Efficacy of near-infrared fluorescence cholangiography using indocyanine green in laparoscopic cholecystectomy: A retrospective study.

Context: While laparoscopy has been the standard procedure for gallstone treatment, recent advances including the use of indocyanine green (ICG) in laparoscopic cholecystectomy have made it easier to understand the biliary tree and reduce the risk of bile duct injury. Aims: In this retrospective study, we aim to determine the efficacy of ICG in near-infrared fluorescence cholangiography (NIRFC) for visualising biliary anatomy. Settings and Design: A total of 90 patients with the symptoms of cholelithiasis were enrolled for this retrospective study. Subjects and Methods: All the patients underwent cholecystectomy approximately 53.8 min (40-90 min) after the intravenous administration of mean volume 1.6 ml (1-2 ml) ICG. The surgeons used NIRFC along with ICG for real-time visualisation of biliary anatomy. Results: The mean operative time for the surgery was 65.7 min (25-120 min) with no post-surgical complications observed in the patients. The average length of stay was 2 days (1-3 days). ICG usage with NIRFC enabled identification of cystic duct, common hepatic and common bile duct, the junction between common hepatic and bile duct, right and left hepatic duct in 87.7%, 94.4%, 80% and 14.4% of cases, respectively. Conclusions: ICG fluorescence allowed successful visualisation of at least 1 biliary structure in 100% of cases.

Effectiveness of plain radiography in diagnosing hollow viscus perforation: study of 1,723 patients of perforation peritonitis.

Gastrointestinal perforations remain the most common cause of surgical pneumoperitoneum since time immemorial. The aim of this study was to find out the effectiveness of plain radiography in diagnosing hollow viscous perforation. A prospective analysis of a total of 1,723 patients of perforation peritonitis between January 2009 and June 2011, confirmed by exploratory laparotomy, was worked out in the study. All these patients had undergone either an upright chest or erect abdominal or both radiographs before undergoing operative procedure. Pneumoperitoneum was evaluated, and the findings were compared with that of exploratory laparotomy. Out of the 1,723 patients of documented perforation on intraoperative finding, 1,537 patients showed pneumoperitoneum on preoperative plain radiography. The overall positivity rate of plain radiography in detecting pneumoperitoneum was 89.20%. The positivity rate was highest for stomach and duodenal perforation (94.19%) and the least for appendicular perforation (7.69%) with highly significant difference (p value, <0.001). In developing world, where there is limited availability of resources and overburden of patients, imposing a limitation in adapting advanced radiological technique as a first line of investigation, plain radiography may be considered as a valuable screening tool in detecting pneumoperitoneum with high positivity rate.

Longest gallbladder: A case report.

INTRODUCTION: A gallbladder mucocele is the distention of the gallbladder by an inappropriate accumulation of mucus. Decreased bile flow, decreased gallbladder motility, and altered absorption of water from the gallbladder lumen are predisposing factors to biliary sludge. However, it is more likely to be a small part of a complex disease process involving inflammation of the gallbladder wall and changes to the lining of the gallbladder changing the consistency of its secretions. We would like to present a case of mucocele gallbladder operated successfully by laparoscopic cholecystectomy. CASE REPORT: Herein, we present a case of 46year old female presenting with symptoms of pain in right hypochondrium with ultrasonographic diagnosis of cholelithiasis undergone successful laparoscopic cholecystectomy with Intraoperative findings of: 1. The length of the gallbladder was measured to be 30cm. 2. A large stone was impacted at the neck of gallbladder, which was leading to mucocele formation. CONCLUSION: Mucocele of gallbladder present an important hurdle in successful laparoscopic cholecystectomy. A habit of calm and slow dissection with precautions should be developed. Clearance of the calot's triangle with limited use of electro cautery should be done before proceeding towards ligation or clip application to various structures.

Primary hydatid cyst of pancreas: Case report and review of literature.

INTRODUCTION: Hydatid disease is caused by the larval stage of Echinococcus granulosus. It most commonly affects the liver and lung. Pancreatic hydatid cyst (PHC) is very rare with incidence of 0.14%-2%. PRESENTATION OF CASE: A 40year old lady presented with epigastric pain for last 3 months. A 5×5cm abdominal lump occupying the epigastric and left hypochondrial region was noted on physical examination. Ultrasonography (USG) and Contrast enhanced Computed Tomogrpahy (CT) revealed a 55×57mm cystic structure in the pancreatic body. Endoscopic ultrasound guided fluid aspiration cytology revealed normal Carcinoembryonic antigen and Amylase levels. Cytological examination was noncontributory. During open surgical exploration, it was found to be a hydatid cyst. After irrigation with scolicidal agent and evacuation of cystic contents, Partial cystectomy with external drainage was done. Histopathological biopsy revealed Hydatid cyst. Post-operative ELISA (Enzyme linked immunosorbent assay) for Echinococcal antigen was positive. DISCUSSION: PHC is a rare entity. Most common mode of spread is hematogenous. Cysts in pancreatic head can present as obstructive jaundice. Cysts in body and tail are usually asymptomatic. USG, CT and Hydaitd serology can help in diagnosis and monitoring recurrence. Surgical exploration is treatment of choice. Options include pericystectomy, partial cystectomy+/- external drainage/omentopexy, marsupialization or cysto-enterostomy. Preoperative and Post-operative anti helminthic (Albendazole) is recommended. CONCLUSION: PHC can masquerade as pseudocyst or cystic neoplasm of pancreas. It should always be considered in the differential diagnosis of cystic pancreatic lesion in patients from endemic regions.

Laparoscopic cholecystectomy in a 2 year old male child with choleilithiasis and recurrent right hypochondrial pain: Case report and review of literature.

INTRODUCTION: Gallstone disease has been considered an uncommon entity in children and infants, but its incidence is reportedly increasing which may be attributed to widespread use of diagnostic imaging (ultrasonography). PRESENTATION OF CASE: An apparently healthy 2 year old male child presented to our Outpatient department with chief complaint of recurrent abdominal pain. The episodes of pain were acute in onset and associated with vomiting. As per the complete examination and findings, a diagnosis of chronic calculous cholecystitis was made. A four port laparoscopic cholecystectomy was done. DISCUSSION: The incidence of gallstones in children in India has not been sufficiently studied. The incidence of gallstone disease in India was found to be 0.3% with the incidence in age group 0-10 being less than 0.1%. In contrast to adult gallstone disease, it has been found that there is no female preponderance in gallstone diseases of infancy. Also, the majority of children having increased haemoglobin turnover develop pigment stones only after 5 years of age. CONCLUSION: The probability of gallstone disease in infants and young children should not be ignored. Gall stones should always be considered as a differential diagnosis when young patients present with complaints of abdominal pain.

Our experience with surgery in situs inversus: Open peptic perforation repair and laparoscopic cholecystectomy in 1 patient and 3 patients respectively.

INTRODUCTION: Situs inversus is a rare autosomal recessive condition associated with complete transposition of abdominal+/- thoracic organs. Surgical diagnosis and surgical procedures in patients with situs inversus is tricky because of the mirror image anatomy of intra-abdominal organs. MATERIALS AND METHODS: A retrospective analysis of 2152 and 1497 patients who underwent laparoscopic cholecystectomy and open peptic perforation repair respectively from June 2014-June 2016 was done. 1 patient and 3 patients with situs inversus underwent open peptic perforation repair and laparoscopic cholecystectomy respectively. A 10mm left para-median port 5cm caudally from xiphoid was used for grasping the infundibulum. Two 5mm ports placed 10cm caudally from costal margin in the mid-clavicular and anterior axillary line were used for dissecting and retracting fundus respectively. A 10mm supra-umbilical camera port was used. RESULTS: A 40year male with situs inversus totalis underwent open peptic perforation repair. Laparoscopic cholecystectomy was done in 3 female patients with situs inversus aged 33-46year (mean 41year). Mean operative time for laparoscopic cholecystectomy was 59min (39-93). There were no intraoperative or post-operative complications. Histopathology revealed chronic inflammation in peptic perforation and cholecystitis. CONCLUSION: Perforation peritonitis in situs inversus can cause diagnostic confusion with free gas under the left hemi diaphragm. Laparoscopic cholecystectomy in situs inversus is ergonomically inconvenient and technically difficult for right handed surgeons. We describe an ergonomically convenient port placement for right handed surgeons in situs inversus.

Malroatation of gut with superior mesenteric artery syndrome and multiple jejunal diverticula presenting as acute intestinal obstruction in 6th decade: A rare case report.

INTRODUCTION: Intestinal malrotation is a disease of neonates and young children presenting as acute intestinal obstruction. Presentation of malrotation in elderly patients with intestinal obstruction is quite rare with only a few cases reported in literature. We report a case of intestinal malrotation presenting as acute obstruction in sixth decade. PRESENTATION OF CASE: A 55 years old male presented to the emergency with features of acute intestinal obstruction. Imaging studies revealed intestinal malrotation. Exploratory laparotomy revealed malrotation with compression of 3rd part of duodenum and terminal ileum by superior mesenteric artery with multiple jejunal diverticula. Bypass procedures (duodenojejunostomy and ileo-colic anastomosis) with appendicectomy were done. DISCUSSION: Malrotation of gut is an anomaly usually presenting in neonatal period with complications such as midgut volvulus. Presentation in adult age is rare with most cases being asymptomatic. Ladd's procedure is the operation of choice with division of the Ladd's bands and appendicectomy being performed. CONCLUSION: Surgeons should keep a flexible approach in management of malrotation of gut presenting in late stages of life as more and more clinical variants to the presentations described in literature are being encountered.

Management of presacral tumors: Our experience with posterior approach.

INTRODUCTION: Presacral tumors are a rare variety of space occupying lesions arising in the presacral space. Most of the tumors are congenital in origin. Due to obscure anatomic location, difficult surgical approach and etiological heterogeneity, tumors arising here pose a diagnostic and therapeutic challenge. We report our experience of 10 cases of presacral tumors with posterior approach being used in 6. MATERIALS AND METHODS: A retrospective analysis was conducted on 10 cases of presacral tumors managed at our hospital during a period of 14 months (May 2013-July 2014). 9 cases were operated while one had advanced disease and was referred for palliative care. Complete en bloc excision of the mass was possible in 8 cases. Finally, presenting complaints, clinical diagnosis, surgical procedure and histopahological findings of the cases were studied. RESULTS: All of our patients were females in the age group of 18-50 (mean 28.4) years. The pathological findings included schwannoma, leiomyosarcoma, hemangiopericytoma, neurofibroma, paraganglioma and rest were developmental cysts. 6 cases were managed using the posterior approach and rest by anterior approach. There was no major complication or mortality in the follow up. CONCLUSION: Complete surgical excision remains the mainstay of therapy. Surgical approach depends upon the location, size, local invasion and surgical expertise of the surgeon. Benign tumors have a good prognosis while the prognosis in malignant tumors remains guarded due to difficulty in obtaining safe resection margins. Posterior approach is an attractive option for low lying, benign tumors that is more direct, with better exposure and quicker recovery.

Volvulus of ileal S-pouch: A rare complication of ileal pouch anal anastomoses.

INTRODUCTION: Ileal pouch anal anastomosis (IPAA) after total proctocolectomy is a frequently performed surgery for medically refractory ulcerative colitis (UC). Volvulus of the ileal pouch as a complication of IPAA is extremely rare. We present a case of volvulus of S-type ileal pouch. PRESENTATION OF CASE: A 28 year old male, with history of total proctocolectomy with IPAA for severe UC in 2009 presented with signs of bowel obstruction. Emergency laparotomy was done and a volvulus of the S-type ileal pouch was derotated and pouchpexy done. DISCUSSION: The IPAA has a wide spectrum of complications, with obstruction of proximal small bowel occurring frequently. Volvulus of the ileal pouch is extremely rare with only 3 reported cases. Early diagnosis and intervention is important to salvage the pouch. Computed tomography (CT) may aid the diagnosis in stable patients. CONCLUSION: The diagnosis of ileal pouch volvulus although rare, should be kept in mind when dealing with patients complaining of recurrent obstruction following IPAA.