Spigelian Hernia: A Case report.

A Spigelian hernia is a hernia through the Spigelian fascia which are difficult to diagnose as they do not present with a subcutaneous swelling and can be dangerous as there is a high risk of incarceration. We report a case of a 51-year-old female who presented to our surgical unit with epigastric pain for 5 days. She was diagnosed with Spigelian hernia with esophagitis and antral gastritis with the help of a computed tomography scan and upper gastrointestinal endoscopy. The diagnosis was confirmed on diagnostic laparoscopy and transabdominal preperitoneal repair of the defect was performed using prolene mesh. Her post-operative period was uneventful. Spigelian hernias are rare and patients can present with atypical symptoms as in this case. Thus, imaging plays a vital role in diagnosis. Management is surgical and has good outcomes. Keywords: case reports; rectus abdominis; ventral hernia.

Indocyanine green fluorescence imaging: Assessment of perfusion at pancreatic resection margin during pancreatoduodenectomy: A cross sectional study.

Background: Clinically relevant-postoperative pancreatic fistula (CR-POPF) is one of the dreaded complications of pancreatoduodenectomy. Vascularity of the stump of the pancreas during pancreatico-enteric anastomosis is considered one of the major determinants of POPF. Indocyanine green (ICG) is one of the modality for vascular assessment; hence, we aimed to evaluate the role of ICG fluorescence imaging to assess the vascularity of the pancreatic stump during pancreatoduodenectomy. Methodology: The study was conducted at Kathmandu Medical College, Kathmandu, Nepal, during the period of 1 year (June 01, 2022-July 31, 2023). All of the patients who were undergoing pancreatoduodenectomy were included in the study. In all cases, intraoperatively, ICG fluorescence detection at the pancreatic stump margin was evaluated using near-infrared light. Results: A total of 28 patients underwent PD during this period. The ICG fluorescence imaging was positive at the pancreatic stump margin in 25 out of the 28 patients (89%), and in three cases, the florescence was negative. In patients who had negative fluorescence, revision of the stump margin was performed. Clinically relevant POPF was noted in 2 out of 28 cases, which had a soft pancreas with a small duct, although the pancreatic stump margin had good ICG florescence per-operatively. Conclusion: ICG is inexpensive and a safe dye to use in clinical practice. We can objectively assess the pancreatic stump vascularity using intraoperative ICG fluorescence imaging, thereby potentially decreasing postoperative pancreatic fistula.

Correlation of the Nutritional Risk Screening 2002 Score With Post-operative Complications in Gastrointestinal and Hepatopancreatobiliary Oncosurgeries.

Introduction The Nutritional Risk Screening 2002 (NRS 2002) is a reliable tool for assessing patients' nutritional status and for identifying those who may benefit from nutritional support before undergoing surgery. However, its application and correlation with post-operative outcomes for Nepalese patients undergoing gastrointestinal and hepatopancreatobiliary oncosurgeries remain unexplored. The objective of this study was to correlate the NRS 2002's nutritional risk with post-operative complications classified by the Clavien-Dindo Classification. Methods A prospective analytical study was conducted at Kathmandu Medical College and Teaching Hospital, with 74 adults who underwent gastrointestinal and hepatopancreatobiliary oncosurgeries between 1st March 2021 and 30th August 2022. The study was conducted following ethical clearance from the Institutional Review Committee of the Hospital. A convenience sampling method was used. Data were analyzed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States). Results Among the 122 patients admitted during the study period, 74 met the inclusion criteria. Using the NRS-2002, 37.8% were found to be at nutritional risk. Such patients had a higher risk of complications and extended hospital stays, supported by an odds ratio of 1.647 (95% confidence interval: 1.223 -2.219) and a p-value of <0.001. Nutritional risk emerged as an independent predictor of post-operative complications. Conclusion The study suggests the potential of NRS-2002 as a significant predictor of outcomes after surgeries for gastrointestinal and hepatopancreatobiliary malignancies in the South Asian context, particularly in Nepal. Tools such as NRS 2002 play a pivotal role in early risk identification, which could subsequently influence both pre-operative and post-operative care strategies, ultimately enhancing patient outcomes.

Evaluating postoperative outcome assessment tools in hepato-pancreato-biliary surgery: A comparative analysis of the comprehensive complication index and Clavien-Dindo classification in a cohort of 1240 patients at a tertiary care center.

Introduction: The comprehensive complication index (CCI) has emerged as a new tool for reporting postoperative complications. The aim of this study is to evaluate and compare the efficacy of CCI and Clavien-Dindo Classification (CDC) in measuring postoperative outcomes in patients undergoing hepato-pancreato-biliary (HPB) surgery. Materials and methods: In this single-centered, prospective, comparative study conducted between January 2022 and March 2023, 1240 patients underwent HPB surgery, including laparoscopic cholecystectomies and complex HPB surgery. Postoperative complications were evaluated utilizing the CCI and CDC indices, and their relationships with length of ICU stay, hospital stay, and return to activity were compared. Results: A total of 117 patients (9.44%) experienced complications of varying grades. There was a strong correlation between CCI and CDC (r=0.982, P <0.001). Both CCI and CDC demonstrated a strong correlation with the length of hospital stay, ICU stay, and return to normal activity. While CCI showed a better correlation with the length of hospital stay (r=0.706 vs. 0.695) and return to normal activity (r=0.620 vs. 0.611) than CDC, the difference was not statistically significant. Conclusion: CCI exhibited a stronger correlation with the length of stay and return to activity; however, no statistically significant advantage was observed over CDC.

Previous Abdominal Scars among Patients Undergoing Laparoscopic Cholecystectomy in a Tertiary Care Centre.

Introduction: Abdominal scars result from various open abdominal surgeries. Laparoscopic surgery in previous open abdominal surgery possesses various challenges to the surgeon like gaining access to the abdominal cavity, and difficulty in dissection due to dense adhesions from previous surgeries for various intraabdominal pathologies. This study aimed to find out the prevalence of previous abdominal scars among patients undergoing laparoscopic cholecystectomy in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients undergoing laparoscopic cholecystectomy in a tertiary care centre from 1 May 2022 to 30 April 2023 after taking ethical approval from the Institutional Review Committee. Palmer's point approach via Hassen open technique or direct optical entry was used for cases with previous abdominal scars to gain access to the abdominal cavity. Patients with symptomatic gallstone diseases were included in the study whereas patients with cholecystitis, pancreatitis, and previous cesarean scar were excluded. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 160 patients undergoing laparoscopic cholecystectomy, previous abdominal scars was found in 40 (25%) patients. Conclusions: The prevalence of previous abdominal scars contributing to intraoperative and post-operative difficulties among patients undergoing laparoscopic cholecystectomy was found to be higher than in studies done in similar settings. Keywords: laparoscopic cholecystectomy; open surgery; prevalence.

Laparoscopic anatomical segmentectomy: A paradigm shift towards minimally invasive liver surgery in Nepal: A cohort study.

Laparoscopic liver resection is taking stride in slowly replacing open surgeries for various hepatic pathologies in many developed countries. However, due to high cost and lack of expertise, there are only a handful of centres in the low-medium income countries who perform advanced laparoscopic liver resections regularly. In this study, a prospective analysis was carried out to assess and report the outcomes of laparoscopic anatomical segmentectomy (LAS) from a single centre in Nepal. Methods: The clinical data of all patients who underwent LAS between 1 October 2021 to 30 September 2022 were prospectively recorded. Demographics, pathological diagnoses, types of resections performed, perioperative parameters, postoperative length of stay, postoperative complications data and IWATE score were collected and analyzed. All operations were performed using the extrahepatic Glissonean technique with the use of indocyanine green dye as an adjunct during the intraoperative period. Results: In the study period, a total of 16 LAS were performed in our centre for various indications. The mean age of the patients in the series was 41.6 years, and seven of 16 patients were male. The majority of the cases were segment 2/3 resection indicated for various pathologies and segment 4b/5 indicated for carcinoma gallbladder. The median hospital stay was 6 days and only two cases developed major complication. There were no mortalities in our series. Conclusions: Taking into account the results produced from a single centre in a low-medium income country, laparoscopic anatomical segmentectomy is technically feasible with an acceptable safety profile.

Ileal perforation secondary to bowel obstruction caused by foreign body bezoar: A case report.

Introduction and importance: Foreign body bezoar is a relatively uncommon variant of bezoars leading to intestinal obstruction and perforation. These are caused by the ingestion of indigestible materials that gradually grow in size. Case presentation: Following is the case of a young female patient with abdominal pain and distension which was associated with nausea, vomiting, and obstipation. Contrast-enhanced computed tomography of the abdomen showed dilated jejunal and ileal loops, and a tubular hypodense structure on terminal ileum. During surgery, we discovered intraluminal foreign bodies and ileal perforation proximal to the ileocecal valve. The findings were suggestive of obstruction and perforation of terminal ileum secondary to foreign body obstruction. The patient was managed successfully with ileocolic resection and anastomosis. Discussion: Patients with bezoars can remain asymptomatic or present with features of bowel obstruction. These are usually discovered while performing radiological imaging for the evaluation of symptoms. Though mild to moderate cases of bezoars resolve with the treatment by chemical dissolution, surgeries should be performed in patients with foreign body bezoars and in whom complications have arose. Conclusion: Ingested foreign body could lead to formation of a bezoar which may cause obstruction and perforation-the sequelae must be kept in mind while managing a patient.

Early Oral Feeding with Vascular Resection among Patients Undergoing Pancreatoduodenectomy in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Pancreatoduodenectomy with vascular resection is performed in locally advanced periampullary malignancies. In our practice, early oral feeding is initiated in patients undergoing pancreatoduodenectomy. This study aims to find the prevalence of early oral feeding with vascular resection among patients undergoing pancreatoduodenectomy. METHODS: This was a descriptive cross-sectional study conducted among hospital records of 152 patients who underwent pancreatoduodenectomy in the department of surgery of a tertiary care hospital from 2016 to 2020. Ethical approval was taken from the Institutional Review Committee (Reference number: 0812202102). Convenience sampling was done. Patients clinical and sociodemographic data were collected and analyzed using Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency, percentage, mean, and median. RESULTS: Among 152 patients undergoing pancreatoduodenectomy, early oral feeding with vascular resection was done in 17 (11.18%) (6.17-16.19 at 95% Confidence Interval). Portal vein and superior mesenteric artery were resected in one (5.88%) and hepatic artery in one (5.88%) patient. Type I, III and IV reconstruction was done in nine (52.9%), five (29.41%) and one (5.88%) respectively. Clinically relevant delayed gastric emptying and postoperative pancreatic fistula were seen in two (11.7%). Complication of Clavien-Dindo Grade III or higher was seen in one (5.88%) patient. One (5.88%) mortality was noted. CONCLUSIONS: The prevalence of early oral feeding with vascular resection among patients undergoing pancreatoduodenectomy was similar to other studies done in similar settings. Early enteral feeding is well tolerated in patients undergoing pancreatoduodenectomy with vascular resection.

Strategies in the Management of Pancreatic Ductal Adenocarcinoma Involving Aberrant Right Hepatic Artery Arising From the Superior Mesenteric Artery.

Introduction The prevailing guidelines do not include the involvement of an aberrant right hepatic artery (aRHA) arising from the superior mesenteric artery in classifying borderline resectable pancreatic ductal adenocarcinoma (BR PDAC). Our novel classification aims to distinguish different entities depending on the location and degree of tumor involvement of aRHA and propose a strategy to manage tumor involvement of aRHA in PDAC. Material and methods The patients who underwent pancreaticoduodenectomy (PD) from September 1, 2018, to August 31, 2022 were analyzed retrospectively, and patients with aRHA were included in the study. Depending on the radiological data, arterial involvement of the aRHA was classified into group I with proximal involvement of the aRHA up to 2 cm from its origin in the superior mesenteric artery (SMA) and group II with distal involvement of aRHA beyond 2 cm from its origin in SMA. In addition, the resection margin status was correlated with the technique employed for managing the tumor-involved artery. Results A total of 122 patients underwent PD during the study period. Eight patients were identified to have tumor involvement of the aRHA arising from the SMA. Among the five patients in group I, three patients who had upfront surgery showed R1 resection regardless of periarterial divestment or resection/reconstruction of the involved artery, whereas R0 resection was achieved in the two patients who had neoadjuvant therapy. All patients in group II had R0 resection regardless of receiving neoadjuvant therapy. There were no significant morbidity and mortality in our series. Conclusion The aRHA should be considered in the classification of BR PDAC. Management strategies should be tailored based on the location and the degree of tumor involvement in the aRHA. We advocate neoadjuvant therapy for proximal involvement and upfront surgery for distal involvement of aRHA to achieve good oncological clearance.

Recurrent Dermatofibrosarcoma Protuberance: A Case Report.

Dermatofibrosarcoma protuberance represents less than 0.1% of all tumors, treatment of which requires wide local excision (≥5cm) but recurrence is not rare. Here we present a 32-year male presented with a swelling of 15 x 6cm over the left lumbar region for which he underwent excision three years ago, the histopathological examination of the swelling, showed a malignant mesenchymal tumor and Immunohistochemistry features were suggestive of Dermatofibrosarcoma protuberance. After three years of interval, he again presented with complaints of swelling in the previously operated site for nine months and underwent excision of the mass with Split Thickness Skin Graft. Although the tumor was confined to the skin and subcutaneous tissue in the present case, the patient didn't undergo any adjuvant radiotherapy to avoid a possible relapse that would infiltrate deeper structures for the first time. Being a recurrent tumor, long-term follow-up is strongly recommended.

Arterial Divestment and Resection in Post-neoadjuvant Pancreatic Adenocarcinoma.

Introduction The advent of neoadjuvant therapy in the management of pancreatic adenocarcinoma has significantly improved the prognosis of the disease. Nevertheless, the only chance of long-term disease-free survival in pancreatic cancer is achieved with complete tumor resection, and artery involvement by the tumor is one of the major determinants in its resectability. We aim to evaluate the feasibility of a novel technique, namely, the periarterial divestment, which has allowed surgeons to clear the tumor tissues off the visceral arteries without the need for arterial reconstruction. Materials and methods In this single-center, retrospective, descriptive, cross-sectional study done between August 2019 and July 2021, seven consecutive patients with histologically confirmed pancreatic ductal adenocarcinoma (PDAC) who underwent neoadjuvant therapy were included. Arterial divestment was performed in six of seven patients and arterial reconstruction was performed in one of the patients. The data on perioperative and the early oncological outcome were recorded. Results Five patients underwent periarterial divestment, one underwent sub-adventitial divestment, and one underwent superior mesenteric artery reconstruction due to deeper tumor infiltration into the arterial wall. The intraoperative frozen section of periarterial tissue was positive in three cases and the final histopathological specimen after the divestment showed a positive margin in two of the cases. The clinically significant postoperative pancreatic fistula was noted in two patients, and one patient experienced grade C post-pancreaticoduodenectomy hemorrhage due to a hepatic artery pseudoaneurysm. Four patients, all of whom underwent periarterial divestment, experienced postoperative diarrhea. There were no mortality and the median postoperative hospital stay was seven days. Conclusion The need for arterial reconstruction in borderline and locally advanced pancreatic cancer can be avoided by using the periarterial divestment technique. Divestment of arteries is technically feasible and can be carried out safely without compromising the patient's oncological outcome. However, further validation of this technique must be done by well-designed studies with a greater sample size.