by Richard C. Lillehei reported successful transplantation of the small intestine in dogs. Five years later in 1964, Ralph Deterling in  Boston  attempted the first human intestinal transplant, albeit unsuccessfully. For the next two decades, attempts at transplanting the small intestine in humans were met with universal failure, and patients died of technical complications,  sepsis , or  graft rejection . However, the discovery of the immunosuppressant  ciclosporin  in 1972 triggered a revolution in the field of transplant medicine. Due to this discovery, in 1988, the first successful intestinal transplant was performed in Germany by E. Deltz, followed shortly by teams in France and Canada. Intestinal transplantation was no longer an experimental procedure, but rather a life-saving therapy. In 1990, a newer immunosuppressant drug,  tacrolimus , appeared on the market as a superior alternative to ciclosporin. In the two decades since, intestine transplant efforts have improved tremendously in both number and outcomes. [ 1 ] [ 2 ]


Failure of the small intestine is life-threatening due to the inability to absorb  nutrients ,  fluids , and  electrolytes  from food. Without these essential substances and the ability to maintain  energy balances ,  homeostasis  cannot be maintained and one's  prognosis  will be dismal. Causes of intestinal failure may be clinically complex, and may result from a combination of nutritional,  infectious ,  traumatic , and  metabolic  complications that affect ordinary  anatomy  and  physiology . [ 3 ]  Many underlying conditions that serve as precursors to failure are genetic or congenital in nature. For example, severe  inflammation ,  ulceration ,  bowel obstruction ,  fistulation ,  perforation , or other pathologies of  Crohn's disease  may severely compromise intestinal function. [ 4 ]  Despite the danger these conditions may pose in themselves, they may lead to even further, more serious complications that necessitate replacement of the diseased intestine. The single leading cause for an intestinal transplant is affliction with  short bowel syndrome , oftentimes a secondary condition of some other form of intestinal disease. [ 5 ] [ 6 ]  Short-bowel syndrome was the cause for 73% of American intestinal transplantations in 2008, followed by functional bowel problems for 15% and other causes representing 12% of cases. [ 7 ]  Natural SBS is mercifully rare, estimated to be 3 per 100,000 births. [ 8 ]  Surgical removal is the most common cause, performed as a treatment for various  gastroenterological  and  congenital  conditions such as Crohn's disease,  necrotizing enterocolitis ,  mesenteric ischemia ,  motility disorder ,  omphalocele / gastroschisis ,  tumors , and  volvulus . [ 9 ]


Regardless of the underlying condition, the loss of intestinal function does not necessarily necessitate a transplant. Several conditions, such as necrotizing enterocolitis or volvulus, may be adequately resolved by other surgical and nonsurgical treatments, especially if SBS never develops. An individual can obtain nutrients intravenously through PN, bypassing food consumption entirely and its subsequent  digestion . Long-term survival with SBS and without PN is possible with  enteral nutrition , but this is inadequate for many patients as it depends on the remaining intestine's ability to adapt and increase its absorptive capacity. [ 3 ]  Although more complicated and expensive to perform, any person may receive PN. Although PN can meet all energy, fluid, and nutrient needs and can be performed at home,  quality of life  can be significantly decreased. On average, PN takes 10 to 16 hours to administer but can take up to 24. Over this time frame, daily life can be significantly hindered as a consequence of attachment to the  IV pump . [ 5 ] [ 10 ]  Over long periods of time, PN can lead to numerous health conditions, including severe  dehydration ,  catheter -related infections, and liver disease. [ 2 ] [ 11 ]  PN-associated liver disease strikes up to 50% of patients within 5–7 years, correlated with a mortality rate of 2–50%. [ 11 ]


Another alternative treatment to transplant for patients with SBS is surgical bowel lengthening via either  serial transverse enteroplasty  (STEP) or the older  longitudinal intestinal lengthening and tailoring  (LILT) technique. Although both procedures contribute to an approximate 70% increase in length, STEP appears somewhat more favorable in terms of lower mortality and progression to transplant. [ 12 ]  Nevertheless, a positive reception to either procedure may reduce the level of PN required, if not negate its required use altogether. [ 8 ] [ 13 ]


There are four  Medicare  and  Medicaid -approved  indications  for intestine transplantation: a loss of two of the six major routes of  venous access , multiple episodes of  catheter -associated life-threatening sepsis, fluid and electrolyte abnormalities in the face of maximal medical therapy, and PN-associated liver disease. Transplants may also be performed if the growth and development of a  pediatric  patient fails to ensue, or in extreme circumstances for patients with an exceptionally low quality of life on PN. [ 14 ] [ 15 ]  A multidisciplinary team consisting of  transplant surgeons ,  gastroenterologists ,  dieticians ,  anesthesiologists ,  psychiatrists , financial representatives, and other  specialists  should be consulted to evaluate the treatment plan and ensure transplantation is the patient's best option.  Psychological  preparations should be made for the transplant team and patient as well. Early referral requires trust between all parties involved in the operation to ensure that a rush to judgment does not lead to a premature transplant. [ 11 ] [ 16 ]


Other  absolute contraindications  to receiving an intestinal transplant include the presence of  systemic  and untreated local infections, malignant cancer, severe  neurological impairment , and severe  cardiac  and/or  pulmonary disease .  These criteria are similar to established guidelines for transplants of other organ types. [ 17 ]  HIV infection is a  relative contraindication  for intestine transplantation; desperate terminal patients may accept a transplant from a HIV-positive donor if they are willing to expose themselves to HIV. [ 14 ]


There are three major types of intestine transplants: an isolated intestinal  graft , a combined intestinal-liver graft, and a  multivisceral graft  in which other  abdominal  organs may be transplanted as well. In the most basic and common graft, an isolated intestinal graft, only sections of the  jejunum  and  ileum  are transplanted. [ 18 ]  These are performed in the absence of liver failure. In the event of severe liver dysfunction due to PN,  enzyme  deficiencies, or other underlying factors, the liver may be transplanted along with the intestine. In a multivisceral graft, the  stomach ,  duodenum ,  pancreas , and/or  colon  may be included in the graft. Multivisceral grafts are considered when the underlying condition significantly compromises other sections of the digestive system, such as intra-abdominal tumors that have not yet  metastasized , extensive venous  thrombosis  or  arterial   ischemia  of the  mesentery , and motility syndromes. [ 11 ] [ 17 ]


Donated  intestines, like all organs, should be matched to a recipient prior to recovery, as to prepare him or her and minimize the time the organ spends outside the  body . [ 5 ]  Potential recipients are placed on the  International Intestinal Transplant Registry  (ITR), where they contribute to the world's growing understanding of intestine transplantation. Before a transplant may be performed, an organ must first be located. In the United States, the matching of all organs is coordinated by the  United Network for Organ Sharing  (UNOS). The standard intestinal donor is deceased with a diagnosis of  brain death . [ 19 ]  In terms of transplant outcomes, brain-dead donors are highly preferable to donors who have suffered  cardiopulmonary death . If respiration can be assisted by a  ventilator , brain-dead donors may exhibit maintainable  cardiac ,  endocrine , and  excretory  function. If appropriately managed, the continuation of  blood flow  and bodily metabolism allows for healthier organs for procurement and additional time to prepare recipients for transplant. [ 20 ]  Furthermore, terminal ileum recovery from living donors is possible., [ 21 ]  and a  laparoscopic technique  is being developed to harvest limited sections of small bowel from living donors. [ 22 ]  When determining potential donor-recipient matches, important characteristics include donor size, age,  tissue  quality, and  ABO  and  histo-compatibility . [ 11 ] [ 21 ]  If the intestine is too large, it may be not transplantable into young or small patients. Ideally, intestines should be selected from donors of lighter weight than the proposed recipients to ensure simple closure of the abdominal wound. [ 23 ]  If a patient is too young or too old, they may not be hardy enough to survive the operation and recovery period. [ 11 ]  If the donor and recipient organs do not meet compatibility requirements, the threat of  organ rejection  by the body is all but certain.


Organ rejection is the unfortunate circumstance of the host  immune system  recognizing the transplanted organ as foreign. This is the most notable complication facing transplant recipients. Through  T-cell receptors ,  T-lymphocytes  are able to distinguish between self and non-self by recognizing  human leukocyte antigens  (HLA) bound to the  major histocompatibility complex  (MHC)  protein  located on the surface of organ  cells . Once identified as foreign, the immune system proceeds to destroy the transplanted tissue. The  panel-reactive antibody  (PRA) test measures the proportion of the population to which a recipient will react via pre-existing  antibodies  to various HLA  antigens ; in other words, how likely a patient is to acutely reject their new transplant. Therefore, it is essential that HLA and PRA statuses are tested for and demonstrate low immunoreactivity of the patient to the graft. [ 2 ] [ 21 ] [ 24 ]  In some cases, a recipient may suffer from  graft-versus-host disease , in which cells of the transplanted organ attack the recipient's cells. [ 25 ]


To ensure proper histocompatibility, tissue quality, and safety from infection,  blood work  should be collected and tested in the laboratory. In addition to HLA and PRA typing, the  complete blood count  (CBC),  coagulation  profile,  complete metabolic panel , and  ABO blood group  determination tests should be performed for both the donor and recipient. [ 2 ]  ABO-incompatible grafts can sometimes be performed on very young pediatric patients, as their immune systems have not fully developed and for whom waiting list mortality remains high. [ 14 ]  Additionally, blood  serum  should be  tested  for the presence of  viruses , including HIV,  hepatitis B  and  C ,  cytomegalovirus  (CMV), and  Epstein–Barr virus  (EBV) antibodies to prevent infection. [ 24 ]  Particularly in the immunocompromised system necessitated by the transplant, these viruses can wreak havoc on the body and become extremely dangerous, even fatal. Even with healthy physiological levels, ABO and HLA compatibilities, and no signs of bacterial, viral, and  fungal  infections, organ transplantation is not without extrasurgical risk. [ 2 ]


A major challenge facing the intestinal transplant enterprise is meeting the need for transplantable intestines, particularly in the United States where the majority of intestinal transplants take place. [ 9 ]  There exists a narrow timeslot between procurement and transplantation that any organ remains viable, and logistical challenges are faced regarding bringing organ and recipient together. During procurement, organs that are being recovered are cooled and  perfused  with preservation solution. This slows organ activity and increases the time they remain viable for transplant. [ 2 ]  Although chilling and perfusion may extend intestinal lifespans by several hours, failure is still imminent unless transplanted. This duration between the cooling of the organ during procurement and the restoration of physiological temperature during implantation is the  cold ischemic time . Due to the sensitivity of the intestine to ischemic injury, many potential donor intestines are lost to the events following brain death and trauma. Furthermore, irreversible intestinal damage is seen after approximately only 5 hours of cold ischemia in the form of  mucosal  damage and bacterial translocation outside the  gastrointestinal tract . Therefore, ensuring cardiac survival and nearby donor-recipient proximity before procurement are essential so organs do not wait too long outside the body and without blood flow. [ 11 ]  Not only is there a lack of transplantable intestines, but a deficiency in the number of centers possessing the capability to carry out the complicated transplant procedure as well. As of 2005 [update] , there were only 61 medical centers in the world capable of executing an intestinal transplant. [ 9 ]  Furthermore, many young, small children, particularly those weighing less than 5  kg , cannot find a transplant due to the lack of size-matched donors. [ 8 ]


Despite these challenges, obtaining an intestine for transplant is rather probable in the United States. In 2008, there were 212 people on the U.S. intestinal transplant waitlist, 94% of whom were U.S. citizens. [ 7 ]  Regardless of transplant type, over half of new registrants are 5 years of age or younger.  Adults  compromise the next largest cohort, followed by pediatric patients aged 6 and older. In 2008, the  ethnic  composition of the intestinal transplant waitlist was 65%  White , 18%  Black , 16%  Hispanic , 1%  Asian , and 0.5% other or  mixed race , resembling the  demographics  of the American general population at the time aside from a below-average Asian cohort. ABO blood types also matched the general population, with 31% A, 14% B, 5% AB, and 50% O. [ 7 ]  In 2004, the average waiting period to receive a transplant was 220 days, [ 21 ]  with a  median  of 142 days in 2008. [ 7 ]  The rate of waitlist additions has shifted from year to year; gains increased until 2006 (with 317 added), but then decreased in 2012 (to 124 added). [ 26 ]  In 2007, only 9% of patients on the U.S. waitlist died while waiting for a transplant. [ 7 ]  Waitlist mortality peaked around 2002 and was highest for liver-intestine (pediatric) patients. Deaths among all pediatric groups awaiting intestine-liver transplants have decreased in the years leading up to 2014 whereas adult intestine-liver deaths have dropped less dramatically. The decrease in recent years is likely due to improved care of infants with intestinal failure and subsequently a decrease in referrals for transplant. [ 26 ]  Although many improvements have been made in the States, outcomes everywhere still demonstrate much room for improvement. Worldwide, 25% of pediatric patients on the waitlist for an intestinal transplant die before they can receive one. [ 8 ]


Following matching of the organ, the complicated procurement of the small bowel can be performed by a team of abdominal transplant surgeons. Once a donor has been selected and approved for donation, several pretreatments may be initiated to destroy  microorganisms  and  immune cells . The donor intestine must be  decontaminated  with several  antibiotics , including  neomycin ,  erythromycin ,  amphotericin B , and  cephalosporin . [ 18 ]  They may also be treated with anti- lymphocyte  antibodies ( anti-thymocyte globulin ,  alemtuzumab ),  irradiation  directed against excessive mesenteric  lymphatic tissue , and have their bowel  irrigated . [ 17 ]


Once donor preparation is accomplished, procurement can begin by utilizing the same standard techniques for all abdominal organ procurements. The team exposes the abdominal cavity and inserts two  cannulae  for the  infusion  of  University of Wisconsin   organ preservation solution  into the  aorta  and  inferior mesenteric vein . As the abdominal organs are cooled  in situ , the surrounding tissue is  dissected  so that they may be quickly extracted. In the next step, the aorta is  cross-clamped , cutting off blood supply to the organs. Once blood and oxygen supply to an organ is cut off, organ death will approach swiftly unless steps are taken to preserve them until transplant. Organs are therefore fully  drained of blood , flushed with cool preservation solution, and removed from the body. [ 2 ] [ 18 ]  In an isolated intestinal transplant, the  colon will be detached  from the small intestine. The  cecum  and  ascending colon  are devascularized, while care is taken to preserve major  vasculature  in the ileum. The jejunum will be separated from the duodenum while preserving the vasculature of the jejunum, ileum, mesentery, and the pancreas. If healthy, the pancreas can oftentimes be retrieved as an additional isolated procurement. The intestinal allograft, when ready to be extracted, is attached by the mesenteric  pedicle , where the vessels converge out of the intestinal system. This pedicle will be  stapled  closed, and can be separated from the body via a  transverse  cut to create a vascular cuff. The complete intestinal allograft can then be removed and wrapped in a surgical  towel . [ 18 ]  The protocols for combined liver and multivisceral procurements are far more complicated and meticulous than isolated intestine alone. [ citation needed ]


First, any abdominal  scar tissue  from previous surgeries must be removed. The aorta and  vena cava  are dissected in preparation for vascular  anastomosis , followed by dissection of the  proximal  and  distal  ends of the digestive tract. Anastomosis is then performed to revascularize the graft. Arterial vessels are connected to the abdominal aorta, below the  kidneys . However, venous drainage, or the reattachment of the transplanted organ to the venous system, may be performed differently depending on the unique intra-abdominal vasculature of the recipient. The graft is usually drained systemically into the  infrarenal  vena cava, [ 15 ]  but may also be drained  portally  into the  hepatic portal  or  superior mesenteric vein . [ 17 ]  The graft is then reperfused with blood and any bleeding is stopped before the proximal and distal ends of the transplant bowel are connected to the original digestive tract. A loop  ileostomy  is then created as to provide easy access for future  endoscopic  observation and  biopsies . A  gastronomy  or  jejunostomy   feeding tube  may be placed before the abdominal wall is closed. [ 2 ]


When a liver is being transplanted in conjunction with the intestine, the recipient must first have their own  liver removed . Following this, the aorta, cava, and portal veins of the donor and recipient are anastomosed. The graft is then flushed before the caval  clamps  are removed. The intestine is then reconstructed as in an isolated intestinal transplant, before being connected to the  bile duct  servicing the new liver. [ 17 ]   Multivisceral transplants  are especially difficult and susceptible to complications because all organs must survive a conjoined procurement, transport, and transplantation. All three of these measures are tailored to the individual needs of the recipient. [ 18 ]  Preservation of the native  spleen , pancreas, and duodenum during a multivisceral transplant can reduce the risk of additional complications related to these structures. [ 11 ]


Following the procedure, the patient is actively monitored in an  intensive care unit  (ICU).  Broad-spectrum antibiotics  are administered, bleeding monitored, and serum  pH  and  lactate  levels measured for evidence of intestinal ischemia. The patient's immune system is strongly modulated immediately post-operation. The  initial phase of treatment  consists of the administration of tacrolimus with  corticosteroids  to suppress T-lymphocyte activation. Next, various assortments of  interleukin-2  (IL-2)  receptor   antagonists  ( daclizumab ,  basiliximab ), anti-proliferation agents ( azathioprine ,  mycophenolate mofetil ), and the drugs  cyclophosphamide  and  sirolimus  are administered on an individual patient basis to further suppress the immune system. [ 11 ]  The  bioavailability  of these drugs is dependent on intestinal  surface area  and transit time, and therefore the length of the allograft determines the immunosuppression regimen. [ 2 ]  Intravenous administration of  prostaglandin E1  is occasionally performed for the first 5 to 10 days following transplant to improve intestinal circulation and a potential dispensing of immunosuppressive effects. [ 2 ] [ 11 ]  The gut is selectively decontaminated against high-risk  flora  and  preventative care  is taken against CMV and fungal infections. [ 11 ]


It is ideal to commence enteral nutrition as early as possible following transplantation. Therefore, a feeding tube connecting to the stomach or jejunum is quickly placed to facilitate rehabilitation. [ 11 ]  If gastrointestinal function is restored, a diet can be reestablished and cautiously advanced as tolerated. Most patients are weaned from PN within 4 weeks of transplantation, and nearly all are free from additional enteral supplementation by one year. [ 14 ]  Evidence for the restoration of function includes decreasing gastrostomy tube returns and increasing  gas  and enteric contents in the ileostomy. [ 2 ]  Routine surveillance endoscopy and biopsies via the ileostomy should be performed with decreasing frequency over several months to observe signs of rejection, ideally before clinical symptoms present themselves. Should the patient continue to perform well through the first post-transplant year, the ileostomy would generally be closed. Should rejection be suspected in the future, endoscopies would be performed and an appropriate antirejection therapy will be tailored. The median time for hospital  discharge  varies between procedures. The median times for isolated intestine, intestine-liver, and multivisceral transplants are 30, 60, and 40 days post-operation respectively. [ 14 ]  Within the first several months,  carbohydrate  and  amino acid  absorptive capacity should normalize, followed by the absorptive capacity for fats. Once enteral nutrition is capable of providing all nutritional needs, PN can be discontinued. [ 2 ]  Nearly all patients with a successful transplant are free of PN within one year. [ 14 ]


Intestinal transplantation is the least performed type of transplant due to a number of unique obstacles. The most major of these is the profound immunosuppression required due to the ability of the intestine to elicit strong immune responses. Because of exposure to a wide range of gut flora and material consumed by the body, the intestinal  epithelium  possesses a highly developed  innate immune system  and  antigen-presenting  abilities. Immunosuppression is the primary determinant of outcome in small bowel transplantation; the risk for graft rejection is increased by under-immunosuppression and for local and systemic infection with over-immunosuppression. [ 11 ]  Ensuring an appropriate dose of immunosuppressant can therefore be difficult, especially as both ciclosporin (14–36%) and tacrolimus (8.5–22%) have generally low bioavailabilities. [ 27 ]  A major problem due to immunosuppression in intestinal transplant patients is post-transplant  lymphoproliferative disorder , in which B-lymphocytes excessively proliferate due to infection by EBV and result in infectious  mononucleosis -like lesions. [ 7 ]  Intestinal transplant recipients are also at risk for chronic  renal failure  because  calcineurin  inhibitors are  toxic  to the kidneys. A transplant recipient must remain on immunosuppressants for the rest of his or her life. [ 14 ]


Intestinal transplants are highly susceptible to infection even more so than the standard immunocompromised recipient of other organs due to the great composition and variety of the gut flora. [ 11 ]  A complex assortment of microorganisms inhabits the human digestive tract, with concentrations of up to 10 4 –10 7   CFU /mL in the jejunoileum and 10 11 –10 12  CFU/mL in the colon. [ 28 ]  While suppression of the immune system may prevent immune attack on the new allograft, it may also prevent the immune system's ability to keep certain gut microbial populations in line. Despite pre and post-decontamination of the transplant, recipients are at risk of local and systemic infection by both natural and external flora. The common symptom of graft dysfunction, whether due to infection, rejection, or some other condition, is  diarrhea . [ 15 ]


Intestinal transplant outcomes have improved significantly in recent years. Despite mild incongruities in survival rate percentages between centers in North America, Europe, Australia, and elsewhere, intestinal transplantations mostly approach survivorship rates of  lung transplantation . [ 11 ]  At one-year, graft survival rates for isolated intestine currently waver around 80%, and 70% for intestine-liver and multivisceral. Over the same time period, patient survival for isolated intestine patients may even exceed 90%, while the more complicated multiorgan transplants do not show any increase in patient survival when compared to patients surviving with the intestinal graft alone. [ 14 ]  The five-year survival rate for patients and transplants ranges from 50 to 80% (overall mean 60%), depending on underlying disease and presurgical  morbidity . Very young (<1 year) and very old (>60 years) patients receiving a transplant have pronounced rates of mortality. [ 14 ] [ 15 ]  After 4 years, pediatric survival significantly worsens compared to adults. [ 14 ]


Several factors relating to superior patient and graft prognosis have proven to be statistically significant. Patients who have been admitted for transplant directly from home rather than the hospital, younger patients over one year of age, those receiving their first transplant, those receiving transplants at experienced transplant centers, and who receive antibody or sirolimus-based induction therapies have increased rates of survival. [ 9 ] [ 15 ]  Furthermore, underlying  etiology , [ 29 ]  the presence of  comorbidity , the frequency of previous surgery, nutritional status, and the level of liver function have been found to affect patient-graft survival . [ 30 ]  Patients with a pre-transplant diagnosis of volvulus were found to possess a lower risk of mortality. [ 29 ]  As of 2008, the longest recorded surviving transplant survived for 18 years. [ 14 ]  Between 1999 and 2008, 131 retransplant procedures were performed in the United States. [ 7 ]


The improvement to quality of life following an intestinal transplantation is significant. Of living patients 6 months after transplant, 70% are considered to have regained full intestinal function, 15% are at partial function, and 15% have had their grafts removed. [ 9 ] [ 14 ]  For those with full function, enteral nutritional  autonomy  is high. [ 7 ]  The ability to resume regular activities such as the ability to consume food and exert control over digestive function is certainly a welcome return for patients. The low quality of life induced by intestinal failure is oftentimes further supplemented by significant  psychosocial   disability  and  narcotic   dependence . Following transplantation, these have been found to generally decrease. [ 15 ]  According to surveys comparing patients who have undergone transplants and those that have not, there seems to be a remarkable improvement for transplant recipients in such areas as  anxiety , depression,  appearance ,  stress ,  parenting ,  impulsiveness ,  optimism ,  medical compliance , and the quality of  relationships . [ 14 ] [ 15 ] [ 31 ]


Receiving an organ transplant of any kind is a highly significant investment financially, but a successful, well-functioning transplant can be very  cost-efficient  relative to alternate therapies. Total charges to maintain PN at home can reach upwards of $150,000 a year, even though the actual cost of nutrition is typically only $18 to $22 a day. [ 5 ] [ 14 ]  This excludes the cost for additional home support, equipment, and the care of PN-related complications. The cost involved in undergoing intestinal transplantation, including the initial hospitalization for the transplant, can range from $150,000 to $400,000, and reoccurring hospitalizations are common up through the second year. Two to three years post-transplant, the financial cost of transplantation reaches parity with PN and is more cost-effective thereafter. [ 11 ] [ 14 ]


Jejunojejunostomy  is a surgical technique used in an  anastomosis  between two portions of the  jejunum . [ 1 ]  It is a type of  bypass  occurring in the  intestine . It may lead to marked reduction in the functional volume of the intestine. This technique is also performed using  Laparoscopic  surgery. [ 2 ]  The surgical procedure can lead to complications including  infections ,  hemorrhage ,  strictures ,  ulcers ,  intestinal obstruction ,  thromboembolism  and  malnutrition . [ 3 ] [ 4 ] [ 5 ]


Jejunostomy  is the surgical creation of an opening (stoma) through the skin at the front of the abdomen and the wall of the  jejunum  (part of the  small intestine ). It can be performed either  endoscopically , or with  open surgery . [ 1 ]


A jejunostomy may be formed following  bowel resection  in cases where there is a need to bypass the distal small bowel and/or colon due to a bowel leak or perforation. Depending on the length of jejunum resected or bypassed the patient may have resultant  short bowel syndrome  and require  parenteral nutrition . [ 2 ]


A jejunostomy is different from a jejunal  feeding tube . A jejunal feeding tube is an alternative to a  gastrostomy   feeding tube  and is commonly used when gastric enteral feeding is contraindicated or carries significant risks.  The advantage over a gastrostomy is its low risk of  aspiration  due to its distal placement. Disadvantages include  small bowel  obstruction,  ischemia , and requirement for continuous feeding. [ 3 ]


The  Witzel jejunostomy  is the most common method of jejunostomy creation. [ 4 ]   It is an open technique where the jejunosotomy is sited 30 cm distal to the  Ligament of Treitz  on the antimesenteric border, with the catheter tunneled in a seromuscular groove. [ citation needed ]


Laparoscopy  (from  Ancient Greek     λαπάρα  ( lapára )  'flank, side' and    σκοπέω  ( skopéō )  'to see') is an operation performed in the  abdomen  or  pelvis  using small  incisions  (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids  diagnosis  or therapeutic interventions with a few small cuts in the abdomen. [ 1 ]


Laparoscopic surgery, also called  minimally invasive procedure , bandaid surgery, or keyhole surgery, is a modern  surgical  technique. There are a number of advantages to the patient with laparoscopic surgery versus an  exploratory laparotomy . These include reduced pain due to smaller incisions, reduced  hemorrhaging , and shorter recovery time. The key element is the use of a  laparoscope , a long fiber optic cable system that allows viewing of the affected area by snaking the cable from a more distant, but more easily accessible location.


Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Specific surgical instruments used in laparoscopic surgery include  obstetrical forceps , scissors, probes, dissectors, hooks, and retractors. Laparoscopic and thoracoscopic surgery belong to the broader field of  endoscopy . The first laparoscopic procedure was performed by German surgeon  Georg Kelling  in 1901.


There are two types of laparoscope: [ 2 ]


The mechanism mentioned in the second type is mainly used to improve the image quality of flexible endoscopes, replacing conventional  fiberscopes . Nevertheless, laparoscopes are rigid endoscopes. Rigidity is required in clinical practice. The rod-lens-based laparoscopes dominate overwhelmingly in practice, due to their fine optical resolution (50 μm typically, dependent on the aperture size used in the objective lens), and the image quality can be better than that of the digital camera if necessary. The second type of laparoscope is very rare in the laparoscope market and in hospitals. [ citation needed ]


Also attached is a  fiber optic  cable system connected to a "cold" light source ( halogen  or  xenon ) to illuminate the operative field, which is inserted through a 5 mm or 10 mm  cannula  or  trocar . The  abdomen  is usually  insufflated  with  carbon dioxide  gas. This elevates the abdominal wall above the internal organs to create a working and viewing space. CO 2  is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures. [ 3 ]


During the laparoscopic procedure, the position of the patient is either in  Trendelenburg position  or in reverse Trendelenburg. These positions have an effect on cardiopulmonary function. In Trendelenburg's position, there is an increased  preload  due to an increase in the venous return from lower extremities. This position results in cephalic shifting of the viscera, which accentuates the pressure on the diaphragm. In the case of reverse Trendelenburg position, pulmonary function tends to improve as there is a caudal shifting of viscera, which improves tidal volume by a decrease in the pressure on the diaphragm. This position also decreases the preload on the heart and causes a decrease in the venous return leading to hypotension. The pooling of blood in the lower extremities increases the stasis and predisposes the patient to develop deep vein thrombosis (DVT). [ 4 ]


Rather than a minimum 20 cm incision as in traditional (open)  cholecystectomy , four incisions of 0.5–1.0 cm, or, beginning in the second decade of the 21st century, a single incision of 1.5–2.0 cm, [ 5 ]  will be sufficient to perform a laparoscopic removal of a  gallbladder .
Since the gallbladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1 cm incision at the patient's navel.
The length of postoperative stay in the hospital is minimal,
and most patients can be safely discharged from the hospital the same day. [ 6 ]


In certain advanced laparoscopic procedures, where the specimen removed is too large to pull through a trocar site (as is done with gallbladders), an incision larger than 10 mm must be made. The most common of these procedures are removal of all or part of the colon ( colectomy ), or removal of the kidney ( nephrectomy ). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected (create an  anastomosis ). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO 2  will have to be maintained in the patient's abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons who choose this hand-assist technique feel it reduces operative time significantly versus the straight laparoscopic approach. It also gives them more options in dealing with unexpected adverse events (e.g., uncontrolled bleeding) that may otherwise require creating a much larger incision and converting to a fully open surgical procedure. [ 7 ]


Conceptually, the laparoscopic approach is intended to minimise post-operative  pain  and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes in the early 21st century, laparoscopic surgery has been adopted by various surgical sub-specialties, including gastrointestinal surgery (including bariatric procedures for  morbid obesity ), gynecologic surgery, and urology. Based on numerous prospective  randomized controlled trials , the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional  hernias  (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers such as cancer of colon. [ 8 ] [ 9 ]


The restricted vision, the difficulty in handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception, and the limited working area are factors adding to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents who wish to focus on this area of surgery gain additional laparoscopic surgery training during one or two years of fellowship after completing their basic surgical residency. In OB-GYN residency programs, the average laparoscopy-to-laparotomy quotient (LPQ) is 0.55. [ 10 ]


Laparoscopic techniques have also been developed in the field of  veterinary medicine . Due to the relatively high cost of the equipment required, it has not become commonplace in most traditional practices today but rather limited to specialty practices. Many of the same surgeries performed in humans can be applied to animal cases – everything from an egg-bound tortoise to a German Shepherd can benefit from MIS. A paper published in JAVMA (Journal of the American Veterinary Medical Association) in 2005 showed that dogs spayed laparoscopically experienced significantly less pain (65%) than those that were spayed with traditional "open" methods. [ 11 ]   Arthroscopy , thoracoscopy, and cystoscopy are all performed in veterinary medicine today.


There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:


Although laparoscopy in adults is widely accepted, its advantages in children are questioned. [ 19 ] [ 20 ]  Benefits of laparoscopy appear to recede with younger age. Efficacy of laparoscopy is inferior to open surgery in certain conditions such as  pyloromyotomy  for infantile hypertrophic  pyloric stenosis . Although laparoscopic  appendectomy  has less wound problems than open surgery, the former is associated with more intra-abdominal  abscesses . [ 21 ]


While laparoscopic surgery is clearly advantageous in terms of patient outcomes, the procedure is more difficult from the surgeon's perspective when compared to conventional, open surgery:


Some of the risks are briefly described below:


In recent years, electronic tools have been developed to aid surgeons. Some of the features include:


Robotic surgery has been touted as a solution to  underdeveloped nations , whereby a single central hospital can operate several remote machines at distant locations. The potential for  robotic surgery  has had a strong military interest as well, with the intention of providing mobile  medical care  while keeping trained doctors safe from battle.  [ citation needed ]


In January 2022, a robot performed the first ever successful laparoscopic surgery without the help of a human. The robot performed the surgery on the soft tissue of a pig. It succeeded at intestinal anastomosis, a procedure that involves connecting two ends of an intestine. The robot, named the Smart Tissue Autonomous Robot (STAR), was designed by a team of Johns Hopkins University researchers. [ 41 ]


There are also user-friendly nonrobotic assistance systems that are single-hand guided devices with a high potential to save time and money. These assistance devices are not bound by the restrictions of common medical robotic systems. The systems enhance the manual possibilities of the surgeon and his/her team, regarding the need of replacing static holding force during the intervention. [ 42 ]


With laparoscopy providing tissue diagnosis and helping to achieve the final diagnosis without any significant complication and less operative time, it can be safely concluded that diagnostic laparoscopy is a safe, quick, and effective adjunct to non‑surgical diagnostic modalities, for establishing a conclusive diagnosis, but whether it will replace imaging studies as a primary modality for diagnosis needs more evidence. [ 43 ]


It is difficult to credit one individual with the pioneering of the laparoscopic approach. In 1901,  Georg Kelling  of  Dresden , Germany, performed the first laparoscopic procedure in dogs, and, in 1910,  Hans Christian Jacobaeus  of Sweden performed the first laparoscopic operation in humans. [ 44 ]


In the ensuing several decades, numerous individuals refined and popularized the approach further for laparoscopy. The advent of computer chip-based television cameras was a seminal event in the field of laparoscopy. This technological innovation provided the means to project a magnified view of the operative field onto a monitor and, at the same time, freed both the operating surgeon's hands, thereby facilitating performance of complex laparoscopic procedures.


The first publication on modern diagnostic laparoscopy by  Raoul Palmer  appeared in 1947, [ 45 ]  followed by the publication of  Hans Frangenheim  and  Kurt Semm , who both practised  CO 2  hysteroscopy from the mid-1970s. [ 46 ]


Patrick Steptoe , one of the pioneers of  IVF , was important in popularizing laparoscopy in the UK. He published a textbook,  Laparoscopy in Gynaecology,  in 1967. [ 47 ]


In 1972, H. Courtenay Clarke invented, published, patented, presented, and recorded on film laparoscopic surgery, with instruments he invented and were marketed by the Ven Instrument Company of  Buffalo, New York . [ 48 ]   He was the first to perform a surgical laparoscopic process with standard sutures [ 49 ]  and simple instruments This was meant to facilitate the application of laparoscopic surgery to all economic sectors by avoiding expensive materials and devices. [ 50 ]


In 1975, Tarasconi, from the Department of Ob-Gyn of the University of Passo Fundo Medical School (Passo Fundo, RS, Brazil), started his experience with organ resection by laparoscopy (Salpingectomy), first reported in the Third AAGL Meeting, Hyatt Regency Atlanta, November 1976 and later published in The Journal of Reproductive Medicine in 1981. [ 51 ]
This laparoscopic surgical procedure was the first laparoscopic organ resection reported in medical literature.


In 1981, Semm, from the gynecological clinic of Kiel University, Germany, performed the first  laparoscopic   appendectomy . Following his lecture on laparoscopic appendectomy, the president of the German Surgical Society wrote to the Board of Directors of the German Gynecological Society suggesting suspension of Semm from medical practice. Subsequently, Semm submitted a paper on laparoscopic appendectomy to the  American Journal of Obstetrics and Gynecology , at first rejected as unacceptable for publication on the grounds that the technique reported on was "unethical," but finally published in the journal  Endoscopy . The abstract of his paper on endoscopic appendectomy can be found at the journal site. [ 46 ] [ 52 ]


Semm established several standard procedures that were regularly performed, such as  ovarian cyst  enucleation,  myomectomy , treatment of  ectopic pregnancy  and finally laparoscopic-assisted vaginal  hysterectomy  (also termed cervical intra-fascial Semm hysterectomy). He also developed a medical instrument company Wisap in  Munich ,  Germany , which still produces various endoscopic instruments. In 1985, he constructed the pelvi-trainer = laparo-trainer, a practical surgical model whereby colleagues could practice laparoscopic techniques. Semm published over 1000 papers in various journals. He also produced over 30 endoscopic films and more than 20,000 colored slides to teach and inform interested colleagues about his technique. His first atlas,  More Details on Pelviscopy and Hysteroscopy  was published in 1976, a slide atlas on pelviscopy, hysteroscopy, and fetoscopy in 1979, and his books on gynecological endoscopic surgery in German, English, and many other languages in 1984, 1987, and 2002. [ 46 ]


In 1985,  Erich Mühe , professor of surgery in Germany, performed the first laparoscopic  cholecystectomy . [ 53 ]  Afterward, laparoscopy gained rapid acceptance for non-gynecologic applications. The first video-assisted laparoscopic surgery was performed in 1987, a laparoscopic cholecystectomy. [ 54 ]  Before this time, the  operating field  was visualised by surgeons directly via a laparoscope.


In 1987,  Alfred Cuschieri  performed the first minimally invasive surgery in the UK with his team at  Ninewells Hospital  after working with multiple researchers from across the world, including  Patrick Steptoe . Cuschieri took advantage of smaller cameras to perform operations with smaller cuts and shorter recovery times. After some controversy and patient deaths, new laparoscopic training centres were set up as most surgeons lacked the necessary specialised training to perform laparoscopic surgery. The first opened in Dundee in 1991 and became the Cuschieri Skills Centre at Ninewells Hospital in 2004. As of 2008, 40 specialist centres around the world base their laparoscopic training on the Cuschieri Skills Centre. [ 55 ]


Prior to Mühe, the only specialty performing laparoscopy on a widespread basis was gynecology, mostly for relatively short, simple procedures such as a diagnostic laparoscopy or tubal ligation. The introduction in 1990 of a laparoscopic clip applier with twenty automatically advancing clips (rather than a single load clip applier that would have to be taken out, reloaded and reintroduced for each clip application) made general surgeons more comfortable with making the leap to laparoscopic cholecystectomies ( gall bladder removal). On the other hand, some surgeons continue to use the single clip appliers as they save as much as $200 per case for the patient, detract nothing from the quality of the clip ligation, and add only seconds to case lengths. Both laparoscopy tubal ligations and cholecystectomies may be performed using suturing and tying, thus further reducing the expensive cost of single and multiclips (when compared to suture). Once again this may increase case lengths but costs are greatly reduced (ideal for developing countries) and widespread accidents of loose clips are eliminated. [ citation needed ]


The  first transatlantic surgery  performed was a laparoscopic  gallbladder  removal in 2001. The first robotic advanced  pediatric surgery  series were performed overseas in Egypt at  Cairo University . [ 56 ] [ 57 ]   Remote surgeries  and  robotic surgeries  have since become more common and are typically laparoscopic procedures.


There are many International and American Surgical Associations involved in surgical education and training for laparoscopy, thoracoscopy and many minimally invasive procedures for both adults and pediatrics. These societies include:


In gynecology, diagnostic laparoscopy may be used to inspect the outside of the  uterus ,  ovaries , and  fallopian tubes , as, for example, in the diagnosis of  female infertility . [ 60 ]  Usually, one incision is placed near the navel and a second near the  pubic hairline . A special type of laparoscope called a  fertiloscope , which is modified for  transvaginal  application, can be used. A dye test may be performed to detect any blockage in the reproductive tract, wherein a dark blue dye is passed up through the  cervix  and is followed with the laparoscope through its passage out into the fallopian tubes to the ovaries. [ 1 ]


A  laparotomy  is a  surgical  procedure involving a surgical incision through the  abdominal wall  to gain access into the  abdominal cavity . It is also known as a  celiotomy .


The first successful laparotomy was performed without anesthesia by  Ephraim McDowell  in 1809 in  Danville, Kentucky . On July 13, 1881,  George E. Goodfellow  treated a miner outside  Tombstone , Arizona Territory, who had been shot in the abdomen with a .32-caliber Colt revolver. Goodfellow was able to operate on the man nine days after he was shot, when he performed the first laparotomy to treat a bullet wound. [ 1 ]


The term comes from the Greek word λᾰπάρᾱ (lapara) 'the soft part of the body between the ribs and hip, flank' [ 2 ]  and the suffix  -tomy , from the Greek word τομή (tome) '(surgical) cut'.


In  diagnostic laparotomy (most often referred to as an  exploratory laparotomy  and abbreviated ex-lap), the nature of the disease is unknown, and laparotomy is deemed the best way to identify the cause.


In therapeutic laparotomy, a cause has been identified (e.g.  colon cancer ) and the operation is required for its therapy.


Usually, only exploratory laparotomy is considered a stand-alone surgical operation. When a specific operation is already planned, laparotomy is considered merely the first step of the procedure.


Depending on incision placement, laparotomy may give access to any abdominal organ or space, and is the first step in any major diagnostic or therapeutic surgical procedure of these organs, which include: [ citation needed ]


The most common incision for laparotomy is a vertical incision in the middle of the abdomen which follows the  linea alba . [ citation needed ]


Midline incisions are particularly favoured in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.


Other common laparotomy incisions include:


Globally, there are few studies comparing perioperative mortality following laparotomy across different health systems.


A study in the UK with more than 180,000 patients aimed to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the United Kingdom National Emergency Laparotomy Audit (NELA) database. A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013–December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Results showed that quantitative futility occurred in 4% of patients (7442/180,987) and median age was 74 years. Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality and surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery. These findings suggest that quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively and should be incorporated into shared decision-making discussions with extremely high-risk patients. [ 11 ]


There are also several national studies looking at 30-day mortality in various health systems including the United Kingdom (the National Emergency Laparotomy Audit- NELA) and Australia and New Zealand (ANZELA). One major prospective study of 10,745 adult patients undergoing emergency laparotomy from 357 centres in 58 high-, middle-, and low-income countries found that mortality is three times higher in low- compared with high- HDI  countries even when adjusted for prognostic factors. [ 12 ]  In this study the overall global mortality rate was 1.6 percent at 24 hours (high 1.1 percent, middle 1.9 percent, low 3.4 percent; P < 0.001), increasing to 5.4 percent by 30 days (high 4.5 percent, middle 6.0 percent, low 8.6 percent; P < 0.001). Of the 578 patients who died, 404 (69.9 percent) did so between 24 h and 30 days following surgery (high 74.2 percent, middle 68.8 percent, low 60.5 percent). Patient safety factors were suggested to play an important role, with use of the  WHO Surgical Safety Checklist  associated with reduced mortality at 30 days. [ citation needed ]


Taking a similar approach, a unique global study of 1,409 children undergoing emergency laparotomy from 253 centres in 43 countries showed that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries, translating to 40 excess deaths per 1000 procedures performed in these settings. Internationally, the most common operations performed were appendectomy, small bowel resection, pyloromyotomy and correction of intussusception. After adjustment for patient and hospital risk factors, child mortality at 30 days was significantly higher in low-HDI (adjusted OR 7.14 (95% CI 2.52 to 20.23), p<0.001) and middle-HDI (4.42 (1.44 to 13.56), p=0.009) countries compared with high-HDI countries. [ 13 ]


Absorption of drugs administered orally was shown to be significantly affected following abdominal surgery. [ 14 ]


A related procedure is  laparoscopy , where cameras and other instruments are inserted into the  peritoneal cavity  via small holes in the abdomen. For example, an  appendectomy  can be done either by a laparotomy or by a  laparoscopic  approach.


There is no evidence of short-term or long-term advantages for peritoneal closure during laparotomy. [ 15 ]


Lateral internal sphincterotomy  is an  operation  performed on the  internal anal sphincter  muscle for the treatment of chronic  anal fissure . The internal anal sphincter is one of two muscles that comprise the anal  sphincter  which controls the passage of  feces . The procedure helps by lowering the resting pressure of the internal anal sphincter, which improves blood supply to the fissure and allows faster healing. [ 1 ]  The procedure has been shown to be very effective, with 96% of fissures healing at a median of 3 weeks in one trial. [ 2 ]


Lateral internal sphincterotomy is the preferred method of surgery for persons with chronic anal fissures, and is generally used when medical therapy has failed. [ 1 ]  It is associated with a lower rate of side effects than older techniques such as posterior internal sphincterotomy and anoplasty, [ 3 ]  and has also been shown to be superior to topical  glyceryl trinitrate  (GTN 0.2% ointment) in long term healing of fissures, with no difference in fecal continence. [ 4 ]


Lateral internal sphincterotomy is a minor operation which can be carried out under either  local  or  general anaesthesia ; a report in 1981 showed that general anaesthesia is preferable due to high rates of fissure recurrence in patients treated under local anaesthesia. [ 5 ]  This operation is generally carried out as a day case procedure. It can be performed with either "open" or "closed" techniques: [ 6 ]


In both techniques the lower one third to one half of the internal sphincter is divided, to lower the resting pressure without destroying the effect of the sphincter. The closed technique results in a smaller wound, but both techniques appear to be similarly effective. [ 7 ]


The  longitudinal intestinal lengthening and tailoring  (Bianchi) procedure is a form of autologous intestinal reconstruction. The small bowel is divided longitudinally in the midline, preserving one leaf of mesentery with its blood supply to each half. This results in two vascularized segments of small bowel which can then be rejoined end-to-end to restore continuity of the small bowel. There are also another ways of performing this procedure. [ 1 ]  it is one of the surgical therapeutic options along with other surgical options such as small bowel  segmental reversal ,  artificial intestinal valve construction ,  electrical pacing of the small bowel ,  serial transverse enteroplasty , or  transplantation  in treatment of  short gut syndrome . [ 2 ]


The procedure was first described by Bianchi in 1980 in a porcine model and first applied clinically by Boeckman and Traylor in 1981. [ 1 ]


A  lower anterior resection , formally known as  anterior resection of the rectum and colon  and  anterior excision of the rectum  or simply  anterior resection  (less precise), is a common surgery for  rectal cancer  and occasionally is performed to remove a diseased or ruptured portion of the intestine in cases of  diverticulitis . It is commonly  abbreviated  as  LAR . [ citation needed ]


LARs are for cancer in the  proximal  (upper) two-thirds of the rectum which lends itself well to resection while leaving the rectal sphincter intact. [ 1 ]


LARs, generally, give a better  quality of life  than  abdominoperineal resections  (APRs). [ 2 ] [ 3 ]  Thus, LARs are generally the preferred treatment for rectal cancer insofar as this is surgically feasible. APRs lead to a permanent colostomy and do not spare the sphincters. [ citation needed ]


Low anterior resection syndrome (LARS) comprises a collection of symptoms mainly affecting patients after surgery for rectal cancer characterized by fecal incontinence (stool and gases), fecal urgency, frequent bowel movements and bowel fragmentation, while some patients only experience constipation and a  feeling of incomplete bowel emptying . [ 4 ] [ 5 ] [ 6 ]    The cause is unclear, and has been thought to be due to nerve damage, or possibly due to loss of the  rectoanal inhibitory reflex. [ 5 ]


Many of the symptoms of LAR syndrome improve over a period of many months. [ 7 ]  The nerves that control the natural contractions of the colon and rectum run along the colon and can be damaged or cut during the surgery. [ citation needed ]   After such damage, the nerves can regrow, but only slowly.


Natural orifice transluminal endoscopic surgery  ( NOTES ) is a  surgical  technique whereby "scarless"  abdominal  operations can be performed with an  endoscope  passed through a natural orifice ( mouth ,  urethra ,  anus ,  vagina , etc.) then through an internal  incision  in the  stomach ,  vagina ,  bladder  or  colon , thus avoiding any external incisions or  scars . [ 1 ] [ 2 ]   Memic's hominis robotic system is the first and only FDA-authorized surgical robotic platform for NOTES procedures. The system is currently at use for transvaginal  hysterectomies  through the  rectouterine pouch  - the removal of the uterus, along with one or both of the  fallopian tubes  and  ovaries , in cases where there is no cancer present, as well as with the removal of  ovarian cysts   [ 3 ]


Ralph John Nicholls  (born 20 May 1943), FRCS (Eng), EBSQ is a retired British colorectal surgeon, Emeritus Consultant Surgeon at  St Mark's Hospital  London and Professor of Colorectal Surgery,  Imperial College London . [ 1 ] [ 2 ]


R. John Nicholls is best known for his work in the development of ileal pouch surgery. With the advancement of  ileal-anal pouch surgery , selected patients with  ulcerative colitis  and  familial adenomatous polyposis (FAP)  requiring surgery can be treated by removing the diseased  colon  also known as the large intestine and  rectum  while preserving the anus, thereby avoiding a permanent stoma ( ileostomy ). This revolutionary operation challenged the conventional procedure used at the time,  total procotocolectomy , which included removal of the  anal sphincter  leaving the patient with an ileostomy for life. [ 3 ]


The technique of  ileal pouch-anal anastomosis (IPAA)  surgery, also known as restorative procotocolectomy (RPC) consists of removal of the diseased colon and rectum, immediately followed by the creation of a surgical join ( anastomosis ) between the small intestine ( ileum ) above and the  anus  below. The reservoir function of the rectum lost by its removal was replaced by the surgical construction of a 'new' rectum made from the ileum to form a so-called "ileal pouch". This enabled the patient requiring surgery for ulcerative colitis and some with familial adenomatous polyposis to avoid a permanent ileostomy by enabling the storage of stool in the pouch as would normally occur in the rectum to be followed by defaecation through the anus at the patient's convenience. [ 4 ]


The drive behind creating and developing  ileo-anal pouch  surgery was to improve the quality of life for select patients who required surgery for their condition and were medically suitable to undergo the procedure.  The decision to undergo the pouch operation was made by the patient based on objective information and their preference between life with a permanent ileostomy or the preservation of defaecation through the anus, in each case with the removal of the disease. [ 5 ]


The pouch operation with anal anastomosis was designed to be the patient's choice between life with an ileostomy or they could choose an elective/optional pouch reconstruction after the colon and rectum needed to be removed due to disease.  The  Kock pouch  procedure developed by Finnish surgeon  Nils Kock  first reported in Sweden in 1969 which is a continent ileostomy, was also an attempt to improve the patient's quality of life, but it still required an opening of the bowel onto the abdominal wall, rather than preservation of the normal route of defaecation through the anus as in restorative proctocolectomy. [ 6 ] [ 7 ] [ 8 ]


Born in Wilby, England, Nicholls attended  Felsted School  and went on to study medicine at Gonville and Caius College in the  University of Cambridge . [ 9 ] [ 10 ]


He completed his clinical training and surgical residency at the London Hospital (known from 1990 as the  Royal London Hospital ) and became a Fellow of the  Royal College of Surgeons in England  in 1972. It was at the London Hospital, that Nicholls trained under British surgeon  Sir Alan Parks . [ 11 ]


Parks operated on his first  ileo-anal pouch  patient in 1976 at the London Hospital and subsequently at  St Mark's Hospital  where he was also a consultant. [ 12 ] [ 13 ]   Nicholls was his first assistant having spent 1976 carrying out research under Fritz Linder [ 14 ]  on an Alexander von Humboldt Fellowship in the Department of Surgery at the  Heidelberg University  in Germany. Nicholls became a Resident Surgical Officer at St Mark's on his return to the UK in 1977. He was also a consultant surgeon to  St Thomas' Hospital , London, from 1982 to 1993 when he left to become Dean of St Mark's.


The  ileal pouch-anal anastomosis  (IPAA) procedure was an advancement from the "straight" ileoanal anastomosis procedure original described by the German surgeon  Nissen  in 1934 and resurrected by the Americans  Ravitch  and  Sabiston  in 1947. [ 15 ]   They described the total removal of the colon and rectum with restoration of intestinal continuity by means of an ileo-anal anastomosis without any formation of an ileal pouch or reservoir.  They procedure resulted in high frequency and urgency of defaecation day and night which made life difficult for many patients. [ 15 ]


Finnish surgeon  Nils Kock  premiered his continent ileostomy procedure in Sweden in 1969.  The procedure known as a  Kock pouch  involved first the removal of the colon, rectum, and anus.  Next, using the last 45 centimetres of the ileum, the construction of an ileal pouch with a valve designed only to allow drainage of its contents when a  catheter  was passed through the stoma on the  abdominal wall .  This allowed many patients to have control over their life by being able to evacuate stool at a time of their choosing. [ 6 ]


When Koch showed that the creation of an ileal reservoir in humans did not compromise the patient's health,  Alan Parks  recognised that the combination of total surgical removal of the disease by excision of the colon and rectum combined with an ileal pouch to replace the lost reservoir of the rectum might achieve the two aims of cure of the disease and acceptable bowel function. Parks then constructed a reservoir or "pouch" made from the last 40–50 centimetres of the small bowel (ileum) after excision of the colon and rectum and joined this to the anus to form an ileo-anal anastomosis.


This not only preserved anal function but the creation of a reservoir was intended to improve the patient's function by reducing the frequency of defaecation as much as was possible. The operation is known by several names globally today including ileal pouch, Parks' pouch, pelvic pouch, S-pouch, J-pouch, W-pouch, Ileal Pouch Anal Anastomosis (IPAA) and restorative proctocolectomy (RPC).  It is also now performed for a number of conditions beyond ulcerative colitis and familial adenomatous polyposis (FAP) including accident or injury, infection, allergic reaction, toxic mega colon, and cancer among others.


Parks and Nicholls published the seminal article on  ileo-anal pouch  surgery entitled "Proctocolectomy without ileostomy for ulcerative colitis" in 1978 published by the British Medical Journal. [ 16 ]   Articles that followed in the surgical literature mainly centred on clinical results including complications and function.  This was followed by period of time during which the shape and size of the reservoir became and area of interest. [ 17 ]  Parks' original design, the so-called "S-pouch", was often followed by difficulty in evacuation of stool due to the retention of a short segment of ileum anastomosed at the anal canal.  The "J-pouch" described by Utsunomiya in 1980 largely avoided this problem. [ 18 ]


The demonstration of an inverse relationship between the capacity of the pouch and the frequency of defaecation led to further designs including the W-pouch described by Nicholls led to further designs including the W-pouch he described in 1987 which was free from defaecation difficulty and appeared also to be followed by fewer bowel actions per 24 hours than the J-pouch. [ 19 ]


Following the unexpected death of Alan Parks on November 3, 1982, [ 20 ]  John Nicholls became the most active pouch surgeon in the United Kingdom. At this time he was still a mid-career surgeon but he had been working with the operation since its inception when he was still a senior registrar (chief resident).


By the early 1980s, the ileal pouch procedure had become part of specialist colorectal surgical practices worldwide. In the United States the Australian-born surgeon  Victor Warren Fazio  at the  Cleveland Clinic  and Roger Dozois [ 21 ] [ 22 ]  at the  Mayo Clinic  began publishing on the operation in the early 1980s greatly increasing its diffusion and there was generous co-operation among these units, St Mark's and colorectal departments in Canada (Zane Cohen), [ 23 ] [ 24 ]  France (Rolland Parc) [ 25 ]  and Italy (Gilberto Poggioli). [ 26 ] [ 27 ] [ 28 ]


Nicholls' other contributions to coloproctology include aspects of rectal cancer related to staging, local surgery, and radiotherapy and his collaboration with Professor Michael Kamm in the field of incontinence. [ 29 ] [ 30 ]   He was a founding member of the European Society of Coloproctology and was first secretary of the Division of Colorectal Surgery of the Union Européenne des Médecins Specialistes (UEMS) which instigated accreditation and certification for  colorectal surgery . [ 31 ]   He was the founder of the International Journal of Colorectal Disease and was its editor from 1986 to 1999.  He then established the journal Colorectal Disease of which he was Editor-in-Chief until his retirement in 2014, during which time the Impact Factor rose to be the second of colorectal journals worldwide. [ 32 ] [ 33 ]


Nicholls became Dean of St Mark's from 1987 and held the position until 1997.  From 1997 to 2001, he was the Clinical Director of St Mark's Hospital.  During this time (from 1997 to 2001), Nicholls was additionally a member of the Specialist Advisory Committee in General Surgery for Higher Surgical Training in Great Britain and Ireland. In 1993 he with his colleague James Thomson, the Clinical Director of St Mark's at the time, created the St Mark's Academic Institute. [ 34 ]   He was appointed Professor of Colorectal Surgery in Imperial College London in 1997 and was Chairman of the Board of Trustees of Northwick Park Institute for Medical Research from 2008 to 2016. [ 35 ]


Fellowships have been awarded to him by many professional bodies including the  Royal College of Physicians  of London, the  American College of Surgeons , the  American Society of Colon and Rectal Surgeons , the surgical Royal Colleges of Edinburgh, Ireland and Glasgow, l'Academie Nationale de Chirurgie, the  British Society of Gastroenterology  (BSG) and the national colorectal societies in Italy, France, Brazil, Spain, Austria, Switzerland, Yugoslavia, Chile, Argentina, Canada, Australia and Poland. He was able to lecture in French, German and Italian. [ 36 ]


Nicholls was the President of the Association of Coloproctology of Great Britain and Ireland in 2000 and of the European Association of Coloproctology in 2004.  With the formation of the European Society of Coloproctology in 2005, which he joined as a founder, he became the Chairman of the Scientific Committee responsible for he scientific programme of the meetings. [ 37 ] [ 38 ]  Nicholls retired from NHS practice in 2006 but kept active in the field of colorectal surgery until his full retirement in 2014.  He has authored over 300 publications and four books. [ 39 ]


Nicholls remains a Patron of the Red Lion Group (RLG), a national support group and charity for people with pouches founded by a group of St Mark's staff and patients in 1994. Nicholls' had an instrumental role in the launch of the Red Lion's Group helping it to be based at St Mark's Hospital and served as the first President of the Red Lion Group from 1994 until Nicholls' retirement from the  National Health Service (NHS)  in 2006. Thereafter, he remained active in research and teaching until his full retirement in 2014. [ 40 ] [ 41 ]


A  Nissen fundoplication , or  laparoscopic Nissen fundoplication  when performed via  laparoscopic surgery , is a  surgical procedure  to treat  gastroesophageal reflux disease  (GERD) and  hiatal hernia . In GERD, it is usually performed when medical therapy has failed; but, with a  Type II (paraesophageal) hiatus hernia , it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal (270° anterior), Belsey (270° anterior transthoracic), Dor (anterior 180–200°), Lind (300° posterior), and Toupet fundoplications (posterior 270°) are alternative procedures with somewhat different indications and outcomes. [ 1 ]


Dr. Rudolph Nissen  (1896–1981) first performed the procedure in 1955 and published the results of two cases in a 1956  Swiss Medical Weekly . [ 2 ]  In 1961 he published a more detailed overview of the procedure. [ 3 ]   Nissen originally called the surgery "gastroplication". The procedure has  borne his name  since it gained popularity in the 1970s. [ 4 ]


The most common indication for a fundoplication is GERD that has failed lifestyle modification and medical management. [ 5 ]  Patients that continue to have reflux symptoms or that have had uncontrolled reflux symptoms for more than 5 years are also candidates for surgical management. [ 6 ]  Complications that arise from long term  GERD  such as severe esophagitis,  stricture  formation, and  ulcer  development, all of which can be seen on  endoscopy , warrant surgical intervention. Presence of  Barrett's esophagus  is not an indication, as the benefit of a fundoplication in preventing progression into  adenocarcinoma  is controversial. [ 6 ]  Respiratory symptoms and upper airway symptoms such as cough,  asthma , hoarseness are also indications for surgical intervention. [ 7 ]  In the pediatric population, infants who fail to thrive or have inadequate weight gain despite  proton-pump inhibitor  (PPI) therapy may also benefit from fundoplication. [ 8 ]


In a  fundoplication , the  gastric fundus  (upper part) of the  stomach  is wrapped, or plicated, around the lower end of the  esophagus  and stitched in place, reinforcing the closing function of the  lower esophageal sphincter  (LES). The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged  esophageal hiatus  of the  diaphragm .
The surgeon should begin with ligating and dividing the  short gastric arteries . [ 9 ]


In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped the entire 360 degrees around the esophagus. In contrast, surgery for  achalasia  is generally accompanied by either a  Dor  or  Toupet  partial fundoplication, which is less likely than a Nissen wrap to aggravate the  dysphagia  that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus. [ citation needed ]


The procedure can be performed with open surgery but is now routinely performed  laparoscopically , as laparoscopic surgery has decreased post-operative complications and decreased hospital stay. [ 10 ]  When used to alleviate gastroesophageal reflux symptoms in patients with  delayed gastric emptying , it is frequently combined with modification of the  pylorus  via  pyloromyotomy  or  pyloroplasty . [ citation needed ]


This procedure can also be completed robotically. Outcomes comparing laparoscopic fundoplication to robotic fundoplication show similar clinical outcomes, but robotic fundoplication is more likely to have an increased length of operative time and financial cost. [ 11 ]


Whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it.  This prevents the reflux of  gastric acid  (in GERD). Although antacids and  PPI  drug therapy can reduce the effects of reflux acid, successful surgical treatment has the advantage of eliminating drug side-effects and damaging effects from other components of reflux such as bile or gastric contents. [ 1 ]  The Nissen fundoplication reduces reflux by reinforcing the  LES  by increasing LES pressure and increasing the LES length. [ 6 ]


Nissen (complete) fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1% and many of the most common post-operative complications minimized or eliminated by the partial fundoplication procedures now more commonly used. Studies have shown that after 10 years, 89.5% of patients are still symptom-free. When compared to stand alone medical therapy with PPIs, Nissen fundoplication has been found to be superior in reducing acid reflux as well as the symptoms associated with reflux. [ 12 ]  Fundoplication was found to be better at increasing  LES  pressure than  PPI  therapy, whilst having similar risk for adverse events. [ 13 ]  In patients with non-acid reflux, a  hiatal hernia , or respiratory symptoms, surgical intervention was found to be more effective at controlling symptoms than  PPIs  alone. [ 7 ]


Complications include "gas bloat syndrome",  dysphagia  (trouble swallowing),  dumping syndrome , excessive scarring, vagus nerve injury and, rarely,  achalasia . [ 14 ]  The fundoplication can also come undone over time in about 5–10% of cases, leading to recurrence of symptoms. If the symptoms warrant a repeat surgery, the surgeon may use  Marlex  or another form of artificial mesh to strengthen the connection. [ 15 ]  Postoperative  ileus , which is common after abdominal surgery, is possible.


In "gas bloat syndrome", fundoplication can alter the mechanical ability of the stomach to eliminate swallowed air by  belching , leading to an accumulation of gas in the  stomach  or small intestine. Data varies, but some degree of gas-bloat may occur in as many as 41% of Nissen patients, whereas the occurrence is less with patients undergoing partial anterior fundoplication. [ 16 ]   Gas bloat syndrome is usually self-limiting within 2 to 4 weeks, but in some it may persist.  The offending gas may also come from dietary sources (especially carbonated beverages), or involuntary swallowing of air ( aerophagia ).  If postoperative gas-bloat syndrome does not resolve with time, dietary restrictions, counseling regarding aerophagia, medications, and correction – either by  endoscopic balloon dilatation [ citation needed ]  or repeat surgery to revise the Nissen fundoplication to a partial fundoplication – may be necessary. [ 16 ]


Acute  dysphagia  or short term trouble swallowing is a symptom that most patients will have after having a fundoplication. Patients who have  dysphagia  prior to surgery are more likely to have some  dysphagia  post-operatively. [ 17 ]  Symptoms of  dysphagia  will often resolve on their own within a few months. [ 18 ]  Short term  dysphagia  is controlled by modifying diet to include more easily swallowed food such as liquids and soft foods. [ 19 ]   Dysphagia  that persists longer than 3 months will need further evaluation, typically with a  barium swallow study ,  esophageal manometry , or  endoscopy . [ 20 ]  Structural changes such as movement of the wrap,  herniation , development of stenosis or stricture may lead to persistent  dysphagia . [ 19 ]  Previously undiagnosed achalasia or a wrap that is too tight may also lead to persistent  dysphagia . [ 18 ]  Depending on the etiology of persistent dysphagia, a trial of  PPI  therapy, endoscopic dilation, or surgical revision may be necessary. [ 21 ]


Vomiting is sometimes impossible or, if not, very painful after a fundoplication, with the likelihood of this complication typically decreasing in the months after surgery. In some cases, the purpose of this operation is to correct excessive vomiting. Initially, vomiting is impossible; however, small amounts of vomit may be produced after the wrap settles over time, and in extreme cases such as  alcohol poisoning  or  food poisoning , the patient may be able to vomit freely with some amount of pain.


Omentopexy  is a  surgical  procedure whereby the  greater omentum  is sutured to a nearby organ. Suture to the  abdominal wall  is used to induce circulation away from the portal circulation into caval circulation. It may also be sutured to another organ to increase  arterial  circulation.


Partial ileal bypass surgery  is a  surgical procedure  which involves shortening the  ileum  to shorten the total  small intestinal  length. [ 1 ]