Ventral hernia repair in India: a Delphi consensus.

PURPOSE: While research on inguinal hernias is well-documented, ventral/incisional hernias still require investigation. In India, opinions on laparoscopic ventral hernia repair (LVHR) techniques are contested. The current consensus aims to standardize LVHR practice and identify gaps and unfulfilled demands that compromise patient safety and therapeutic outcomes. METHODS: Using the modified Delphi technique, panel of 14 experts (general surgeons) came to a consensus. Two rounds of consensus were conducted online. An advisory board meeting was held for the third round, wherein survey results were discussed and the final statements were decided with supporting clinical evidence. RESULTS: Experts recommended intraperitoneal onlay mesh (IPOM) plus/trans-abdominal retromuscular/extended totally extraperitoneal/mini- or less-open sublay operation/transabdominal preperitoneal/trans-abdominal partial extra-peritoneal/subcutaneous onlay laparoscopic approach/laparoscopic intracorporeal rectus aponeuroplasty as valid minimal access surgery (MAS) options for ventral hernia (VH). Intraperitoneal repair technique is the preferred MAS procedure for primary umbilical hernia < 4 cm without diastasis; incisional hernia in the presence of a vertical single midline incision; symptomatic hernia, BMI > 40 kg/m2, and defect up to 4 cm; and for MAS VH surgery with grade 3/4 American Society of Anaesthesiologists. IPOM plus is the preferred MAS procedure for midline incisional hernia of width < 4 cm in patients with a previous laparotomy. Extraperitoneal repair technique is the preferred MAS procedure for L3 hernia < 4 cm; midline hernias < 4 cm with diastasis; and M5 hernia. CONCLUSION: The consensus statements will help standardize LVHR practices, improve decision-making, and provide guidance on MAS in VHR in the Indian scenario.

Comparison of INSAT-3D retrieved total column ozone with ground-based and AIRS observations over India.

Ozone plays an important role in the thermal structure and chemical composition of the atmosphere. The present study compares the temporal and spatial distributions of Total Column Ozone (TCO) over the Indian sub-continent retrieved from a geostationary Indian National Satellite (INSAT-3D) and Atmospheric Infrared Sounder (AIRS). The INSAT-3D TCO values are also evaluated against the Dobson spectrophotometer observations at two locations. The inter-comparison results reveal a good correlation of 0.8, the bias of -5 DU, and Root Mean Square Error (RMSE) of 15 DU approximately between the TCO retrieved from INSAT-3D and AIRS. The lowest RMSE and highest correlation coefficient were found in the pre-monsoon season. The INSAT-3D and AIRS show reasonable agreement with the RMSE varying between 10 and 30 DU. On the other hand, evaluation of the INSAT-3D TCO with the ground-based observations from Dobson spectrophotometers located at New Delhi and Varanasi showed fair agreement with a maximum monthly mean correlation coefficient of 0.68 and 0.76, respectively, and RMSE varying from 11 to 16 DU for both the stations. The seasonal distribution of TCO and its variation over the Indian region has also been studied using INSAT-3D and AIRS data. The analysis exhibits strong seasonal variations, with higher values in pre-monsoon season and minimum values in winter season. The noticeable seasonal variability of TCO can be attributed to complex combination of photochemical and dynamical processes in the troposphere and stratosphere. The main objectives of the study are to compare the INSAT-3D TCO with two independent ground-based Dobson spectrophotometer observations and Atmospheric Infrared Sounder (AIRS) aboard NASA's Aqua satellite.

OSSI (Obesity and Metabolic Surgery Society of India) Guidelines for Patient and Procedure Selection for Bariatric and Metabolic Surgery.

BACKGROUND: India is the largest hub for bariatric and metabolic surgery in Asia. OSSI is committed to improve the quality of care and set the standards for its practice in India. METHODS: The first draft of OSSI guidelines was prepared by the secretary, Dr. Praveen Raj under the guidance of current President, Dr. Arun Prasad. All executive council members were given voting privileges, and the proposed guidelines were circulated on email for approval of the executive council. Guidelines were finalized after 100% agreement from all voting members and were also circulated among all OSSI members for their suggestions. RESULTS: OSSI upholds the BMI criteria for bariatric and metabolic surgery of 2011 IFSO-APC guidelines. In addition to this, we recognize that waist circumference of ≥ 80 cm in females and ≥ 90 cm in males along with obesity related co-morbidities may be considered for surgery. In addition to standard procedures as recommended by IFSO, OSSI acknowledges the additional procedures, and a review of literature for these procedures is presented in the discussion. CONCLUSION: The burden of obesity in India is one of the highest in the world and with numbers of bariatric and metabolic procedures rising rapidly; there is a need for country specific guidelines. The Indian population is unique in its phenotype, genotype and nutritional make up. This document enlists guidelines for surgeons and allied health practitioners as also multiple other stake-holders like primary health physicians, policy makers, insurance companies and the Indian government.

How Much Does Large-Scale Crop Residue Burning Affect the Air Quality in Delhi?

Elevated PM2.5 concentrations frequently cause severe air pollution events in Delhi. Till recently, the effect of crop residue burning on the air quality in Delhi has not been fully quantified and the approaches to control the impact of fire emissions have not been effective. In this study, for the first time, we quantified the statewise contribution of post-monsoon crop residue burning in the northwestern states of India to surface PM2.5 concentrations in Delhi using several sensitivity experiments with the Weather Research and Forecasting model coupled with Chemistry (WRF-Chem) and FINNv1.5 fire emission inventory. Results were evaluated with ground-based observations in Delhi (21 stations), Punjab, and Haryana (14 stations). On average, ∼20% of PM2.5 concentration in Delhi during the post-monsoon season (October-November) was found to be contributed by nonlocal fire emissions. However, on typical air pollution events, fire emissions contributed as high as 50-75% (80-120 µg/m3) to PM2.5 in Delhi, highlighting the importance of both external transport and local emissions to PM2.5 pollution in Delhi.

Influence of Cr Substitution and Temperature on Hierarchical Phase Decomposition in the AlCoFeNi High Entropy Alloy.

While the AlCoFeNi high entropy alloy exhibits a single ordered B2 phase at high temperature, both the substitution of ferromagnetic Co with antiferromagnetic Cr, and lower annealing temperatures lead to a tendency for this system to decompose into a two-phase mixture of ordered B2 and disordered BCC solid solution. The length scale of this decomposition is determined by the combination of composition and annealing temperature, as demonstrated in this investigation by comparing and contrasting AlCoFeNi with the AlCo0.5Cr0.5FeNi alloy. The resulting phase stability has been rationalized based on solution thermodynamic predictions. Additionally, it is shown that replacement of Co by Cr in the AlCoFeNi alloy resulted in a substantial reduction in saturation magnetization and increase in coercivity. The microhardness is also strongly influenced by the composition and the length scale of B2 + BCC decomposition in these high entropy alloys.

Microstructural Design for Improving Ductility of An Initially Brittle Refractory High Entropy Alloy.

Typically, refractory high-entropy alloys (RHEAs), comprising a two-phase ordered B2 + BCC microstructure, exhibit extraordinarily high yield strengths, but poor ductility at room temperature, limiting their engineering application. The poor ductility is attributed to the continuous matrix being the ordered B2 phase in these alloys. This paper presents a novel approach to microstructural engineering of RHEAs to form an "inverted" BCC + B2 microstructure with discrete B2 precipitates dispersed within a continuous BCC matrix, resulting in improved room temperature compressive ductility, while maintaining high yield strength at both room and elevated temperature.

Previously implanted intra-peritoneal mesh increases morbidity during re-laparoscopy: a retrospective, case-matched cohort study.

PURPOSE: Laparoscopic ventral hernia repair (LVHR) with intra-peritoneal mesh placement is standard surgical treatment of abdominal wall hernias. During laparoscopic re-intervention, we examined adhesions that develop after previous intra-peritoneal mesh placement and ascertained morbidity and risk of adverse events. METHODS: This is a retrospective, case-matched comparison of three patient groups-previous intra-peritoneal mesh (Group A), previous abdominal surgery (Group B) and no previous abdominal surgery (Group C). Matching was based on surgical procedure performed during laparoscopic re-intervention in Group A. Adhesions were described as grade, extent of previous mesh/scar involvement, involvement of abdominal quadrants and dissection technique required for adhesiolysis, each component being assigned value from 0 to 4. Total adhesion score (TAS) was generated as summative score for each patient (0 to 16). Access/adhesiolysis-related injuries, additional port requirement, deviations from planned surgery, operative time and length of hospital stay was noted. Relative risk of adverse events, i.e., inadvertent injuries and deviations from planned surgery, was calculated for Group A. RESULTS: Adhesion characteristics were most severe (highest TAS) in Group A. Access injuries occurred in 5, 4, 1.3% in Groups A, B, C, respectively. Adhesiolysis-related injury rate was 9%, 2.6% in Groups A, B, respectively. Relative risk of adverse events was 4 for Group A (compared to Groups B and C combined). Additional port requirement was highest for Group A. Mean operative time and length of hospital stay was significantly longer in Group A for LVHR. CONCLUSIONS: Intra-peritoneal mesh placement is associated with adhesion formation that may increase risk during subsequent laparoscopic surgery.

Abrogation of red blood cell G6PD enzyme activity through Heat treatment: development of survey material for the UK NEQAS G6PD scheme.

INTRODUCTION: Participation in external quality assessment (EQA) is central to the maintenance of high-quality laboratory results in patient diagnosis and clinical trials. Laboratories in the TAF112582 DETECTIVE study (ClinicalTrials.gov identifier: NCT01376167) are enrolled in the United Kingdom National Quality Assessment Scheme (UK NEQAS) for glucose-6-phosphate dehydrogenase (G6PD) quantitative assay, which utilizes ovine (sheep) blood as a readily available source of apparently G6PD-deficient survey material. A substitute for sheep blood was sought because some non-UK sites in the study encountered participation difficulties due to the strict regulations on the import of sheep blood into their countries. METHODS: G6PD activity in normal human donor blood was abrogated by the action of heat under controlled conditions. Residual G6PD activity in the heated samples was measured by UK NEQAS using the Trinity Biotech 345 kit (Trinity Biotech) and a Jenway 6715 UV/Vis spectrophotometer with external temperature control to monitor enzyme kinetics and linearity over a set time. Heat-treated material was also assayed for G6PD activity and assessed for its acceptability as EQA survey material by selected UK laboratories. RESULTS: Blood heated at 45 °C for 15 h showed a reduction in G6PD activity of 76.3 ± 4.6% (n = 6) and was considered acceptable as EQA material in terms of appearance and behaviour by the majority of UK sites in the trial. CONCLUSIONS: We have developed a simple heat-treatment procedure to produce EQA survey material with low/intermediate G6PD activity, similar to that found in females heterozygous for G6PD deficiency.

Assessment of aerosols optical properties and radiative forcing over an Urban site in North-Western India.

The present work is aimed to analyze aerosols optical properties and to estimate aerosol radiative forcing (ARF) from January to December 2013, using sky radiometer data over Rohtak, an urban site in North-Western India. The results reveal strong wavelength dependency of aerosol optical depth (AOD), with high values of AOD at shorter wavelengths and lower values at longer wavelength during the study period. The highest AOD values of 1.07 ± 0.45 at 500 nm were observed during July. A significant decline in Ångström exponent was observed during April-May, which represents the dominance of coarse mode particles due to dust-raising convective activities. Aerosols' size distribution exhibits a bimodal structure with fine mode particles around 0.17 µm and coarse mode particles with a radius around 5.28 µm. Single scattering albedo values were lowest during November-December at all wavelengths, ranging from 0.87 to 0.76, which corresponds to the higher absorption during this period. Aerosols optical properties retrieved during observation period are used as input for SBDART (Santa Barbara DISORT Atmospheric Radiative Transfer) to estimate the direct ARF at the surface, in the atmosphere and at the top of the atmosphere (TOA). The ARF at the TOA, surface and in the atmosphere are found to be in the range of -4.98 to -19.35 W m-2, -8.01 to -57.66 W m-2 and +3.02 to +41.64 W m-2, respectively. The averaged forcing for the whole period of observations at the TOA is -11.26 W m-2, while at the surface it is -38.64 W m-2, leading to atmospheric forcing of 27.38 W m-2. The highest (1.168 K day-1) values of heating rate was estimated during November, whereas the lowest value (0.084 K day-1) was estimated for the February.

Tethered balloon-born and ground-based measurements of black carbon and particulate profiles within the lower troposphere during the foggy period in Delhi, India.

The ground and vertical profiles of particulate matter (PM) were mapped as part of a pilot study using a Tethered balloon within the lower troposphere (1000m) during the foggy episodes in the winter season of 2015-16 in New Delhi, India. Measurements of black carbon (BC) aerosol and PM <2.5 and 10µm (PM2.5 & PM10 respectively) concentrations and their associated particulate optical properties along with meteorological parameters were made. The mean concentrations of PM2.5, PM10, BC370nm, and BC880nm were observed to be 146.8±42.1, 245.4±65.4, 30.3±12.2, and 24.1±10.3µgm-3, respectively. The mean value of PM2.5 was ~12 times higher than the annual US-EPA air quality standard. The fraction of BC in PM2.5 that contributed to absorption in the shorter visible wavelengths (BC370nm) was ~21%. Compared to clear days, the ground level mass concentrations of PM2.5 and BC370nm particles were substantially increased (59% and 24%, respectively) during the foggy episode. The aerosol light extinction coefficient (σext) value was much higher (mean: 610Mm-1) during the lower visibility (foggy) condition. Higher concentrations of PM2.5 (89µgm-3) and longer visible wavelength absorbing BC880nm (25.7µgm-3) particles were observed up to 200m. The BC880nm and PM2.5 aerosol concentrations near boundary layer (1km) were significantly higher (~1.9 and 12µgm-3), respectively. The BC (i.e BCtot) aerosol direct radiative forcing (DRF) values were estimated at the top of the atmosphere (TOA), surface (SFC), and atmosphere (ATM) and its resultant forcing were - 75.5Wm-2 at SFC indicating the cooling effect at the surface. A positive value (20.9Wm-2) of BC aerosol DRF at TOA indicated the warming effect at the top of the atmosphere over the study region. The net DRF value due to BC aerosol was positive (96.4Wm-2) indicating a net warming effect in the atmosphere. The contribution of fossil and biomass fuels to the observed BC aerosol DRF values was ~78% and ~22%, respectively. The higher mean atmospheric heating rate (2.71Kday-1) by BC aerosol in the winter season would probably strengthen the temperature inversion leading to poor dispersion and affecting the formation of clouds. Serious detrimental impacts on regional climate due to the high concentrations of BC and PM (especially PM2.5) aerosol are likely based on this study and suggest the need for immediate, stringent measures to improve the regional air quality in the northern India.

Variability in optical properties of atmospheric aerosols and their frequency distribution over a mega city "New Delhi," India.

The role of atmospheric aerosols in climate and climate change is one of the largest uncertainties in understanding the present climate and in capability to predict future climate change. Due to this, the study of optical properties of atmospheric aerosols over a mega city "New Delhi" which is highly polluted and populated were conducted for two years long to see the aerosol loading and its seasonal variability using sun/sky radiometer data. Relatively higher mean aerosol optical depth (AOD) (0.90 ± 0.38) at 500 nm and associated Angstrom exponent (AE) (0.82 ± 0.35) for a pair of wavelength 400-870 nm is observed during the study period indicating highly turbid atmosphere throughout the year. Maximum AOD value is observed in the months of June and November while minimum is in transition months March and September. Apart from this, highest value of AOD (AE) value is observed in the post-monsoon [1.00 ± 0.42 (1.02 ± 0.16)] season followed by the winter [0.95 ± 0.36 (1.02 ± 0.20)] attributed to significance contribution of urban as well as biomass/crop residue burning aerosol which is further confirmed by aerosol type discrimination based on AOD vs AE. During the pre-monsoon season, mostly dust and mixed types aerosols are dominated. AODs value at shorter wavelength observed maximum in June and November while at longer wavelength maximum AOD is observed in June only. For the better understanding of seasonal aerosol modification process, the aerosol curvature effect is studied which show a strong seasonal dependency under a high turbid atmosphere, which are mainly associated with various emission sources. Five days air mass back trajectories were computed. They suggest different patterns of particle transport during the different seasons. Results suggest that mixtures of aerosols are present in the urban environment, which affect the regional air quality as well as climate. The present study will be very much useful to the modeler for validation of satellite data with observed data during estimation of radiative effect.

Carbonaceous aerosols and pollutants over Delhi urban environment: Temporal evolution, source apportionment and radiative forcing.

Particulate matter (PM2.5) samples were collected over Delhi, India during January to December 2012 and analysed for carbonaceous aerosols and inorganic ions (SO4(2-) and NO3(-)) in order to examine variations in atmospheric chemistry, combustion sources and influence of long-range transport. The PM2.5 samples are measured (offline) via medium volume air samplers and analysed gravimetrically for carbonaceous (organic carbon, OC; elemental carbon, EC) aerosols and inorganic ions (SO4(2-) and NO3(-)). Furthermore, continuous (online) measurements of PM2.5 (via Beta-attenuation analyser), black carbon (BC) mass concentration (via Magee scientific Aethalometer) and carbon monoxide (via CO-analyser) are carried out. PM2.5 (online) range from 18.2 to 500.6µgm(-3) (annual mean of 124.6±87.9µgm(-3)) exhibiting higher night-time (129.4µgm(-3)) than daytime (103.8µgm(-3)) concentrations. The online concentrations are 38% and 28% lower than the offline during night and day, respectively. In general, larger night-time concentrations are found for the BC, OC, NO3(-)and SO4(2-), which are seasonally dependent with larger differences during late post-monsoon and winter. The high correlation (R(2)=0.74) between OC and EC along with the OC/EC of 7.09 (day time) and 4.55 (night-time), suggest significant influence of biomass-burning emissions (burning of wood and agricultural waste) as well as secondary organic aerosol formation during daytime. Concentrated weighted trajectory (CWT) analysis reveals that the potential sources for the carbonaceous aerosols and pollutants are local emissions within the urban environment and transported smoke from agricultural burning in northwest India during post-monsoon. BC radiative forcing estimates result in very high atmospheric heating rates (~1.8-2.0Kday(-1)) due to agricultural burning effects during the 2012 post-monsoon season.

Minimally Invasive Anal Fistula Treatment (MAFT)-An Appraisal of Early Results in 416 Patients.

Minimally invasive anal fistula treatment (MAFT) was introduced to minimize early postoperative morbidity, preserve sphincter continence, and reduce recurrence. We report our early experience with MAFT in 416 patients. Preoperative MRI was performed in 150 patients initially and subsequently thereafter. The technique involves fistuloscope-aided localization of internal fistula opening, examination and fulguration of all fistula tracks, and secure stapled closure of internal fistula opening within anal canal/rectum. MAFT was performed as day-care procedure in 391 patients (93.9 %). During surgery, internal fistula opening could not be located in 100 patients (24 %). Seven patients required readmission to hospital. Mean visual analog scale scores for pain on discharge and at 1 week were 3.1 (1-6) and 1.6 (0-3), respectively. Mean duration for return to normal activity was 3.2 days (2-11 days). Fistula recurrence was observed in 35/134 patients (26.1 %) at 1 year follow-up. MAFT may be performed as day-care procedure with benefits of less pain, absence of perianal wounds, faster recovery, and preservation of sphincter continence. However, long-term results from more centers are needed especially for recurrence.

An early South Asian dust storm during March 2012 and its impacts on Indian Himalayan foothills: a case study.

The impacts of an early South Asian dust storm that originated over the western part of the Middle East and engulfed northwest parts of India during the third week of March 2012 have been studied at four different stations covering India and Pakistan. The impacts of this dust storm on aerosol optical properties were studied in detail at Delhi, Jodhpur, Lahore and Karachi. The impact could also be traced up to central Himalayan foothills at Manora Peak. During dust events, the aerosol optical depth (AOD) at 500 nm reached a peak value of 0.96, 1.02, 2.17 and 0.49 with a corresponding drop in Ångström exponent (AE for 440-870 nm) to 0.01, -0.02, 0.00 and 0.12 at Delhi, Jodhpur, Lahore and Karachi, respectively. The single scattering albedo (SSA) at 675 nm was relatively lower at Delhi (0.87) and Jodhpur (0.86), with absorption Ångström exponent (AAE) less than 1.0, but a large value of SSA was observed at Lahore (0.98) and Karachi (0.93), with AAE value greater than 1.0 during the event. The study of radiative impact of dust aerosols revealed a significant cooling at the surface and warming in the atmosphere (with corresponding large heating rate) at all the stations during dust event. The effect of this dust storm was also seen at Manora Peak in central Himalayas which showed an enhancement of ~28% in the AOD at 500 nm. The transport of dust during such events can have severe climatic implications over the affected plains and the Himalayas.

Cuckoo search algorithm based satellite image contrast and brightness enhancement using DWT-SVD.

This paper presents a new contrast enhancement approach which is based on Cuckoo Search (CS) algorithm and DWT-SVD for quality improvement of the low contrast satellite images. The input image is decomposed into the four frequency subbands through Discrete Wavelet Transform (DWT), and CS algorithm used to optimize each subband of DWT and then obtains the singular value matrix of the low-low thresholded subband image and finally, it reconstructs the enhanced image by applying IDWT. The singular value matrix employed intensity information of the particular image, and any modification in the singular values changes the intensity of the given image. The experimental results show superiority of the proposed method performance in terms of PSNR, MSE, Mean and Standard Deviation over conventional and state-of-the-art techniques.

Iatrogenic enterotomy in laparoscopic ventral/incisional hernia repair: a single center experience of 2,346 patients over 17 years.

PURPOSE: Iatrogenic enterotomy (IE) during laparoscopic ventral/incisional hernia repair (LIVHR) is reported to be associated with poorer surgical outcomes. We report our experience with diagnosis, management and complications in patients who had IE during LIVHR at our tertiary referral institute between 1994 and 2011. METHODS: We retrospectively reviewed prospectively collected data of 2,346 patients who underwent LIVHR from 1994 to 2011. We identified 33 patients who had IE during LIVHR. All surgical procedures were performed by five consultants and fellows under supervision who followed a standardized operative protocol. Patients were followed up for 6 months to evaluate morbidity, mortality, additional surgical procedures, unplanned readmissions and hospital stay. RESULTS: Mortality occurred in 2 patients (6 %). Complications occurred in 16 patients (48.5 %). Median hospital stay was 3 days (2-36). Unplanned readmission was required in 6 patients (18 %). In 18 patients, (55 %) additional surgical procedures were required within 6 months of LIVHR. In 5 patients, the enterotomy was recognized postoperatively. These patients had worst outcomes [mortality 40 %, additional surgical procedures were required in all patients (100 %) and median hospital stay was 12 days (range 7-36)]. CONCLUSION: Iatrogenic enterotomy is a serious complication during LIVHR. IE is associated with mortality, morbidity, additional surgical procedures, unplanned readmissions and prolonged hospital stay. In patients where IE was recognized postoperatively, the prognosis was worst.

Enhanced mechanical strength and biocompatibility of electrospun polycaprolactone-gelatin scaffold with surface deposited nano-hydroxyapatite.

In this study for the first time, we compared physico-chemical and biological properties of polycaprolactone-gelatin-hydroxyapatite scaffolds of two types: one in which the nano-hydroxyapatite (n-HA) was deposited on the surface of electrospun polycaprolactone-gelatin (PCG) fibers via alternate soaking process (PCG-HAAS) and other in which hydroxyapatite (HA) powders were blended in electrospinning solution of PCG (PCG-HAB). The microstructure of fibers was examined by scanning electron microscopy (SEM) and transmission electron microscopy (TEM) which showed n-HA particles on the surface of the PCG-HAAS scaffold and embedded HA particles in the interior of the PCG-HAB fibers. PCG-HAAS fibers exhibited the better Young's moduli and tensile strength as compared to PCG-HAB fibers. Biological properties such as cell proliferation, cell attachment and alkaline phosphatase activity (ALP) were determined by growing human osteosarcoma cells (MG-63) over the scaffolds. Cell proliferation and confocal results clearly indicated that the presence of hydroxyapatite on the surface of the PCG-HAAS scaffold promoted better cellular adhesion and proliferation as compared to PCG-HAB scaffold. ALP activity was also observed better in alternate soaked PCG scaffold as compared to PCG-HAB scaffold. Mechanical strength and biological properties clearly demonstrate that surface deposited HA scaffold prepared by alternate soaking method may find application in bone tissue engineering.

Single port versus multiple port laparoscopic cholecystectomy-a comparative study.

Single port laparoscopic cholecystectomy (SPLC) was introduced to minimize postoperative morbidity and improve cosmesis. We performed a comparative study to assess feasibility, safety and perceived benefits of SPLC. Two groups of patients (104 each) with comparable demographic characteristics were selected for SPLC and multiport laparoscopic cholecystectomy (MPLC) between May 2010 to March 2011. SPLC was performed using X cone® with 5 mm extra long telescope and 3 ports for hand instruments. MPLC was performed with traditional 4 port technique. A large window was always created during dissection to obtain the critical view of safety. Data collection was prospective. The primary end points were post-operative pain and surgical complications. Secondary end points were patient assessed cosmesis and satisfaction scores and operating time. The mean VAS scores for pain in SPLC group were higher on day 0 (SPLC 3.37 versus MPLC 2.72, p = 0.03) and equivalent to MPLC group on day 1(SPLC 1.90 versus MPLC 1.79, p = 0.06). Number of patients requiring analgesia for breakthrough pain (SPLC 21.1 % versus MPLC 26.9 %, p = 0.31) was similar. Number and nature of surgical complications was similar (SPLC 17.3 % versus MPLC 21.2 %, p =0.59). Mean patient assessed cosmesis scores (SPLC 7.96 versus MPLC 7.16, p = 0.003) and mean patient satisfaction scores (SPLC 8.66 versus MPLC 8.16, p = 0.004) were higher in SPLC group indicating better cosmesis and greater patient satisfaction. SPLC took longer to perform (61 min versus 26 min, p = 0.00). Conversion was required in 5 patients in SPLC group. SPLC appears to be feasible and safe with cosmetic benefits in selected patients. However, challenges remain to improve operative ergonomics. SPLC needs to be proven efficacious with a high safety profile to be accepted as standard laparoscopic technique.

Withania somnifera chemotypes NMITLI 101R, NMITLI 118R, NMITLI 128R and withaferin A protect Mastomys coucha from Brugia malayi infection.

Withania somnifera is an ayurvedic Indian medicinal plant whose immunomodulatory activities have been widely used as a home remedy for several ailments. We recently observed immunostimulatory properties in the root extracts of chemotypes NMITLI-101, NMITLI-118, NMITLI-128 and pure withanolide, withaferin A. In the present study, we evaluated the potential immunoprophylactic efficacies of these extracts against an infective pathogen. Our results show that administration of aqueous ethanol extracts (10 mg/kg) and withaferin A (0·3 mg/kg), 7 days before and after challenge with human filarial parasite Brugia malayi, offers differential protection in Mastomys coucha with chemotype 101R offering best protection (53·57%) as compared to other chemotypes. Our findings also demonstrate that establishment of B. malayi larvae was adversely affected by pretreatment with withaferin A as evidenced by 63·6% reduction in adult worm establishment. Moreover, a large percentage of the established female worms (66·2%) also showed defective embryogenesis. While the filaria-specific immunological response induced by withaferin A and NMITLI-101 showed a mixed Th1/Th2 phenotype, 118R stimulated production of IFN-γ and 128R increased levels of IL-4. Taken together, our findings reveal potential immunoprophylactic properties of W. somnifera, and further studies are needed to ascertain the benefits of this plant against other pathogens as well.

Management of common bile duct stones in the laparoscopic era.

There is no consensus regarding the ideal management of concurrent gallbladder and common bile duct (CBD) stones. Currently the treatment protocol involves most commonly a sequential approach consisting of endoscopic sphincterotomy followed by laparoscopic cholecystectomy or a single stage laparoscopic procedure, including cholecystectomy and exploration of the CBD. For this article literature search was performed using online search engines, Google, Pubmed, the online Springer link library and the Cochrane Database Systematic Review. Review articles, prospective and retrospective studies which detailed or compared the various treatment strategies for CBD stones were selected and analyzed. This review article aims to provide an insight into the optimal management of CBD stones in different clinical scenarios. Endoscopic sphincterotomy has inherent morbidity and complications like CBD stone recurrence whereas laparoscopic CBD exploration demands considerable expertise which is available only at specialized centres. The clinical presentation of the patient, number of stones, size of CBD, available resources and technical expertise at hand are an important consideration for the ideal management in different scenarios.