Bilateral seminomas coexisting with adenomatoid tumor: An unusual occurrence.

Coexistence of bilateral seminomas and adenomatoid tumor is rare. We encountered an interesting case of bilateral testicular seminomas along with a paratesticular nodule which was diagnosed as an adenomatoid tumor on histology. Although seminomas and adenomatoid tumor are frequent neoplasms, bilaterality and their coexistence have been rarely described and can pose diagnostic difficulties. Herein, we describe a case of a 53-year-old man who presented with bilateral testicular swellings which were diagnosed as bilateral seminomas with an adenomatoid tumor in the left paratesticular region on histopathology. The pathological findings of these coexistent tumors and the utility of immunohistochemistry in establishing a correct diagnosis in such scenarios are discussed.

Mini Totally Extra-Peritoneal Repair of Inguinal Hernia with All 5 mm Ports: An Innovative "555 Technique".

BACKGROUND: Totally extra-peritoneal (TEP) repair of inguinal hernia is now a standard surgical technique. A 12 mm incision in infra-umbilical region for Hasson trocar is must for TEP repair of inguinal hernia. This is the only technique known to laparoscopic surgeons. We have innovated a "555 Technique" for completing Mini TEP repair of inguinal hernia by using all three 5 mm ports. METHODS: Sixty-one consecutive patients were subjected for TEP repair of inguinal hernia by our innovative "555 Technique" since October 2014. A simple "Manish Retractor" is devised to make extra-peritoneal space with 5 mm trocar. Fifty-nine cases were men and 2 cases were women. The mean age of patients was 44.6 years (range 23-82 years). RESULTS: Out of 61 cases, 27 were indirect inguinal hernia (23 unilateral, 4 bilateral), 32 direct inguinal hernia (21 unilateral, 11 bilateral), 1 femoral hernia, and 1 obturator hernia. One patient of indirect inguinal hernia had sliding hernia with sigmoid colon. Sixty cases were successfully operated by "555 Technique." There was conversion to trans-abdominal pre-peritoneal repair (TAPP) in 1 case. The average time for insertion of 5 mm trocar in preperitoneal space by our technique was 150 seconds. No complications were noted on 6 months follow-up. Small infra-umbilical scar was cosmetically more acceptable to patients. CONCLUSION: "555 Technique" is a feasible option without compromising the principles of TEP repair for inguinal hernia. Innovation of simple "Manish Retractor" is the key in completing Mini TEP repair. This technique is simple, less invasive, less morbid, and cost effective as it avoids dependence over costly Hasson trocar with better cosmetic results.

Solitary neurofibroma of the adrenal gland not associated with type-1 neurofibromatosis.

Neurofibromas are tumors of neural origin. They can be solitary or may be associated with neurofibromatosis type-1 (NF-1). These are mostly seen in the head and neck region, upper extremities or along the nerves. Visceral neurofibromas are extremely rare. In this paper, we present an unusual case of solitary neurofibroma of the adrenal gland not associated with NF-1.

Primary endobronchial histiocytic sarcoma in a case of papillary carcinoma thyroid: a complex clinical scenario.

Histiocytic sarcoma is a rare malignant neoplasm showing histiocytic differentiation. We document a case of a 55-year-old man presenting with cough and breathlessness following a subtotal thyroidectomy for infiltrating papillary thyroid carcinoma. An endobronchial growth was seen on endoscopy. Histopathologic examination revealed a neoplasm of histiocytic lineage with positivity for leucocyte common antigen, Vimentin, CD68, CD4, and CD45RO. To the best of our knowledge, primary endobronchial histiocytic sarcoma in association with infiltrating papillary thyroid carcinoma has not been reported in the literature so far. Our case emphasizes the importance of clinicopathologic and radiologic correlation in resolving difficult diagnostic dilemmas.

Malignancy of parathyroid: An uncommon clinical entity.

Parathyroid carcinoma is a very rare cause of hyperparathyroidism. The diagnosis is usually established on histopathological grounds of capsular and vascular invasion, but a potential clue to the diagnosis is also offered by the severity of clinical profile, abrupt onset of symptoms, and a high degree of hypercalcemia and raised serum parathyroid hormone (PTH). We report a case of an elderly female with a prolonged history of generalized weakness and bone pain along with bilateral renal calculi, classical bony lesions, and a high serum calcium and PTH level who underwent a right inferior parathyroidectomy considering a parathyroid adenoma as our diagnosis. However, the biopsy report was consistent with a parathyroid carcinoma, and so, she was further subjected to an ipsilateral hemithyroidectomy as a completion procedure. So, we would like to emphasize that its preferable to have a high index of suspicion for parathyroid carcinoma when these clues are present, than to miss the opportunity for surgical cure in the first go by failing to consider it in the differential diagnosis.

Laparoscopic totally extraperitoneal repair of inguinal hernia: a policy of selective mesh fixation over a 10-year period.

INTRODUCTION: The issue of mesh fixation in laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia repairs remains unresolved. The need for fixing the mesh arises from the fear of increasing recurrence rates. However, specific complications have emerged as a result of mesh fixation. MATERIALS AND METHODS: A retrospective analysis of 822 laparoscopic TEP hernia repairs in 634 patients over a 10-year period in a single surgical unit was performed. A policy of selective mesh fixation was followed and guidelines regarding indications of mesh fixation formulated. Recurrence rates and complications specific to mesh fixation were evaluated. RESULTS: Mesh was fixed in only 28 of 822 repairs. There were 6 (0.7%) recurrences. No neuropathic or mesh-fixation-related complications were noted in a follow-up period ranging from 10 to 82 months. CONCLUSIONS: Avoiding routine fixation of the mesh helps in decreasing complications and operative costs with acceptable recurrence rates. However, a policy of selective mesh fixation is advocated, based on specific indications.

Factors influencing development of subcutaneous carbon dioxide emphysema in laparoscopic totally extraperitoneal inguinal hernia repair.

BACKGROUND: There is a paucity of published data on the incidence of subcutaneous emphysema and the causative factors responsible for its occurrence during laparoscopic procedures. This study was undertaken to evaluate the incidence and factors associated with the occurrence of subcutaneous emphysema in patients undergoing a laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. MATERIALS AND METHODS: The prospective study included 100 patients who presented with a primary inguinal hernia and underwent an elective laparoscopic TEP hernia repair from November 2003 to May 2005. Various factors, including age, body mass index (BMI), type of hernia (i.e., unilateral or bilateral, indirect or direct), duration of surgery, and end-tidal carbon-dioxide tension (start and peak), were evaluated. A grading system was evolved to document clinically apparent subcutaneous emphysema immediately and at 6 and 24 hours after the surgical procedure. RESULTS: A BMI <25, longer operating time (especially >1 hour), and higher end-tidal carbon-dioxide tension (start, peak, and difference) were found to be significantly associated with the development of subcutaneous emphysema. Age and type of hernia -- unilateral versus bilateral, direct versus indirect -- were not found to be statistically significant factors. CONCLUSIONS: The incidence of subcutaneous emphysema in laparoscopic extraperitoneal hernia repairs is high and largely under-reported. Once it is noted, the progression of the surgical emphysema during this type of surgery can have serious complications (e.g., cardiovascular and hemodynamic disturbances) unless timely, appropriate measures are taken. Etiology of subcutaneous emphysema is multifactorial, with no single factor having a prominent association.

Retroperitoneoscopic heminephrectomy of a horseshoe kidney for calculus disease.

Retroperitoneoscopic management of complications of a horseshoe kidney provides a feasible and effective alternative to conventional management. We describe a patient who had presented with multiple calculi and a poorly functioning left moiety of a horseshoe kidney, in whom we performed a retroperitoneoscopic left heminephrectomy. Most of the previous reports of laparoscopic nephrectomy have been described via the transperitoneal route. Division of the isthmus was done using ultrasonic shears. The patient had an uneventful recovery and was discharged within 24 hours.

Subcutaneous carbon dioxide emphysema following endoscopic extraperitoneal hernia repair: possible mechanisms.

We report on a patient who developed subcutaneous emphysema with hypercarbia during an endoscopic, totally extraperitoneal (TEP) repair of an inguinal hernia. The possible mechanisms of carbon dioxide (CO2) insufflation causing emphysema of the subcutaneous tissues are discussed and ways to prevent it are proposed.