A review of the first 100 robotic cholecystectomies with a new cart-based surgical robot at a tertiary care centre.

Background: Robotic cholecystectomy appears to be a natural evolution of the well-established gold standard procedure for gallstones, namely laparoscopic cholecystectomy. Akin to the early days of laparoscopy, robotic surgery is associated with a learning curve. We present our experiences in adapting to robotic surgery after the first 100 robotic cholecystectomies at a minimal access surgery tertiary care hospital. Material and Methods: The first consecutive 100 robotic cholecystectomies performed by a single surgeon on the Versius robotic surgical system (CMR Surgical, UK) were included in the study. Patients unwilling to give consent and complex pathologies such as gangrene, perforation and cholecystoenteric fistulas were excluded from the study. Operative time, robotic setup time, incidence and indication for conversion to manual (laparoscopic) procedure were recorded while subjective assessment of interruptions due to machine alarms and errors was made. All data were compared between the first 50 and last 50 procedures. Results: Our data revealed a gradual reduction in operative time from 28.53 min for the first 50 procedures to 22.06 min for the last 50 procedures. An improvement in draping and setup times was also noted, reducing from 7.74 to 5.14 min and 7.96 to 5.32 min, respectively. There were no conversions during the last 50 procedures, though the first 50 procedures resulted in 3 conversions to a laparoscopic procedure. In addition, we also noted a subjective reduction in the incidence of machine errors and alarms as we became more versed with the robotic system. Conclusion: Our single-centre experience indicates that newer modular robotic systems present a rapid and natural progression for experienced surgeons looking to venture into robotic surgery. The well-established advantages of robotic surgery in the form of enhanced ergonomics, three-dimensional vision and improved dexterity are validated as indispensable aids in a surgeon's armamentarium. Our initial experience reveals that robotic surgery for more common surgical procedures such as cholecystectomies will be rapidly accepted, safe and effective. There is a need to innovate and expand the range of instrumentation and energy devices available.

Bioconjugate-loaded solid lipid nanoparticles for enhanced anticancer drug delivery to brain cancer cells: An in vitro evaluation.

Background & objectives: The treatment of brain cancer is still challenging for an oncologist due to the presence of the blood-brain barrier (BBB) which inhibits the entry of more than 98 per cent of drugs used during the treatment of brain disease. The cytotoxic drugs used in chemotherapy for brain cancer treatment also affect the normal cells due to lack of targeting. Therefore, the objective of the study was to develop tween 80-coated solid lipid nanoparticles (SLNs) loaded with folic acid-doxorubicin (FAD) conjugate for site-specific drug delivery to brain cancer cells. Methods: The FAD conjugate was synthesized by the conjugation of folic acid with doxorubicin and characterized by Fourier transform infrared spectroscopy and proton nuclear magnetic resonance spectroscopy. SLNs loaded with FAD were prepared by the solvent injection method. The SLNs were characterized by the particle size, zeta potential, surface morphology, entrapment efficiency, etc. Results: The average particle size of FAD conjugate-loaded SLNs (SLN-C) was found to be 220.4±2.2 nm, with 36.2±0.6 per cent entrapment efficiency. The cytotoxicity and cellular uptake were determined on U87 MG cell lines. Half maximal inhibitory concentration value of the SLN-C was found to be 2.5 µg/ml, which confirmed the high antitumour activity against brain cancer cells. Interpretation & conclusions: The cell line studies confirmed the cytotoxicity and internalization of SLN-C in U87 MG brain cancer cells. The results confirmed that tween 80-coated SLNs have the potential to deliver the doxorubicin selectively in the brain cancer cells.

Nisin and nisin-loaded nanoparticles: a cytotoxicity investigation.

OBJECTIVE: Nisin is an antibacterial peptide with anticancer properties, but the main drawback is its rapid enzymatic degradation and limited permeation across the cell membrane. This research aims to overcome these drawbacks by developing nisin-loaded nanoparticles (NPN) with improved cytotoxic effects. SIGNIFICANCE: PLGA nanoparticles are one of the most effective biodegradable and biocompatible drug delivery carriers. In the present study, nisin-loaded nanoparticles showed enhanced anticancer effects. METHODS: NPN was prepared by a double emulsion solvent evaporation method and characterized for different parameters. The cytotoxic investigation of NPN was carried out on various cell lines, including A549, SW-620, HT-29, PC-3, MDA-MB-231, MCF-7, MiaPaca-2, and fR2 by sulforhodamine B (SRB) assay. Mechanistic investigation of cellular cytotoxicity was performed by using bright-field microscopy, DAPI staining, intracellular reactive oxygen species (ROS), changes in mitochondrial membrane potential (ΔΨm), Western blotting and cellular uptake study. A comparative cytotoxicity study of nisin and NPN was performed on normal breast epithelial cells (fR2). RESULTS: NPN showed spherical shape, 289.09 ± 3.63 nm particle size, and 63.37 ± 3.12% entrapment efficiency. NPN was more cytotoxic to the MDA-MB-231 cell line, showing higher nuclear fragmentation, ROS generation, depletion of ΔΨm, and enhanced intracellular uptake with apoptosis signs compared with nisin and with no cytotoxicity on normal cells. CONCLUSIONS: The findings suggest that nisin delivery via PLGA nanoparticles can be used to treat cancer without significant effects on healthy cells.

Cisplatin-loaded albumin nanoparticle and study their internalization effect by using ß-cyclodextrin.

The present study with aim at enhancing the therapeutic and anti-cancer properties of cisplatin (CPT)-loaded bovine serum albumin (BSA) nanoparticles. The BSA nanoparticles containing CPT (CPT-BSANPs) were successfully prepared by the desolvation technique. The physicochemical characterization of the CPT-BSANPs were used by Fourier transformed infrared spectroscopy (FTIR), scanning electron microscopy (SEM) and atomic force microscopy (AFM). The particle size of CPT-BSANPs was found less than 200 nm with 75.02 ± 0.15% entrapment efficiency (EE), while zeta potential and PDI were -17.6 mV and 0.2, respectively. In vitro release behavior of the CPT from the carrier suggests that about 64% of the drug gets released after 48 hrs. The anti-cancer activities of the CPT-BSANPs were tested on MCF-7 cell lines. Our studies show that CPT-BSANPs nanoparticles showed specific targeting and enhanced cytotoxicity to MCF-7 cells when compared to the bare CPT. Thus results suggest that CPT-BSANPs fallowed caveolae-mediated endocytosis, it may become better option for intracellular delivery of anticancer drug.

Carbopol-olive oil-based bigel drug delivery system of doxycycline hyclate for the treatment of acne.

OBJECTIVE: The objective of this study was to prepare and evaluate the doxycycline hyclate containing bigel for the effective treatment of acne. METHODS: Bigels are biphasic systems formed by water-based hydrogels and oil-based organogel. Carbopol 940 was used to prepare the hydrogel phase, whereas Span-60 and olive oil for the oleogel phase. RESULTS: The microstructure of bigel confirmed the oil in water type emulsion formation. The average droplet size of formulations was found 15-50 µm, and a bell-shaped droplet distribution curve, rheological, or viscosity studies suggested that the consistency and stability of bigel decrease with high organogel concentration. Three formulations (F1, F2, and F3) of the different ratios of hydrogel:oleogel (60:40, 70:30, and 80:20) were prepared in which F1 was less stable compared to F2 and F3. The drug content of F2 and F3 was respectively 79.94 and 71.33%. Formulation F2 was found more effective as compared to F3 based on in vitro drug release studies. Bigel also showed better results during in vivo studies at the rabbit ear model, which reduce acne diameter up to 1.10 mm from 4.9 mm while gel reduced it up to 1.20 mm.

Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature.

With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.

Impact of COVID-19 pandemic on bariatric surgery in India: An obesity and metabolic surgery society of India survey of 1307 patients.

BACKGROUND: Although safe practice guidelines were issued by the Obesity and Metabolic Surgery Society of India (OSSI) in the end of May 2020, surgeons have been in a dilemma about risk of subjecting patients to hospitalisation and bariatric surgery. This survey was conducted with the objective to evaluate the risk of coronavirus disease-19 (COVID-19) infection in peri- and post-operative period after bariatric and metabolic surgery (BMS). METHODS: A survey with OSSI members was conducted from 20 July 2020 to 31 August 2020 in accordance with EQUATOR guidelines. Google Form was circulated to all surgeon members through E-mail and WhatsAppTM. In the second phase, clinical details were captured from surgeons who reported positive cases. RESULTS: One thousand three hundred and seven BMS were reported from 1 January 2020 to 15 July 2020. Seventy-eight per cent were performed prior to 31 March 2020 and 276 were performed after 1 April 2020. Of these, 13 (0.99%) patients were reported positive for COVID-19 in the post-operative period. All suffered from a mild disease and there was no mortality. Eighty-seven positive cases were reported from patients who underwent BMS prior to 31 December 2019. Of these, 82.7% of patients had mild disease, 13.7% of patients had moderate symptoms and four patients succumbed to COVID-19. CONCLUSION: BMS may be considered as a safe treatment option for patients suffering from clinically severe obesity during the COVID-19 pandemic. Due care must be taken to protect patients and healthcare workers and all procedures must be conducted in line with the safe practice guidelines.

Laparoscopic splenectomy for large splenic pseudocyst: A rare case report and review of literature.

Laparoscopic splenectomy is gaining popularity due to less morbidity and minimal operative complications. Nowadays, laparoscopic splenectomy is the approach of choice for both benign and malignant diseases of the spleen. Splenic pseudocyst due to non-traumatic cause has been very rarely reported in literature. We report an interesting case of a rare large splenic pseudocyst without a history of previous abdominal trauma, treated successfully by laparoscopic technique and discuss literature for the same.

Laparoscopic adrenalectomy for ganglioneuroma presenting as an adrenal incidentaloma.

Adrenal incidentaloma (AI) has now become a common finding in clinical practice with advances in abdominal imaging. The prevalence of AI as reported in the literature is 0.2%-3%. Ganglioneuroma (GN) is often a benign non-functioning adrenal tumour, which has been rarely reported as AI in literature. Confirmed diagnosis of GN can only be done by histopathological examination. GNs are often asymptomatic even if they are large, and adrenalectomy is treatment for GN, with good prognosis after surgical removal. Here, we report a patient with an incidental adrenal mass that was managed laparoscopically and diagnosed as an adrenal GN on histopathology.

Laparoscopic Roux-en-Y gastric bypass: Outcomes of a case-matched comparison of primary versus revisional surgery.

INTRODUCTION: Laparoscopic adjustable gastric banding and laparoscopic sleeve gastrectomy are popular bariatric procedures. Certain complications may necessitate revision. Adverse outcomes are reported after revisional bariatric surgery. We compared patients undergoing revisional versus primary laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIALS AND METHODS: This was retrospective comparative 1:1 case-matched analysis of revisional LRYGB Group A versus primary LRYGB (pLRYGB/Group B). Matching was based on body mass index (BMI) and comorbidities. BMI decrease at 6 and 12 months post-surgery, comorbidity resolution, operative time, morbidity and length of hospital stay (LOS) were compared. Total decrease in BMI, i.e., change from before initial bariatric procedure to 12 months after revision for Group A was also compared. RESULTS: Median BMI (inter-quartile range) for Group A decreased to 44.74 (7.09) and 41.49 (6.26) at 6 and 12 months, respectively, for Group B corresponding figures were 38.74 (6.9) and 33.79 (6.64) (P = 0.001 and P = 0.0001, respectively). Total decrease in BMI (Group A) was 9.8, whereas BMI decrease at 12 months for Group B was 15.2 (P = 0.23). Hypertension resolved in 63% (Group A), 70% (Group B) (P = 0.6). Diabetes resolution was 80% (Group A), 63% (Group B) (P = 0.8). Operative time for Groups A, B was 151 ± 17, 137 ± 11 min, respectively (P = 0.004). There was no difference in morbidity and LOS. CONCLUSION: Comorbidity resolution after revisional and pLRYGB are similar. Less weight loss is achieved after revision than after pLRYGB, but total weight loss is comparable. Revisional surgery is safe when performed by experienced surgeons in high-volume centres.

Acute pancreatitis as an unusual early post-operative complication following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) at present one of the most commonly performed surgical treatments for morbid obesity worldwide. There are some complications regarding this procedure in the literature. This report presents a patient who developed acute pancreatitis immediate post-LSG. Patient was referred to our institute on 10th post-operative day with a complaint of fever, nausea, abdominal pain and leucocytosis. A diagnostic laparoscopy showed pancreatitis. Post-operatively, the patient was managed on treatment line of acute pancreatitis and recovered well. LSG is a common procedure in bariatric, and the most common complications are leakage and bleeding from the suture line. However, we encountered pancreatitis after LSG which is a rarely reported complication after LSG. We hypothesise that the development of acute pancreatitis in patients undergoing LSG is not well recognised and reported.

Case report of ventral hernia complicating bariatric surgery.

Ventral hernias (VHs) are common in the bariatric population with incidence of around 8% of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). The factors contributing to the incidence of VH includes high intra-abdominal pressures, previous histories of abdominal surgeries, defects in fascial structure and reduced healing tendency. There is a high index of suspicion in BS patients with VH for hernia complications which can be lethal after LRYGB. Here, we present a case where VH complicated the LRYGB surgery.

Epidermoid cyst at a rare location, as a content of inguinal hernia: A case report with a review of the literature.

Epidermoid cysts can occur in a variety of locations including the face, trunk, neck, extremities, and scalp. No case of epidermoid cyst as content of inguinal hernia has been reported so far; however, cases with dermoid, teratoma, lipoma, lymphangioma and leiomyoma as content of inguinal canal have been reported. A 29-year-old female presented with a lump in the left inguinal region that was clinically diagnosed as left inguinal hernia. The patient was planned for laparoscopic inguinal hernia repair after routine investigation. Intraoperatively, a cystic mass was found to be attached to the left round ligament that was excised completely. Histopathological report was consistent with epidermal inclusion cyst. Inguinal epidermoid cyst mimicking inguinal hernia is a rare entity. If such a cyst is encountered during operation, it should be completely excised.

Targeted SLNs for management of HIV-1 associated dementia.

CONTEXT: HIV-1 associated dementia (HAD) is an evolving disease in the category of neurological disorders. OBJECTIVE: Nifedipine-loaded solid lipid nanoparticles (SLNs) were developed and coated with Tween 80 to facilitate enhanced brain drug delivery for the treatment of HAD. MATERIALS AND METHODS: SLNs were prepared using solvent injection method. Lipids consisted of tristearin, hydrogenated soya phosphatidylcholine (HSPC) (1.5:1 w/w). Nifedipine was model drug in this study. Tween 80 (0.5% v/v) was taken as key modulator. SLNs were characterized for particle shape, size, zeta potential, entrapment efficiency, in vitro drug release, DNA fragmentation, cytotoxicity potential and in vivo studies. RESULTS: The SLNs (plain and coated) were found to be in nanometric in size (∼120 nm) with more than 70% entrapment efficiency. In vitro drug release profile reflected sustained release up to 48 h. Tween 80-coated SLNs showed higher percentage of DNA fragmentation in vitro and enhanced cell viability in sulforhodamine assay (rat cortical cells) as compared to plain drug and uncoated SLNs due to facilitated uptake of SLNs and reversal of P-gp efflux by virtue of Tween 80. Biodistribution study performed on vital organs, i.e. brain, heart, liver, spleen, lungs and kidney showed increased accumulation of Tween 80-coated SLNs in the brain. DISCUSSION AND CONCLUSION: Tween 80 enhanced localization of SLNs in the brain as compared to uncoated SLNs. This approach can be employed effectively to transport chemotherapeutics across the BBB for management of HIV-1 associated dementia and other ailments.

Postlaparoscopic cholecystectomy biloma in the lesser sac: A rare clinical presentation.

Bilomas resulting as a complication of cholecystectomy are often due to a leak from an inadequately secured cystic duct stump, an accessory bile duct or a duct of Luschka in the gallbladder fossa of the liver. Occasionally, bilomas may have an unusual presentation. We describe here a rare case of biloma in the lesser sac after an uneventful laparoscopic cholecystectomy.

Residual gallbladder stones after cholecystectomy: A literature review.

BACKGROUND: Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy. MATERIALS AND METHODS: Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up. RESULTS: Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct. CONCLUSION: Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.

Adrenal angiomyolipoma: A case report and review of literature.

Angiomyolipoma (AML) is a rare mesenchymal tumour arising from perivascular epithelioid cells. It is most commonly seen in kidney, but rarely AML can arise in extra renal sites. Adrenal AML is a very rare clinical entity, and very few cases have been reported so far. We present our experience with a 43-year-old female, who presented with right flank pain. Magnetic resonance imaging showed a right adrenal mass. Laparoscopic adrenelectomy was performed, and the histopathology report confirmed the diagnosis of AML. Patient was discharged uneventfully.

Laparoscopic retrieval of an unusual foreign body.

Ingestion of foreign body is a serious problem commonly encountered in our clinical practice. Most of them pass spontaneously, whereas in others endoscopic or surgical intervention is required because of complications or non-passage from the gastrointestinal tract. We present here a case of teaspoon ingestion, which did not pass spontaneously. Laparoscopic retrieval of teaspoon was done from mid jejunum after enterotomy and the patient recovered uneventfully. Right intervention at the right time is of paramount importance.

Cell-Penetrating Peptides as Keys to Endosomal Escape and Intracellular Trafficking in Nanomedicine Delivery.

This review article discusses the challenges of delivering cargoes to the cytoplasm, for example, proteins, peptides, and nucleic acids, and the mechanisms involved in endosomal escape. Endocytosis, endosomal maturation, and exocytosis pose significant barriers to effective cytoplasmic delivery. The article explores various endosomal escape mechanisms, such as the proton sponge effect, osmotic lysis, membrane fusion, pore formation, membrane destabilization/ disruption, and vesicle budding and collapse. Additionally, it discusses the role of lysosomes, glycocalyx, and molecular crowding in the cytoplasmic delivery process. Despite the recent advances in nonviral delivery systems, there is still a need to improve cytoplasmic delivery. Strategies such as fusogenic peptides, endosomolytic polymers, and cell-penetrating peptides have shown promise in improving endosomal escape and cytoplasmic delivery. More research is needed to refine these strategies and make them safer and more effective. In conclusion, the article highlights the challenges associated with cytoplasmic delivery and the importance of understanding the mechanisms involved in endosomal escape. A better understanding of these processes could result in the creation of greater effectiveness and safe delivery systems for various cargoes, including proteins, peptides, and nucleic acids.

Cationic nanocarriers: A potential approach for targeting negatively charged cancer cell.

Cancer, a widespread and lethal disease, necessitates precise therapeutic interventions to mitigate its devastating impact. While conventional chemotherapy remains a cornerstone of cancer treatment, its lack of specificity towards cancer cells results in collateral damage to healthy tissues, leading to adverse effects. Thus, the quest for targeted strategies has emerged as a critical focus in cancer research. This review explores the development of innovative targeting methods utilizing novel drug delivery systems tailored to recognize and effectively engage cancer cells. Cancer cells exhibit morphological and metabolic traits, including irregular morphology, unchecked proliferation, metabolic shifts, genetic instability, and a higher negative charge, which serve as effective targeting cues. Central to these strategies is the exploitation of the unique negative charge characteristic of cancer cells, attributed to alterations in phospholipid composition and the Warburg effect. Leveraging this distinct feature, researchers have devised cationic carrier systems capable of enhancing the specificity of therapeutic agents towards cancer cells. The review delineates the underlying causes of the negative charge in cancer cells and elucidates various targeting approaches employing cationic compounds for drug delivery systems. Furthermore, it delves into the methods employed for the preparation of these systems. Beyond cancer treatment, the review also underscores the multifaceted applications of cationic carrier systems, encompassing protein and peptide delivery, imaging, photodynamic therapy, gene delivery, and antimicrobial applications. This comprehensive exploration underscores the potential of cationic carrier systems as versatile tools in the fight against cancer and beyond.