MIS for enucleation of leiomyoma of the oesophagus-strategic approach and experience of 19 cases.

INTRODUCTION: Leiomyoma of the oesophagus, although rare, is the most common benign tumour to occur in the organ. Surgical approaches have evolved over time from an open thoracotomy or laparotomy to video-assisted thoracoscopic or laparoscopic and now robotic enucleation. We report a series of 19 cases of leiomyoma of the middle- and lower-third oesophagus treated by minimally invasive surgery. PATIENTS AND METHODS: A retrospective analysis of 19 cases operated at a single tertiary care centre in India was performed. After the diagnosis of a benign oesophageal neoplasm on computed tomography (CT) and endosonography, laparoscopic transhiatal enucleation of the tumour for lower third ( n = 16) and right-sided video-assisted thoracoscopic excision for middle-third tumours ( n = 3) were performed. Dor fundoplication was done after the excision of leiomyomas from the lower oesophagus. RESULTS: The most common symptom at presentation was retrosternal burning in lower oesophageal tumours, while tumours in the middle third of the oesophagus were asymptomatic and incidentally detected. The size of the tumour ranged from 3 cm to 8 cm in the largest dimension on contrast-enhanced CT scan. The mean operative time was 93 min ranging from 61 to 137 min. The average blood loss was 53 ml. No patient had an iatrogenic oesophageal mucosal injury. There were no conversions to open surgery or major complications including post-operative leak or death. Post-operative recovery was uneventful. CONCLUSION: The transhiatal approach to lower oesophageal leiomyomas is strategic to avoid complications of thoracoscopy, minimally invasive, cost-effective as compared to robotic surgery, suitable for adequate exposure and safe in the hands of an experienced laparoscopic surgeon.

Long-term outcomes of laparoscopic longitudinal pancreatojejunostomy and modified Frey's procedure for patients of chronic pancreatitis: A 10-year experience.

INTRODUCTION: To mitigate the morbidity associated with open procedures for chronic pancreatitis (CP), there is a paradigm shift towards the laparoscopic approach. However, since these procedures are technically demanding, literature is still limited. We present our experience and long-term outcomes in the management of CP with laparoscopic surgical procedures. PATIENTS AND METHODS: This is a retrospective observational study of patients who underwent a laparoscopic surgery for CP between 2009 and 2019. Pain scores using the Visual Analogue Scale (VAS) were compared pre- and postoperatively. In patients with diabetes, the pre- and post-operative insulin requirement was compared. RESULTS: Data of 62 patients were analysed. The mean duration of follow-up was 69 (±22) months. All patients had pain relief post-surgery. The relief of pain was sustained, with the median VAS scores being 1 at 3- and 5-year follow-up. There was a decrease in the median insulin requirement of diabetic patients, which was significant at 3-month and 1-year follow-up ( P < 0.05). CONCLUSION: Our study demonstrates that laparoscopic surgical procedures offer long-term pain control with low morbidity. Effective ductal decompression may result in a short-term improvement of the endocrine function of the gland.

Laparoscopic concomitant cholecystectomy and splenectomy for true left-sided gall bladder with hereditary spherocytosis.

A true left-sided gall bladder (LSG) is a rare finding, is mostly discovered incidentally and often presents with symptoms similar to those of a normally positioned gall bladder. The diagnosis in most cases is intraoperative. The surgical technique is frequently difficult, with an increased risk of intraoperative injuries and conversion to open surgery. In this case report, we describe a rare scenario of a young male with hereditary spherocytosis who presented with jaundice and splenomegaly. The diagnosis of LSG was made by chance during pre-operative imaging. The patient was successfully managed with a splenectomy and a cholecystectomy via the minimal access approach in the same setting.

Laparoscopic transhiatal stapled closure of spontaneous pleuroesophageal fistula: A case report.

Pleuroesophageal (PE) fistula (PEF) is rare and usually presents secondary to tuberculous mediastinal lymphadenopathy, Boerhaave syndrome, penetrating foreign bodies, erosive oesophagitis, post-mediastinal and gastroesophageal surgeries and neoplasm. We present a case of spontaneous PEF, successfully treated laparoscopically with stapling done through the hiatus.

Laparoscopic peritoneal dialysis catheter insertion: an oasis harnessed-experience and results at a tertiary care centre in India.

BACKGROUND: Peritoneal dialysis is a life sustaining renal replacement therapy for patients with end stage renal disease. In comparison to hemodialysis it offers better mobility and independence to patients. A number of techniques including open, laparoscopic and fluoroscopy guided, and their modifications, have been described for intraperitoneal catheter insertion. We describe our technique and results of laparoscopic peritoneal dialysis (PD) catheter insertion at a tertiary care centre in India. CASE SERIES: 48 patients were referred from the department of nephrology at our centre for laparoscopic PD catheter insertion. A two port technique was used in 37 patients and three port technique was implemented in the rest for simultaneous adhesiolysis and/or omentectomy. A straight tip catheter was tunneled through the rectus muscle in all patients. Two patients had incisional hernia from a previous abdominal surgery which was repaired concomitantly with onlay meshplasty. RESULTS: The operative time ranged between 20 and 35 min under general anaesthesia. Three patients were subjected to urgent start dialysis of which one patient developed peridrain leak as an early complication which was managed conservatively. All other patients were commenced on peritoneal dialysis two weeks after surgery. There was no other surgical site occurrence or episodes of peritonitis reported in a 6 month follow up period with the department of nephrology. CONCLUSION: In the era of minimal access surgery, the laparoscopic approach is feasible for widespread and safe use for PD catheter insertion. The benefits of PD can thus be made available to patients at civil hospitals even with a basic laparoscopy setup.

Persistent omphalomesenteric duct and urachus presenting as an umbilical hernia.

Vitellointestinal duct anomalies, although one of the most frequent malformations to be found (2%-3% in population), they are most unlikely to cause symptoms. A persistent Vitellointestinal duct can induce abdominal pain, bowel obstruction, intestinal haemorrhage and umbilical sinus, fistula or hernia which commonly occurs in children. Patent vitellointestinal duct or persistent omphalomesenteric duct is a very unusual congenital anomaly which occurs in 2% of the population related to the embryonic yolk stalk. Similarly, urachal anomalies remain a rare finding, with the most common being a cyst or sinus followed by patent urachus and rarely a urachal diverticulum. Presenting symptoms include periumbilical discharge, pain and a palpable mass.Here, we report a case of an adult patient with patent vitellointestinal duct and urachus identified intraoperatively on diagnostic laparoscopy when being operated for umbilical hernia repair.

A Never Described Variant of the Cervical Rib Causing Arterial Thoracic Outlet Syndrome: World's First Case.

Cervical ribs, also known as Eve's ribs, are rare and found in 1% of population. They are more common in females and more common on right side. They are asymptomatic in 90% of cases. Cervical rib fused with transverse process of sixth vertebra is rarer. We present a case of dry gangrene of lateral three fingers with right radial and subclavian artery thrombosis with rest pain, due to right cervical rib fused with transverse process of sixth vertebra. After development of line of demarcation of the dry gangrene, patient was operated for excision of cervical rib and sixth cervical vertebral transverse process followed by Ray's amputation of right second finger. Postoperative course was uneventful. Patient was discharged with oral anticoagulation and a healthy wound in right hand.

Comparison of efficacy and safety of the enhanced-view totally extraperitoneal (eTEP) and transabdominal (TARM) minimal access techniques for retromuscular placement of prosthesis in the treatment of irreducible midline ventral hernia.

BACKGROUND: Retromuscular plane for mesh placement is preferred for ventral hernia repair. With the evolution of minimal access surgeries, newer techniques to deploy a mesh in the sublay plane have evolved. We compared two such minimally invasive approaches for repair of irreducible ventral midline hernia with respect to the efficacy and safety of the procedures. PATIENTS AND METHODS: This is a retrospective study of a prospectively maintained database of 73 patients operated with retromuscular placement of mesh for irreducible ventral midline hernia by enhanced-view totally extraperitoneal (eTEP) or transabdominal retromuscular (TARM) repair. We recorded and compared the intraoperative and post-operative complications, post-operative pain score, recovery, recurrence, subjective technical ease of procedure and patient satisfaction after 3 months and 12 months of the surgery. RESULTS AND CONCLUSION: Thirty-eight patients were operated by eTEP technique and the subsequent 35 were operated by TARM repair. There was no significant difference in the outcome of surgery and complications by the two techniques. However, there was a significant subjective technical ease in the TARM group due to ergonomic triangulated port placement and adhesiolysis and reduction of hernia contents under vision. The number of ports used and post-operative pain were, however, higher in the TARM group as compared to that of the eTEP group. Nearly 96% of the patients belonging to both groups were satisfied with their surgery after a year on telephonic follow-up. However, further studies and follow-up of patients would be required to establish the advantage of one technique over the other.

Laparoscopic surgery for non-obstetric acute abdomen in pregnancy: A retrospective case series review.

BACKGROUND: Laparoscopic techniques have been used during pregnancy by obstetricians since the 1970's, primarily to diagnose and treat ectopic and heterotopic pregnancies. Pregnancy was considered as an absolute contraindication to laparoscopy by surgeons as recently as 1991, and a few still doubt the safety of minimal access in gravid patients. When an emergent operation is indicated, the surgery should not be withheld on the sole basis of patient's gravid state. On the contrary, the alleviation of maternal disease is thought to take priority because the health of the foetus is dependant on the mother. MATERIALS AND METHODS: This is a retrospective study of a case series of 18 obstetric patients who presented with non-obstetric causes of acute abdomen requiring surgical intervention. Ultrasonography and magnetic resonance imaging (MRI) along with other laboratory investigations were carried out to reach the diagnosis. Laparoscopic surgery was considered as the modality of treatment. All the patients were given the necessary care post-surgery and were followed up till parturition to look for any complications. RESULTS: The data were analysed considering the presentation, diagnostic variations and the surgical modifications statistically. CONCLUSION: The decision of surgery should be prompt and should be weighed against complications of conserving the patient. Due to the diagnostic limitations of ultrasonography, MRI should be coupled to confirm the diagnosis. Laparoscopy offers less analgesic requirements and shorter hospital stay. The operative time is highly subjective to the experience and training of the surgeon and the laparoscopic set-up itself.

Predicting Mortality in Fournier Gangrene and Validating the Fournier Gangrene Severity Index: Our Experience with 50 Patients in a Tertiary Care Center in India.

OBJECTIVE: To identify factors that dictate morbidity and mortality in patients with Fournier's Gangrene and validate the Fournier gangrene severity index (FGSI). MATERIALS AND METHODS: We prospectively studied 50 patients with FG from January 2016 to December 2016 pertaining to their presenting signs, intraoperative findings, and postoperative wound management and outcome. We also checked the power of the FGSI to predict the outcome of the patients in terms of mortality. Receiver operating characteristic curve was used to determine the optimum cutoff of FGSI score to predict mortality. Principle component analysis was performed to check for the possibility of reduction in the number of factors included in the FGSI. RESULTS: The mean age at presentation was 53 ± 16 years with a mortality rate of 24%. Factors associated with mortality were increasing age (p = 0.0001), presence of diabetes (p = 0.002), bed-ridden status (p = 0.001), alcoholic liver disease (p = 0.005), altered international normalized ratio (p > 0.005), late presentation (p = 0.001), and a FGSI score of > 9 at admission (p = 0.004). The mean FGSI score among survivors was 4.39 ± 3.80 compared to 14.22 ± 3.93 among those who died. The area under the curve FGSI score to predict mortality at a cutoff of 9 was 0.961 (95% CI 0.910-1.000). CONCLUSION: Increasing age, diabetes, alcoholic liver disease, bed-ridden status, delayed hospital presentation, and an altered international normalized ratio at presentation are associated with higher mortality in FG. The FGSI at admission should be used to identify patients with serious prognosis requiring intensive care.

Laparoscopic parastomal hernia repair: A modified technique of mesh placement in Sugarbaker procedure.

INTRODUCTION: Conventional surgery for parastomal hernia entails primary suture repair or stoma relocation. Laparoscopic surgery has advantages of less pain, faster post-operative recovery and better cosmesis. While the Sugarbaker technique has been valued for least recurrences, however, it exposes the stomal loop to the parietal surface of the mesh exposing it to complications. We report a modification of mesh placement after primary defect repair to improvise the safety of meshplasty and to minimise mesh erosions into the stomal loop of bowel. PATIENTS AND METHODS: Patients with permanent stoma presenting with a parastomal bulge leading to difficulty with stoma care or abdominal distention or pain were included in the study. A pre-operative computed tomography scan was performed in all patients to rule out any recurrence of primary pathology for which stoma was created and to study the abdominal musculature and defects. RESULTS: Of 14 patients, 12 patients had end-sigmoid stoma, one had end ileostomy following surgery for ulcerative colitis and one had urinary conduit. The size of the defect varied from 4.5 cm to 6 cm in diameter, and the average duration of surgery was 125 min. Pain assessed on VAS score was higher in the first 12 h, and all were started on orals on the next day, and average hospital stay was 4.2 days. The longest follow-up of 7 years and shortest of 15 months did not reveal any complications as recurrence, seroma, mesh infections or erosions into the stoma. CONCLUSION: Modified placement of composite mesh is safe and helps in minimising mesh-related complications of the Sugarbaker technique for parastomal hernias.

Laparoscopic cholecystectomy with choledochoduodenostomy in a patient with situs inversus totalis.

A 50-year-old female presented to us with features of obstructive jaundice. Investigations revealed cholelithiasis with single large impacted calculus in the common bile duct (CBD) and significant dilatation of extrahepatic biliary tree. Incidentally, the patient was also detected to have situs inversus totalis (SIT). Attempt at extraction of the calculus in the CBD by endoscopic retrograde cholangiography failed, and a 7F stent was placed. The patient was subjected to laparoscopic cholecystectomy, CBD exploration with the extraction of the offending calculus and laparoscopic choledochoduodenostomy (LCDD). The patient had an uneventful recovery and is since discharged. PubMed search did not reveal LCDD in SIT as a procedure reported in literature to the best of our knowledge.

Laparoscopic surgery for solitary insulinoma in the absence of IOUS.

BACKGROUND: Insulinomas are the most common pancreatic neuroendocrine neoplasms. In spite of adequate pre-operative localisation, conventional surgical methods rely on intraoperative palpation. Intraoperative ultrasonography (IOUS) is said to aid in accurate localisation, decreases morbidity. Laparoscopic removal of pancreatic endocrine neoplasms is beneficial due to magnification and minimal invasion; however, in the absence of IOUS, error of judgement may lead to conversion to open surgery, thereby relying on 'palpation method' to localise the tumour. We combined laparoscopic surgical removal of insulinomas using an innovative method of 'laparoscopic finger palpation' with intraoperative blood glucose monitoring and frozen section for surgical cure. MATERIALS AND METHODS: Patients were evaluated and investigated by the department of endocrinology and referred for surgical management of insulinoma. Pre-operative localisation of insulinoma was done by either contrast-enhanced computerised tomography angiogram - arterial and venous phase, or endoscopic ultrasound (EUS) or DOTATATE scan. Intraoperative localisation was done by laparoscopic dissection and 'laparoscopic finger palpation'. After enucleation, the specimen was sent for frozen section, and in the interim period, serial monitoring of blood glucose was done by the anaesthetist. Maintenance of glucose levels for more than 45 min after enucleation and confirmation of neuroendocrine tumour on frozen section was the end point of surgical procedure. RESULTS: A total of 19 patients were subjected to laparoscopic removal of solitary insulinomas. Enucleation was performed in 16 patients successfully. In three patients, laparoscopic distal pancreatectomy was performed. Three patients had pancreatic duct leak, of which two patients responded to conservative approach and the third patient required drainage by USG-guided pigtail catheter. All patients are cured of their disease and no patient has had recurrence so far. CONCLUSION: Multidisciplinary approach involving laparoscopic palpation, frozen sections and intraoperative blood sugar monitoring helps laparoscopic management of solitary insulinomas without IOUS.

Anaesthetic Management in Transoral Endoscopic Thyroidectomy.

Young females undergoing thyroid surgery are apprehensive about the surgical scar. This leads to the introduction of Transoral Endoscopic Thyroidectomy (TOET). TOET is gaining popularity for its minimally invasive and cosmetically sound approach to perform thyroidectomies in young patients. The surgical site being the mouth orifice poses a challenge to the anaesthesiologist to secure a definitive airway. The case report is that of a young female undergoing TOET for whom we have successfully performed nasal intubation with a North Pole ivory endotracheal tube (ET).

Efficacy and safety of a polyherbal formulation in hemorrhoids.

BACKGROUND: The medical management of hemorrhoids should include an integrated approach. This integrated approach can be achieved by polyherbal formulations containing anti-inflammatory, styptics, analgesics, and laxative effect which reduce inflammation, pain, and bleeding, and increase gastro-intestinal motility and soften stools. One such polyherbal kit is "Arshkeyt™, a 7 day kit," which consists of oral tablets and powder along with topical cream. OBJECTIVE: Efficacy and safety of Arshkeyt™, a 7 day kit, a marketed polyherbal formulation was evaluated in comparison with conventional therapy practiced in surgery outpatient departments. MATERIALS AND METHODS: Patients (n = 90) with hemorrhoids were randomly allocated to receive either Arshkeyt™ or standard therapy (combination of oral Isabgul powder and 2% lidocaine gel) for 14 days. Assessment on the basis of rectal symptoms and proctoscopic examination was done on day 0, 7, and 14 to derive a "composite score" which ranged from 0 to 25 by a blinded evaluator. The primary endpoint was number of patients achieving composite score 0 at the end of therapy (day 14). Inter-group analysis was done using Chi-square test. RESULTS: On day 14, the composite score of 0 was achieved in 15 patients of Arshkeyt™ group versus 6 patients receiving standard therapy. The symptoms and signs which showed significant improvement in Arshkeyt™ group compared to standard treatment group were the tenesmus (visual analog score) score (P = 0.047), anal sphincter spasm (P = 0.0495) and a decrease in the grade of hemorrhoids (P = 0.0205) on day 14. Arshkeyt™ was also more beneficial in case of bleeding hemorrhoids as compared to nonbleeding hemorrhoids (P < 0.05). The incidence of adverse drug reactions in both groups was comparable and no patient required any treatment for the same. CONCLUSION: "Arshkeyt™, a 7 day kit," was effective in the treatment of hemorrhoids and had a good safety profile.

Applying consequential LCA to support energy policy: land use change effects of bioenergy production.

Luxembourg aims at complying with the EU objective of attaining a 14% use of bioenergy in the national grid by 2020. The increase of biomethane production from energy crops could be a valuable option in achieving this objective. However, the overall environmental benefit of such option is yet to be proven. Consequential Life Cycle Assessment (CLCA) has shown to be a useful tool to evaluate the environmental suitability of future energy scenarios and policies. The objective of this study was, therefore, to evaluate the environmental consequences of modifying the Luxembourgish agricultural system to increase maize production for biomethane generation. A total of 10 different scenarios were modelled using a partial equilibrium (PE) model to identify changes in land cultivation based on farmers' revenue maximisation, which were then compared to the baseline scenario, i.e. the state of the agricultural sector in 2009. The results were divided into three different consequential decision contexts, presenting differing patterns in terms of land use changes (LUCs) but with minor shifts in environmental impacts. Nevertheless, energy from maize production would imply substantially higher environmental impacts when compared with the current use of natural gas, mainly due to increases in climate change and agricultural land occupation impacts. The results are discussed based on the consequences they may generate on the bioenergy policy, the management of arable land, the changes in import-export flows in Luxembourg and LUCs in the domestic agricultural system. In addition, the specific PE+LCA method presented intends to be of use for other regional studies in which a high level of site-specific data is available.

Laparoscopic adrenalectomy for large tumours: Single team experience.

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the procedure of choice to treat benign functioning and non-functioning adrenal tumours. With improving experience, large adrenal tumours (> 5 cm) are being successfully tackled by laparoscopy. This study aims to present our single unit experience of LA performed for large adrenal masses. MATERIALS AND METHODS: Forty-six laparoscopic adrenalectomies performed for large adrenal lesions more than 5 cm during the period 2001 to 2010 were reviewed. RESULTS: A total of 46 adrenalectomies were done in 42 patients. The mean tumour size was 7.03 cm (5-15 cm). Fourteen patients had tumour size more than 8 cm. The lesions were localised on the right side in 17 patients and on the left side in 21 patients with bilateral tumours in 4 patients. Functioning tumours were present in 32 of the 46 patients. The average blood loss was 112 ml (range 20-400 ml) with the mean operating time being 144 min (range 45 to 270 min). Five patients required conversion to open procedure. Three of the 46 patients (6.52%) on final histology had malignant tumours. CONCLUSION: LA is safe and feasible for large adrenal lesions. Mere size should not be considered as a contraindication to laparoscopic approach in large adrenal masses. Graded approach, good preoperative assessment, team work and adherence to anatomical and surgical principles are the key to success.

Laparoscopic adrenalectomy: Gaining experience by graded approach.

INTRODUCTION: Laparoscopic adrenalectomy (LA) has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success. MATERIALS AND METHODS: The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA). The indications in Group A were pheochromocytoma (n=7), Conn's syndrome (n=3), Cushing's adenoma (n=2), incidentaloma (n=2); and in Group B, Cushing's disease (CD) following failed trans-sphenoid pituitary surgery (n = 8); ectopic ACTH- producing Cushing's syndrome (n=1) and congenital adrenal hyperplasia (CAH) (n=1). The lateral transabdominal route was used. RESULTS: The age group varied from 12-54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40-270 min) and 190 min (150-310 min) in Group B. Average blood loss was 136.93 cc (20-400 cc) in Group A and 92.5 cc (40-260 cc) in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1-3 days) in Group A and 2.6 days (2-4 days) in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson's syndrome. The mean follow up was of 24.16 months (4-61 months). CONCLUSION: LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.