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.

Laparoscopic modified e-tep repair of concomitant inguinal and ventral hernias.

BACKGROUND: Laparoscopic hernia repair in recent times has gained the most acceptance among both the surgical community and the patient groups, as it has proven benefits of lesser postoperative hospital stay and less pain scores. The incidence of both inguinal and ventral hernias has increased significantly in the present days. Various methods have been postulated by different surgical groups for repairing the same but no there is no standard consensus on managing concomitant inguinal and ventral hernias. The conventional e-TEP requires an extensive dissection with increased operative time. We present our experience in managing cases with both inguinal and primary M2/M3 and W1 ventral hernias with or without divarication of recti using a modified up to down approach for inguinal hernia followed by down to up approach for the ventral hernia, from a tertiary care center in South India. MATERIALS AND METHODS: We managed 16 cases with simultaneous incidence of inguinal and primary M2/M3 and W1 ventral hernias with or without divarication of recti between January 2022 and November 2023. Institute ethical committee clearance and informed consent was obtained from all the 16 patients. They were all subjected to an extra peritoneal repair of both the hernias. All the demographic data, intraoperative data, postoperative complications and follow up were digitally stored. All patients were followed up for six months after surgery. RESULTS: Out of 16 patients, 15 were males and 1 was female. The mean age was 48 years and the mean BMI of all the patients was 29.2 kg/m2. The postoperative recovery was smooth in all patients and being discharged within 24 h after surgery. The pain scores of all patients were significantly lower than patients who underwent intraperitoneal repair. CONCLUSION: e-TEP hernia repair is gaining popularity and has amused the hernia surgical community. Our method of e-TEP RS repair in cases with concomitant inguinal and primary M2/M3 W1 ventral hernias with or without divarication helps in addressing both the hernias in the extra-peritoneal space. Our technique reduces the area of dissection needed for mesh placement and preserves the integrity of abdominal musculature in the upper abdomen when compared with the conventional technique. It further allows extension of the e-TEP inguinal space into the Rectro rectus space without much alteration in the port arrangement allowing simultaneous repair of groin and umbilical hernias. Good knowledge of anatomy and laparoscopic skills are pertinent for safe and effective hernia repair by this technique.

A rare case of duodenal inversum- A laparoscopically manageable entity.

Duodenal inversum is a rare disease not frequently encountered in clinical practice. The diagnosis is usually made late due to its rarity. Many other causes of abdominal pain like ulcer disease, pancreatitis, malrotation are mostly thought of initially and the diagnosis is usually missed. Only a few cases of duodenal inversum present with outlet obstruction. Duodenojejunostomy is perhaps the ideal management for duodenal inversum if the patient presents with outlet obstruction. Our intention is to create awareness of such a rare disease with an available definitive treatment option in the form of minimally invasive surgery. One such case of a 31-year-old man is described that was successfully managed by laparoscopic duodenojejunostomy.

Effectiveness of pectoralis major myocutaneous flap in the surgical management of oral cancer: A retrospective study.

INTRODUCTION: Over 80,000 oral cancer cases get diagnosed each year in India, majority undergoing extensive resections owing to their late presentation. Pectoralis major myocutaneous (PMMC) flap is a pedicled axial pattern flap which is based on thoracoacromical artery. It is readily available as a viable alternative to free flap reconstruction, especially for the economically poor and malnourished patients. Its proximity to head and neck structures gives added advantage to reconstruct complex and large volume oral and maxillofacial defects. It provides a relatively good possibility of functional and aesthetic restoration providing both mucosal lining and skin cover. MATERIALS AND METHODS: This was a prospective observational study of 29 PMMC flap reconstructions, conducted between 2013-2016. The reconstruction outcomes assessed in this study were divided into two categories namely "success" and "failure" based on certain functional parameters observed during follow-up of 1 year. The complications were broadly classified as major/minor and flap related/non-flap related. We assessed the feasibility of using a PMMC flap for reconstructing various subsites of oral cavity cancer. Further, the association of patient variables with complication rates and outcome of reconstruction were analysed. RESULTS: Out of 29 patients overall complications were noted in 15 (51.7%) cases with a female preponderance. Flap-related complications were noted in 9 whereas non-flap-related complications were seen in 6 patients. Major and minor complications were noted in 2 (both flap related) and 13 cases respectively. Complete full thickness flap necrosis was not encountered in any patient. Patients with flap skin paddle size ≤ 36 cm2 (n = 12) had significantly increased overall complication rates. Despite complications a high success rate (93.1%, n = 27) was achieved with this mode of reconstruction. CONCLUSION: The PMMC flap reconstruction is a versatile, reliable and an affordable single staged procedure with a high success rate in terms of achieving treatment goals. Although it has moderately high complication rates, but PMMC flap proved to be a workhorse in locally advanced cases of head and neck cancer at the end of 1 year follow-up.

Effects of water deficit stress on agronomic and physiological responses of rice and greenhouse gas emission from rice soil under elevated atmospheric CO2.

Rice is the foremost staple food in the world, safeguarding the global food and nutritional security. Rise in atmospheric carbon dioxide (CO2) and water deficits are threatening global rice productivity and sustainability. Under real field conditions these climatic factors often interact with each other resulting in impacts that are remarkably different compared to individual factor exposure. Rice soils exposed to drought and elevated CO2 (eCO2) alters the biomass, diversity and activity of soil microorganisms affecting greenhouse gas (GHG) emission dynamics. In this review we have discussed the impacts of eCO2 and water deficit on agronomic, biochemical and physiological responses of rice and GHGs emissions from rice soils. Drought usually results in oxidative stress due to stomatal closure, dry weight reduction, formation of reactive oxygen species, decrease in relative water content and increase in electrolyte leakage at almost all growth and developmental phases of rice. Elevated atmospheric CO2 concentration reduces the negative effects of drought by improving plant water relations, reducing stomatal opening, decreasing transpiration, increasing canopy photosynthesis, shortening crop growth period and increasing the antioxidant metabolite activities in rice. Increased scientific understanding of the effects of drought and eCO2 on rice agronomy, physiology and GHG emission dynamics of rice soil is essential for devising adaptation options. Integration of novel agronomic practices viz., crop establishment methods and alternate cropping systems with improved water and nutrient management are important steps to help rice farmers cope with drought and eCO2. The review summarizes future research needs for ensuring sustained global food security under future warmer, drier and high CO2 conditions.

Sella Turcica Bridging As A Predictor Of Class II Malocclusion-An Investigative Study.

BACKGROUND: Sella turcica, the bony depression located in sphenoid bone houses and protects the pituitary gland. Formation and development of the sella turcica and teeth share, in common, the involvement of neural crest cells. The anterior part of the sella turcica is believed to develop mainly from neural crest cells, and dental epithelial progenitor cells differentiate through sequential and reciprocal interaction with neural crest-derived mesenchyme. Thus, any structural deviations in the sella, like bridging or roofing, are believed to be related to specific deviations in the facial skeleton and dental anomalies. Until now, there have been no studies concerning the prevalence of sella turcica bridging in skeletal Class II subjects. OBJECTIVE: The aim of this study was to analyse the prevalence of sella turcica bridging in subjects with class I and class II skeletal types and to check whether sella can be considered as diagnostic marker for skeletal class II malocclusion. MATERIALS AND METHODS: Lateral cephalometric images of 205 subjects in the age range of 13 to 25 years were retrospectively analysed and classified for the type of skeletal malocclusion and the radiographs were evaluated for the prevalence of bridging of the sella in these subjects. RESULTS: The results show significance in the prevalence of sella turcica bridging (partial/complete) among subjects with skeletal class II malocclusion.

Development and validation of a training and assessment tool for laparoscopic radical nephrectomy. / Desarrollo y validación de una herramienta de entrenamiento y evaluación para la nefrectomía radical laparoscópica.

INTRODUCTION: Laparoscopic radical nephrectomy(LRN) is a cornerstone in managing renal cancer and small renal masses. Twenty-first century surgical training faces challenges, thus must be efficient and safe so surgeons attain relevant skills, protecting patients and operative outcomes. This study aimed to systematically develop a tool for training and assessment in LRN and validate the developed tool for use by trainee urologists. METHODS: This prospective, longitudinal, multi-institutional study was undertaken from September 2014 - June 2015. Healthcare Failure Mode and Effect Analysis was utilised for development and followed by validation where the assessment tool was distributed to five specialists to increase content validity. Four experts were observed as a multi-institutional approach. Hand-assisted, transperitoneal and retroperitoneal approaches were considered. RESULTS: The LRN Assessment Tool comprised four phases, 17 processes, 41 sub-processes. Four surgeons and operating teams were observed across four hospitals for 19.5hours (5.75h hand-assisted, 8.75h trans-peritoneal, 5h retro-peritoneal). After hazard analysis, three checklists were constructed. Those for hand-assisted LRN and transperitoneal LRN contained four phases, 20 processes, 33 sub-processes and that for retroperitoneal LRN contained four phases, 20 processes, 30 sub-processes. These were merged to form one assessment tool. The final result was a four phase LRN Assessment Tool with 17 processes, 41 sub-processes. All participants agreed the final LRN Assessment Tool included pertinent steps. CONCLUSIONS: The LRN Assessment Tool was developed using Healthcare Failure Mode and Effect Analysis risk analysis to ensure hazardous procedural sub-steps were included. Validation ascertained important processes were not overlooked. Full application through a pilot study must be undertaken.

The role of cognitive training in endourology: a randomised controlled trial. / El papel de la formación cognitiva en la endourología: un ensayo controlado aleatorizado.

INTRODUCTION: Cognitive training is an important training modality which allows the user to rehearse a procedure without physically carrying it out. This has led to recent interests to incorporate cognitive training within surgical education but research is currently limited. The use of cognitive training in surgery is not clear-cut and so this study aimed to determine whether, relative to a control condition, the use of cognitive training improves technical surgical skills on a ureteroscopy simulator, and if so whether one cognitive training method is superior. METHODS: This prospective, comparative study recruited 59 medical students and randomised them to one of three groups: control- simulation training only (n=20), flashcards cognitive training group (n=20) or mental imagery cognitive training group (n=19). All participants completed three tasks at baseline on the URO Mentor simulator followed by the cognitive intervention if randomised to receive it. Participants then returned to perform an assessment task on the simulator. Outcome measures from the URO Mentor performance report was used for analysis and a quantitative survey was given to all participants to assess usefulness of training received. RESULTS: This study showed cognitive training to have minimal effects on technical skills of participants. The mental imagery group had fewer laser misfires in the assessment task when compared to both control and flashcards group (P=.017, P=.036, respectively). The flashcards group rated their preparation to be most useful when compared to control (P=.0125). Other parameters analysed between the groups did not reach statistical significance. Cognitive training was found to be feasible and cost effective when carried out in addition to simulation training. CONCLUSION: This study has shown that the role of cognitive training within acquisition of surgical skills is minimal and that no form of cognitive training was superior to another. Further research needs to be done to evaluate other ways of performing cognitive training.

Paratharmone related protein (peptide): A novel prognostic, diagnostic and therapeutic marker in Head & Neck cancer.

Parathyroid hormone-related protein (PTHrP) is a promising modality of assessment of different critical features of cancer. It is a protein member of parathyroid hormone family, secreted by certain physiologic cells and by malignant tumors in an increased amount. Recent studies have confirmed that PTHrP massively contributes to malignant behaviour of oral cancers-cell proliferation, migration and invasiveness. Strong correlation was found between PTHrP overexpression and local bone invasion and percentage of tumor cells in metastatic nodes. Normal range of PTHrP in serum is 0.7-2.6ρmol/litre. Its down-regulation blocks cell cycle of cancer cell lines and inhibits cell proliferation and colony formation. PTHrP can be used as a diagnostic aid, prognostic marker and excellent research arena for designing novel anti-neoplastic drugs.

King's Health Partners' Prostate Cancer Biobank (KHP PCaBB).

The KHP PCaBB was established in 2013 and recruits donors from the Urology or Oncology Departments at Guy's Hospital in London (UK). Prostate cancer patients may be approached to give their consent for biobanking at any point in their treatment pathway, which allows residual material from their earlier diagnosis to be transferred and used by the Biobank. Currently, patients are specifically asked to donate samples of blood and surplus prostate tissue as well as permitting access to their clinical and pathological data that continues to be added throughout the course of their disease. Between 2013 and 2015, 549 prostate cancer patients gave their consent to the biobank and, the tissue repository collected 489 blood samples, 120 frozen prostate tissue samples and 1064 formalin fixed paraffin embedded diagnostic blocks.Prostate cancer has become a chronic disease in a large proportion of men, with many men receiving multiple subsequent treatments, and their treatment trajectory often spanning over decades. Therefore, this resource aims to provide an ideal research platform to explore potential variations in treatment response as well as disease markers in the different risk categories for prostate cancer.A recent audit of the KHP PCaBB revealed that between 2013 and 2015, 1796 patients were diagnosed with prostate cancer at King's Health Partners (KHP), out of which 549 (30.6%) gave their consent to KHP PCaBB. Comparisons between demographic and clinical characteristics of patients who had consented compared to the total patient population revealed that the KHP PCaBB is demographically representative of the total prostate cancer patient population seen in Guy's and St Thomas' NHS Foundation Trust (GSTT). We observed no differences in distribution of ethnicity (p = 0.507) and socioeconomic status (p = 0.097). Some differences were observed in clinical characteristics, specifically with treatment type - which differed significantly between the patients who had given consent and total patient population.The KHP PCaBB has thereby amassed a rich data and tissue repository that is largely reflective of both the demographic and clinical diversity within the total prostate cancer patient population seen at KHP, making it an ideal platform for prostate cancer research.

Morphological variations of median maxillary labial frenum: A clinical study.

BACKGROUND: Median maxillary labial frenum (MMLF) appears as a fold of mucous membrane extending from the lining of the mucous membrane of the lips towards the crest of the alveolar ridge on the labial surface. MMLF can demonstrate certain variations in their shape, size and position, both among individuals and within the same individual at different ages. Many clinicians, not being aware of the normal variations of median maxillary labial frenum misinterpret them as pathological entities. OBJECTIVES: The objectives of the study were to determine the prevalence of morphologic variations of MMLF, to classify the morphological variations of MMLF on the basis of their location on the frenum and to compare the morphological variations of MMLF among different age groups and genders. MATERIALS AND METHODS: The study was conducted on 700 males and 700 females of age 5 to 74 yrs, chosen randomly. They were equally divided on the basis of age into 7 groups, each group having equal gender distribution. The morphological variations of MMLF were classified according to Sewerin's classification and the attachments on the freni were further sub-classified. RESULTS: The commonest type of frenum was found to be the simple type, whereas bifid frenum was not found at all. Statistically significant difference was found in proportion of types of frenum among the different age groups and also in proportion of types of frenum among the different sites of presence of frenal attachments. No statistically significant difference was found in proportion of types of frenum in male and female subjects. CONCLUSION: This study shows that MMLF presents with an array of morphological variations. These morphological variations may sometimes pose a complicating factor in maintaining oral hygiene, speech, mastication, esthetics, denture construction, etc. Hence, appropriate recognition of frenal variations and subsequent modification of treatment procedures are essential for a successful outcome of therapy.

Precision surgery and genitourinary cancers.

The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of "precision medicine", contemporary urologic surgery has entered a technology-driven era of "precision surgery", which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of "precision surgery" in the management of genitourinary cancers.

Variations in outcomes for Indigenous women with breast cancer in Australia: A systematic review.

This systematic review examines variations in outcomes along the breast cancer continuum for Australian women by Indigenous status. Multiple databases were systematically searched for peer-reviewed articles published from 1 January 1990 to 1 March 2015 focussing on adult female breast cancer patients in Australia and assessing survival, patient and tumour characteristics, diagnosis and treatment by Indigenous status. Sixteen quantitative studies were included with 12 rated high, 3 moderate and 1 as low quality. No eligible studies on referral, treatment choices, completion or follow-up were retrieved. Indigenous women had poorer survival most likely reflecting geographical isolation, advanced disease, patterns of care, comorbidities and disadvantage. They were also more likely to be diagnosed when younger, have advanced disease or comorbidities, reside in disadvantaged or remote areas, and less likely to undergo mammographic screening or surgery. Despite wide heterogeneity across studies, an overall pattern of poorer survival for Indigenous women and variations along the breast cancer continuum of care was evident. The predominance of state-specific studies and small numbers of included Indigenous women made forming a national perspective difficult. The review highlighted the need to improve Indigenous identification in cancer registries and administrative databases and identified key gaps notably the lack of qualitative studies in current literature.

A systematic review of inequalities in psychosocial outcomes for women with breast cancer according to residential location and Indigenous status in Australia.

BACKGROUND: The aim of this systematic review was to examine variations in psychosocial outcomes by residential location and Indigenous status in women diagnosed with breast cancer (BC) in Australia. METHODS: Systematic searches were undertaken using multiple databases covering articles between 1 January 1990 and 1 March 2015 focusing on adult women with BC in an Australian setting and measuring quality of life (QOL), psychological distress or psychosocial support. RESULTS: Thirteen quantitative and three qualitative articles were included. Two quantitative and one qualitative article were rated high quality, seven moderate and the remaining were low quality. No studies examining inequalities by Indigenous status were identified. Non-metropolitan women were more likely to record lower QOL relating to breast cancer-specific concerns and reported a lack of information and resources specific to their needs. Continuity of support, ongoing care and access to specialist and allied health professionals were major concerns for non-metropolitan women. Non-metropolitan women identified unmet needs in relation to travel, fear of cancer recurrence and lack of psychosocial support. CONCLUSIONS: Overall, there was a lack of evidence relating to variations in psychosocial outcomes for women with BC according to residential status or Indigenous status. While the review identified some specific concerns for non-metropolitan women with BC, it was limited by the lack of good quality studies using standardised measures. Copyright © 2016 John Wiley & Sons, Ltd.

Significant enhancement of magnetoresistance with the reduction of particle size in nanometer scale.

The Physics of materials with large magnetoresistance (MR), defined as the percentage change of electrical resistance with the application of external magnetic field, has been an active field of research for quite some times. In addition to the fundamental interest, large MR has widespread application that includes the field of magnetic field sensor technology. New materials with large MR is interesting. However it is more appealing to vast scientific community if a method describe to achieve many fold enhancement of MR of already known materials. Our study on several manganite samples [La(1-x)Ca(x)MnO3 (x = 0.52, 0.54, 0.55)] illustrates the method of significant enhancement of MR with the reduction of the particle size in nanometer scale. Our experimentally observed results are explained by considering model consisted of a charge ordered antiferromagnetic core and a shell having short range ferromagnetic correlation between the uncompensated surface spins in nanoscale regime. The ferromagnetic fractions obtained theoretically in the nanoparticles has been shown to be in the good agreement with the experimental results. The method of several orders of magnitude improvement of the magnetoresistive property will have enormous potential for magnetic field sensor technology.

Primary Peritoneal Papillary Serous Cystadenocarcinoma - A Rare Malignancy.

Primary peritoneal papillary serous carcinoma is a rare primary malignancy diffusively involving the peritoneum of abdomen and pelvis. Epithelial ovarian cancers and primary peritoneal cancers arise from the common germinal epithelium which develops from the coelomic epithelium. Due to a common embryonic origin of the ovary and the peritoneum, carcinoma of the ovary and primary peritoneal carcinoma have much histological similarity. However the incidence of Primary peritoneal serous carcinoma is considerably lower than that of epithelial ovarian cancer and is mostly seen in elderly women. Early stages of this disease may be asymptomatic; symptoms of the advance stages of the disease include abdominal distention, abdominal lump, non-specific abdominal pain, vomiting and dyspnoea all as a result of massive ascites. Patients diagnosed with primary peritoneal papillary serous carcinoma are treated using the same staging, surgical and chemotherapeutic approach as epithelial ovarian cancer because of the similarities in biological behavior.