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Since 1987, when EA Wickham coined the term “minimally invasive procedure” in British Medical Journal (1), it was clear that the efforts of IbnSina, who used candles and sunlight in surgical operations from the beginning of 6th century (2), have advanced in a new direction to create a new approach to surgery. A minimally invasive procedure is distinct from a noninvasive procedure. These procedures may result in a shorter hospital stay or allow outpatient treatment. When there is minimal damage to biological tissues at the point of entry of instrument(s), the procedure is called minimally invasive. A minimally invasive surgery (MIS) typically involves the use of endoscopic devices, remote-controlled instruments, indirect observation of the operative field through an endoscope, or the use of similar devices, and is performed through the skin or through anatomical openings.We searched medical databases like Pubmed and ISI web of sciences using the terms “endoscopic surgery” or “minimally invasive” and found 36,484 published articles. We calculated that the number of papers published between 2006 and 2011, was about four times the number of papers published before 2000 (n = 7456 vs. n = 25478). These statistics indicate the importance and evolution of this new field of science. They also underline the increase in the number of scientists and researchers in the field of minimally invasive surgical sciences (3). However, the Journal Citation Report in the ISI web of knowledge showed that in 2010, there were 187 indexed journals on MIS. Thus, there is a major gap between the number of researchers in this field and the published journals. Considering the necessity of establishing new journals for researchers, we proposed to establish and publish our journal titled, “Minimally Invasive Surgical Sciences”. This journal is the official journal of the Mediterranean and Middle Eastern Endoscopic Surgery Association (MMESA) and MIS research center of Tehran University of Medical Sciences. MMESA connects scientists in the Mediterranean and Middle Eastern countries while the MIS research center attempts to connect scientists from Iran and countries bordering the Caspian Sea. MMESA connects surgeons in European countries with Middle Eastern and North African MIS surgeons and was been established by Prof. J. Melloti in 1990. This organization is a non-profit, non-governmental body that aims to connect researchers in this field and promote MIS scientists from the above-mentioned regions. Scientific productivity is increasing in different regions of the world,and the scientific productivity of the Islamic Republic of Iran is one of the highest among all countries of the Middle East region. Due to the important role of planning in achieving the top position in this region, we aimed to establish a unique research center for MIS scientists. Thus, the MIS research center was established in 2009 that Supports journal as well. The journal of Minimally Invasive Surgical Sciences (MinSurgery) is a clinical journal officially published by the MMESA and the MIS Research Center of Tehran University of Medical Sciences, and it targets all clinicians active in the field of MIS. This journal was founded in 2011 by “Professor Abdolreza Pazouki” and “Professor Jose M. Schiappa”. The Journal is a peer-review compilation of interdisciplinary findings and global research on MIS and includes original manuscripts, meta-analyses and reviews, health economic papers, debates, and consensus statements of clinical relevance in MIS. In addition, consensus evidential reports not only highlight new observations, original studies, results accompanied by innovative treatments, and all other relevant topics, but also include elucidation of disease mechanisms, important clinical observations, and letters on articles published in the journal. The journal welcomes all types of manuscripts and other scientific communications, including original manuscripts, meta-analyses and reviews, health economic papers, debates, and consensus statements of clinical relevance in MIS (4). To ensure that both surgical and non-surgical procedures are addressed equally, the scope of this journal includes surgical sciences as well as non-surgical methods. Articles from streams such as cardiology, pain and anesthesiology, gastroenterology, pulmonology can be submitted to the journal. In the last decade, all surgical techniques have been modified to use the MIS approach, primarily because of the less invasive procedures and fewer complications. Gynecologists, general surgeons, urologists, orthopedists, neurosurgeons, and ENT specialists use MIS methods in their routine operations. We invite all clinical practitioners, researchers, and surgeons who are active in the field of MIS to submit their valuable papers through our online submission system and provide solutions for the various issues in this field.

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Background: There are several methods for the ligation of structures during minimally invasive
operations. The hem-o-lok clip is a nonabsorbable polymer clip with a lock engagement
feature. There are few reports about its use in minimally invasive general surgical procedures.
Objectives: In this report, we describe our experience with the hem-o-lok clip during basic,
minimally invasive, general surgery procedures and the adverse events during application
of the hem-o-lok.
Patients and Methods: We retrospectively reviewed all laparoscopic appendectomies (LAs),
cholecystectomies (LCs), and splenectomies (LSs), performed by 6 general surgeons at a
university-affiliated hospital over 4 years. Clip failure was defined as intraoperative or postoperative
bleeding due to clip malfunction that necessitated placement of another clip, conversion
to an open procedure, or postoperative re-exploration. Leakage from the cystic duct
and appendiceal stump was also considered clip failure. A search of the US Food and Drug
Administration Manufacturer and User Facility Device Experience (MAUDE) database using
the appropriate keywords was performed on July 7, 2011. This online resource contains reports
of adverse events involving medical devices.
Results: Over a 4-year period, 856 laparoscopic operations, comprising 770 LC, 55 LS, and 31
LA, were performed. We did not observe any incidence of clip failure. There were 22 reports of
hem-o-lok clip failure in the MAUDA database. Eighty-two percent (n = 18) of clip failures were
reported during laparoscopic nephrectomy. There was no report of failure after LA. There
were 2 reported clip failures after LC (with bile leakage) and 1 after LS (tearing of splenic vessels
with intraoperative bleeding). There was also a report of migration of the hem-o-lok clip
into the common bile duct, which occurred 4 years after a complicated LC.
Conclusions: Hem-o-lok clips that are properly applied during basic laparoscopic procedures
are a secure option for the ligation of the structures. Surgeons must be educated regarding
the proper application technique.

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Background: Catheterization of central veins is a routine technique which is widely used in general hospitals and medical intensive care units. It should be carefully performed and managed to prevent adverse side effects. Case Presentation: In this case report, we describe a case of lost guide wire during central venous catheterization, which was successfully treated with a minimally invasive surgical technique. Conclusions: Inattention is the main cause of the retained guide wires. The interventional angiography is usually successful as the first line therapy.

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Context

The current literature suggests that minimally invasive surgery is associated with faster recovery and less morbidity than open surgery. Parenchyma-sparing pancreatectomy is minimally invasive surgery, including enucleation, inferior head pancreatectomy, spleen-preserving distal pancreatectomy, and central pancreatectomy, combined pancreatectomy such as inferior head pancreatectomy plus spleen-preserving distal pancreatectomy, and subtotal distal pancreatectomy (spleen-preserving).

Evidence Acquisition

Parenchyma-sparing pancreatic resection is mainly used for benign neoplasms, including intraductal papillary mucinous neoplasm (IPMN), mucinous cystadenoma, serous cystadenoma, and small sized neuroendocrine tumors including insulinoma.

Results

Parenchyma-sparing pancreatectomy can be applied for benign pancreatic lesions. Assistance with pancreatic stenting and/or laparoscopy is recommended in some cases to prevent from complications.

Conclusions

Recent advancements of surgical techniques have allowed us to perform several types of parenchyma-sparing pancreatic resection.

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Background

The phrase “minimally invasive” is used loosely due to the wide range of surgical options and generally means a procedure not involving a large open incision. In 1998, Dr. Paolo Miccoli at the University of Pisa developed a technique of minimally invasive video-assisted thyroidectomy (MIVAT) for patients presenting with small thyroid nodules. The procedure involves a smaller incision, limited exposure, and endoscopic magnification to better visualize the smaller surgical field. From this point, thyroidectomy or hemi-thyroidectomy is performed using endoscopic instrumentation. Indications were initially limited to single, small non-malignant thyroid nodules, however the indications have gradually expanded since this surgery’s initial implementation.

Objectives

We feel that this article provides an up-to-date research on the MIVAT procedure, while highlighting its rapidly expanding indications and excellent outcomes.

Patients and Methods

The current patient selection criteria includes small thyroid nodules (<35 mm in diameter), a relatively normal thyroid gland (about <25 cubic cm), no evidence of severe thyroiditis, and no previous neck surgery or radiation.

Results

The advantages of MIVAT compared with conventional thyroidectomy include improved cosmetic results, less postoperative pain and reduced hospital stay without any difference in safety, completeness or morbidity compared with the conventional approach. The primary drawback appears to be an increased operative time, which can be reduced as the surgeon becomes more comfortable with the procedure.

Conclusions

As shown in the literature, MIVAT is a safe and effective alternative in the treatment of some thyroid diseases within the selection criteria. With the same level of complications, it offers a few significant advantages over the conventional thryoidectomy.

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Background

Although many studies have demonstrated the feasibility of single-incision laparoscopic (SILS) appendectomy, this procedure has not become routine. In part this may be due to the perception that SILS appendectomy has additional resource requirements compared to conventional laparoscopic appendectomy in terms of personnel, time and equipment.

Objectives

The purpose of this prospective study was to assess the feasibility of a UK trainee performing routine SILS appendectomy with standard equipment.

Patients and Methods

Prospective analysis of all consecutive adults who underwent laparoscopy for presumed appendicitis was performed. Cases were performed either by a senior trainee who exclusively performed SILS appendectomy on all patients using standard laparoscopic equipment, or other senior or junior trainees performing a conventional three-port laparoscopic appendectomy.

Results

Seventeen patients had SILS operations: 15 appendectomies, one resection of inflamed Meckel’s diverticulum and one appendectomy with oophorectomy. SILS was successfully completed in 14 cases whilst in three cases one extra port was added. Comparison of the 15 SILS operations that involved an appendectomy only with consecutive cohorts of three-port appendectomies performed by junior and senior trainees showed no significant difference in complications or length of hospital stay. There was no significant difference in operating time between SILS and junior trainee (P = 0.54), however the senior trainees had a significantly reduced operating time as compared to both SILS and junior trainee groups (P = 0.01).

Conclusions

SILS appendectomy can be successfully performed by trainees on all-comers with comparable resource utilisation and clinical outcomes to those achieved by junior trainees performing a conventional three-port laparoscopic approach.

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Introduction

Since 1996 with improvement of endoscopic instrumentation several novel minimally invasive techniques have been developed to perform thyroid operations. The advantages of endoscopic procedure includes better magnification of anatomy, improved illumination of the operation field, earlier recovery, better pain control, and better cosmetic results. Yet it’s performed rarely and only by few surgeons around the world, as it has some limitations like the size of the nodule.

Case Presentation

We herein present a patient with right-sided thyroid cold nodule and follicular presentation on fine needle aspiration (FNA), which successfully underwent endoscopic thyroidectomy through an axillary incision in Hazrat Rasul Akram hospital and tolerated the procedure well without any complications and was discharged with a very good condition.

Conclusions

If the indications and contraindications of minimally invasive thyroidectomy are taken into account, it seems to be a safe procedure and regarding the benefits of this procedure, it's recommended that surgeons pay more attention to this newly developed technique.

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Introduction

Multiple unilateral congenital diaphragmatic hernias (CDH) are extremely rare, described only five times in the medical literature. Concurrent ipsilateral Bochdalek and Morgagni hernias are rarer still with only two cases previously described. In all reported cases of multiple concurrent defects, the hernias were repaired in an open fashion, either via a thoracotomy or laparotomy with both of the two combined Bochdalek and Morgagni hernias repaired via laparotomy.

Case Presentation

In this case report we have a 2-day-old who developed respiratory distress and on CT scan was found to have a congenital diaphragmatic hernia (CDH) or eventration. This patient is ideal for this case report because he meets a lot of the previously established criteria for minimally invasive repair of congenital diaphragmatic hernias - minimal respiratory compromise, no congenital heart defects - and he has synchronous defects which have very rarely been seen before. Here we present the first reported case of concurrent ipsilateral Bochdalek and Morgagni hernias repaired in a one-stage minimally invasive fashion, approaching the Bochdalek hernia thoracoscopically and the Morgagni laparoscopically. The patient had a quick recovery post-operatively and he continues to do well.

Conclusions

From this experience, we argue that in the right circumstances a completely minimally invasive approach can be taken for synchronous congenital diaphragmatic hernias.

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Preserving normal tissue during surgery has become increasingly important for better outcome after operation. Because of this, minimally invasive procedures have been developed. There are many pain procedures with minimally invasive method to aid fluoroscopy.

The percutaneous vertebroplasty or kyphoplasty instead of screw fixation for many kinds of compressed fractures with 90% success rate is a good example (1). The percutaneous radiofrequency ablation of medial branch of dorsal ramus for facet mediated vertebral pains is another example with good results (2).

The percutaneous trigeminal ganglion radiofrequency ablation instead of microvascular decompression in elderly people has success rate of 80% - 90% (3). Spinal column stimulator and intrathecal pump implantation are expensive and useful methods of treating persistent pains such as failed back surgery syndrome and CRPS (4).

Recently, the percutaneous transformational decompression of disc with ozone or laser or coblation in bulging or moderate protrusion of lumbar or cervical discs or in disco genic pain instead of discectomy or screw fixations, have become popular. In 1973, Kambin (originally Iranian orthopedic surgeon) started percutaneous decompression of disc by nucleotomy in USA (5). Later, he reported 72 percent success rate with modified Hijikata approach (6). In 1985, Onik et al. introduced nucleotomy with motorized shaver (7). Ascher performed the first laser discectomy in mid-1980s. He used Nd: YAG laser and the good to fair range response to that method was 78% (8).

Minimally invasive percutaneous transforaminal endoscopic discectomy was initiated by Kambin in 1988. Kambin described The triangular safe zone in transforaminal approach in 1990 (4). Tsou and Yeung, in 2002 , reported the same efficacy for endoscopic discectomy and conventional open surgery (9). They reported 91% success rate for this approach (10). Nevertheless, there are some failed cases such as migrated fragments or high canal compromised herniation (11).

With recent advances, endoscopic discectomy will gradually replace open discectomy in near future.

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Background

Preliminary studies have indicated advantages of mesh fixation using fibrin glue in TAPP compared with tack fixation.

Objectives

We report the results of a prospective experience in fixing mesh during TAPP with absorbable tacks.

Patients and Methods

50 consecutive men (who had bilateral inguinal hernia) were enrolled and followed up for at least 1 year. The primary measured outcome was pain experienced in day 1 of post-op. The secondary outcomes measured were postoperative scores of pain at rest, discomfort, and fatigue, foreign-body sensation, and hernia recurrence after 12 months. The outcomes were measured using a visual analogue scale, a verbal rating scale and numerical rating scales. A comparison was done within a historical group with the same demographic and hernia characteristics where the meshes have been fixed with fibrin glue.

Results

The group of tacks ‘TAPP’ showed good results concerning the level of pain, fatigue and foreign body sensation comparable with those of the historical group. There were significant differences concerning the length of surgery where absorbable tacks performed better. Regarding cost of surgery, the fibrin glue showed effective results.

Conclusions

The use of absorbable tacks during TAPP confers significant benefit regarding the operating time, however it is a disadvantage due to the cost when compared with fibrin glue.

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Hysterectomy is one of the most commonly performed surgical procedures. Laparoscopic hysterectomies have been shown to be associated with lower blood loss, shorter hospital stay and recovery time, early return to normal activity and work, fewer wound infections, less pain, and shorter operation time in experienced hand (1-4).

In spite of advantages of these minimally invasive procedures, abdominal hysterectomy remains the most common procedure.

The slow adaption of laparoscopic hysterectomy can be due to insufficient exposure and training during residency, lack of hospital equipment, and deficiency in support from colleagues (5, 6).

Steps toward a successful laparoscopic hysterectomy are as below:

1) The operating table should be kept low so that the surgeon monitors the process directly in an ergonomic working environment.

We keep arms tucked at the sides and keep patient into steep trendelenburg position during of the operation.

2) Placement of a uterine manipulator: preferably the HOHL (STORZ Company).

3) Correct abdominal entry and trocar placement: We inserted the first trocar (12 mm) through the umbilicus. The lower right and left quadrant trocar (usually 5 mm) were placed under direct vision. These trocars were placed laterally to the rectus abdominis approximately 2 cm above and 2 cm medial to the anterior superior iliac spine. As well, 8 cm above and paralleling lower left trocar site, an additional 5 mm trocar was placed.

4) At first, we ligated and cut round ligament of both side by using of 5 mm ligaSure (Covidien (Medtronic)). Then, we dissected the anterior and posterior peritoneum by using harmonic scalpel or monopolar cautery and mobilized and push down the bladder in anterior and ureter at both sides in posterior. Indeed, we describe a new approach by saving uterosacral ligament by transverse incision one centimeter above it and extending peritoneal incision at both posterolateral of uterus adjacent to utero ovarian ligament and then we push down the peritoneum at both sides. So we can prevent most uretral injury during clumping and ligating of uterine artery. In women with one or more previous cesarean delivery, this area may be scarred and it is important to stay relatively high on the uterus during the dissection. If fat is encountered, a reassessment of the route of dissection is recommended because the fat belongs to the bladder, this may indicate that the dissection is moving too close to the bladder.

5) Then we ligated and cut the utero ovarian ligament (if we plan to save ovaries) or infundibulopelvic ligament (if we plan to remove ovaries) by using 5 mm ligaSure instrument.

6) We used a 5 mm ligaSure for ligating and cutting uterine vessels at the level of internal cervical os.

7) We save uterosacral ligament by cutting and separating the vaginal cuff about one centimeter above these ligaments by palpating the HOHL uterine elevator edges by harmonic scalped or monopolar electrocautery surgical instrument. HOHL is a uterine elevator with hard edge which elevates vaginal cuff for safe cutting its edge at the end of total laparoscopic hysterectomy. This technique also prevents ureter injury in this stage of operation.

8) Removal of the uterus: Pull the uterus inside the vagina if it fits. Enlarge uterus that cannot be removed by vaginal route, can be carefully morcellated either transvaginally by using a 10 blade scalpel or transabdominally by using an electronic morcellator.

9) Vaginal cuff closure: We used quill PDO 14 cm × 14 cm for suturing vaginal cuff via laparoscopic route. In some cases, we safely closed the vaginal cuff vaginally by using vicryl or chromic catgut. In a running fashion, to include the vaginal mucosa and the pubocervical and rectovaginal fascia. Then, we irrigated the pelvis and assured hemostasis at all pedicle sites.

10) Port site closure: The fascia at the 12 mm incision closed using 0 vicryl sutures with fascia closure device. The skin is closed with 4 - 0 monocryl or nylon suture. We can inject 20 cc of 0.5% marcaine at all incision sites to postoperative pain reduction immediately.

Cystoscopy is not a routine procedure, but in selected patients, it was performed after vaginal closure to determine the presence of signs of ureteral or bladder injury (Five minutes prior to vaginal closure, the patient is treated with 5cc of indigo carmine intravenously).

We have to know that a normal cystoscopy dose not rule out a delayed manifestation of thermal injury to either the ureter or the bladder.

Postoperative care:

We prescribed enough pain relief treatment and antiemetic for our patients. Patient goes home, the following day of operation or two days after, for close observation for early diagnosis of some postoperative complications that may occur. Our patients may return to their moderate activities by 2 - 3 weeks following surgery.

In summary, total laparoscopic hysteroscopy is a safe and effective surgical procedure for patients who need hysterectomy. We do approximately 180 - 200 laparascopic hysterectomy cases annually with rare cases of urethral, vesical, and large bowel complications.

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Background

Since the early 1990s, endoscopic adrenalectomy has become the gold standard surgical approach for the adrenal gland. Also, lateral transperitoneal adrenalectomy (LTA) which is the most widely used approach accompanies that.. Posterior retroperitonoscopic adrenalectomy (PRA) is another safe and effective approach for the adrenal gland. However, it has not gained global popularity. This is largely attributed to the unfamiliarity of surgeons with the ergonomics and executional steps of the procedure, and the relevant retroperitoneal anatomy. Misconceptions held by both surgeons and anesthesiologists regarding the consequences of the high-pressure retroperitoneal insufflation required may also be a contributing factor. The aim of this article is to provide a detailed description of PRA in a manner which allows the proper acquisition of the knowledge required to perform the procedure safely and effectively.

Methods

To achieve the objective of this article, it has been broadly divided into three sections including background, operative technique, and comments. The background provides an introduction to the procedure and its advantages. The section about operative technique provides a detailed description of the preoperative preparatory phase, the proper access, and the executional steps of the procedures supplemented with illustrative figures. It also provides insight into potential hazards related to the anatomy of the adrenal veins, and the means of dealing with variant anatomy. The comments’ section deals with the procedure’s learning curve, and the factors affecting it. It also describes the ideal case for the commencement of the learning curve. A clarification of the misconceptions surrounding PRA is also provided in this section.

Conclusion

With thorough technical knowledge and an adequate learning curve, PRA could serve as the surgeon’s preferred surgical approach to the adrenal gland within the confines of its selection criteria.

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Background

In the era of minimal access thyroid surgery, the terms minimal access and minimally invasive are often used interchangeably and in most instances this is far from being accurate. The aim of this article is to examine the characteristics and potential of one of the first minimal access thyroid procedures described; minimally invasive video-assisted thyroidectomy (MIVAT).

Methods

The purpose of this article was obtained by almost two decades of experiences with the procedure at the authors’ center, and a systemic literature review was undertaken of all available medical literature to evaluate available literature by conducting a PubMed search limited to articles originally written in English language between the years 1997 and 2016. The search was limited by using the terms: minimally invasive thyroid surgery, video-assisted, endoscopic, and robotic thyroidectomy. The procedure’s design, radicality and safety, learning curve, cost, advantages and disadvantages were addressed. MIVAT’s potential as a surgical tool for thyroid pathology was also addressed by evaluating its indications, contraindications, and limitations.

Results

MIVAT is a gasless hybrid procedure that is comparable to conventional thyroidectomy (CT) in terms of radicality and safety, with the added advantage of reduced early postoperative voice and swallowing symptoms. MIVAT has a relatively rapid learning curve with an additional advantage over other minimal access procedures; the ability of being adopted by the low-volume surgeon at a cost and time comparable to CT, but with improved patient satisfaction. Furthermore, it is non-inferior to procedures free of a neck scar in terms of patient satisfaction. MIVAT’s main drawback is that it is limited by its strict selection criteria. It is a viable treatment option for all types of thyroid pathologies. However, its role in therapeutic neck dissection remains to be validated.

Conclusions

MIVAT is a safe and effective procedure which is obviously described in its name “minimally invasive”. It seems that in the era of innovative technologies and scarless-in-the neck thyroid surgery, MIVAT is here to stay.

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Dear editor,

Nowadays advancement in all field of surgery, especially in minimally invasive surgery (MIS) has been occurred dramatically. An important part of this progression is due to the exchange of new information and innovations in the international congress , according to high-grade recommendations and high-level evidences by experienced surgeons based on valuable guidelines, including SAGES guidelines (1).

The benefits of MIS is becoming increasingly apparent that the procedure leads to better outcomes, shorter hospitalization, faster recovery, more accurate than the open method and finally better preserving the body’s physiology (2).

12th international congress of minimally invasive surgeries and techniques was held in Iran, Tehran, Razi international congress hall, from 9 to 11 November 2016 in the presence of expert MIS surgeons and other specialist from Iran and other countries. Professor Mohammad Farhadi and Abdolreza Pazouki were presented as president of the Congress and scientific secretary of the congress respectively.

Totally 119 submitted articles in abstract form were received through the MISTIC-2016 congress website and 103 (86.5%) of them were accepted that 80 (77.7%) articles considered as oral presentation and 23 (22.3%) articles accepted for poster presentation. Seven workshops were held, including Medical ethics, Laparoscopic sleeve gastrectomy, Laparoscopic colorectal surgery, Laparoscopic hernia repair, Laparoscopic liver surgery and intra-operative ultrasonography, minimally invasive plastic and reconstructive surgery and Nutritional support after bariatric surgery.

A total of 207 presentations and 7 panels were held on various subjects in MIS by invited speakers from Iran and other countries, including Professor Amjad Parvaiz from UK, Professor Biijan Ghavami from Switzerland, Professor Reza Kianmanesh from France, Professor Hamid Abbasi and Professor Kiarash Aramesh from USA.

Target audience includes general surgeons, MIS and bariatric surgeons, vascular surgeons, cardiovascular surgeons, neurosurgeons, orthopedic surgeons, plastic surgeons, colorectal surgeons, gynecologists, urologists, pediatric surgeons, thoracic surgeons, anesthesiologists, sport medicine specialists, nutritionists and nurses.

Also the congress was attended by 301 participants from Iran and other countries such as China, Iraq, United Arab Emirates, Turkey and Afghanistan.

In order to train critical factors for safe laparoscopic cholecystectomy, based on SAGES expert Delphi consensus, eight live surgery was performed by expert MIS surgeons (3). Given the importance of MIS in metabolic and bariatric surgery, as well as new innovations and rapid changes in this field and new recommendations of International Federation for the surgery of obesity (IFSO), a main part of the congress was devoted to this field (4).

Our aim in organizing this congress, was the exchange of knowledge and new techniques in MIS surgery field and we believe that holding such congresses can be effective in the advancement of surgical science worldwide.

Also we hope that the next session of congress in 2018, to be held in Tehran, more efficient.

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Dear Editor,

Dengue is an important arbovirus infection that becomes the public health threaten in several countries, at present. The expansion of the endemic area to non-tropical area results in new emerging infection in several countries. The dengue is generally an acute febrile illness with hemorrhagic complication (1). The hemorrhagic complication in dengue has a wide clinical spectrum and it is sometime serious (2). The requirement of surgical management is sometimes an important concern for the surgeon. Some dengue patients with severe bleeding such as massive gastrointestinal bleeding might need surgical management and the minimally invasive surgery plays an important role in those cases. The endoscopic management is proved useful in that situation (3, 4). Nevertheless, the transfusion is usually required for correction of the hemostatic problem in those cases since only endoscopic injection treatment is usually not adequate for management (5). The recommendation on using minimally invasive surgery in dengue patient is still controversial. Some studies report that, the minimally invasive surgery in dengue patient is discouraged due to the limitation of effectiveness (6). According to a recent report from Malaysia, Ng et al. concluded that “early surgical intervention in perforated gastric ulcer is vital in preventing further complication and reducing the risk of mortality (7).” In case with suspicious hemoperitoneum due to dengue, the laparoscope approach is also reported as a safe diagnostic approach (8). In order to select a minimally invasive surgery in dengue patient, several considerations, especially patient’s condition are important. A supportive primary prevention by recombinant hemostatic agent should be considered in case with high risk (9). In case which require emergency surgery, the use of classical approach is indicated and the appropriated plan for platelet transfusion helps improve clinical outcome (10). A specific study in this issue is interesting and recommended.