Training and credentialing in Robotic Surgery in India: Current perspectives.

Robotic surgery has changed the landscape of surgery and ushered in a new era of technology-assisted minimally invasive surgery. There is a paradigm shift from traditional open surgeries to minimal access surgery, with robotic surgery being the new standard of care in some surgical fields. This change comes with an unprecedented influx of innovations in technology related to minimal access surgery, robotics and artificial intelligence. Despite the exponential advances in technology, there is a lacuna in the training and credentialling of robotic surgeons. In India, no dedicated training curriculum exists for trainees in robotic surgery. Thus, as robotic surgery continues to develop in India, it is imperative that robust training and credentialing systems are in place to ensure that patient safety and surgical outcomes are not compromised.

Expression and clinicopathological correlation of Ki-67 in gallbladder carcinoma.

INTRODUCTION: Gallbladder cancer is an aggressive cancer with short median survival from the time of diagnosis. Improved understanding of the pathological molecular mechanisms of gallbladder carcinogenesis is important to refine the diagnosis, prognosis, and also to develop novel targeted therapies for patients with advanced Gallbladder cancer (GBC) malignancy. Ki-67 is a marker of cell proliferation and its detection by immunohistochemistry is considered to be an effective method for the detection of prognosis in several tumors. In the present study, we have analyzed expression of immunohistochemical marker Ki-67 in gallbladder carcinoma and its correlation with clinicopathological and radiological parameters. MATERIALS AND METHODS: This prospective observational study was conducted from December 2017 to July 2020. The patients of newly diagnosed gallbladder cancer were enrolled as per the inclusion and exclusion criteria defined in the study protocol. Contrast-enhanced computer tomography of the chest and abdomen and serum tumor markers such as carbohydrate antigen (CA)-19.9, carcinoembryonic antigen, and CA 125 were done. Immunohistochemical expression of Ki-67 was evaluated on biopsy tissue from the gallbladder mass. RESULTS: Fifty newly diagnosed patients of carcinoma gallbladder were included in the present study. The correlation was studied between clinicodemographic parameters and Ki-67, but no association was found with age, gender, and symptoms. There was a weak positive correlation between Ki-67 and direct bilirubin, serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, and alkaline phosphatase (P = 0.094; 0.126; 0.542; and 0.328, respectively). There was a weak positive correlation between body mass index (Kg/m2) and Ki-67, but this correlation was not statistically significant (P = 0.304). CONCLUSIONS: Ki-67 is a marker of proliferation and it correlated with histological differentiation, jaundice and liver function tests, presence of stones, and location of metastases but did not correlate with stage and extent of disease.

Expression of Human epidermal growth factor receptor 2, Survivin, Enhancer of zeste homolog -2, Cyclooxygenase-2, p53 and p16 molecular markers in Gall bladder carcinoma.

INTRODUCTION: Gallbladder cancer exhibits striking variability in the global rates, reaching epidemic levels for some regions and ethnicities. The basis of its variability resides in differences in environmental exposure and intrinsic genetic predisposition to carcinogenesis. There is little information present regarding genetic and molecular alterations in gall bladder cancer (GBC). We, therefore, have evaluated the molecular marker expression in GBC and studied their correlation with clinicopathological staging. MATERIALS AND METHODS: This prospective observational study was conducted on newly diagnosed GBC patients from July 2017 to July 2020. After complete staging workup, the GBC biopsy samples paraffin block was tested for molecular markers estrogen receptor (ER), progesterone receptor (PR), p53, p16, Human epidermal growth factor receptor 2 (HER 2-neu), Survivin, Enhancer of zeste homolog-2 (EZH2), and Cyclooxygenase-2 (COX-2) expression by immunohistochemistry. RESULTS: Fifty newly diagnosed patients of carcinoma gall bladder were included in the present study. Age was ranged from 29 - 69 years (mean 53.42). p53 was the most common positive marker in 74% of patients, survivin in 58%, COX-2 in 44%, and p16 in 42% whereas Her 2 neu and EZH-2 were positive in 16% of patients each. None of the patients of GBC were ER or PR positive. There was a significant difference between the various groups in terms of the distribution of histological grade and Her 2 neu (χ2 = 9.886, P = 0.014) but not with other markers. Furthermore, there was a significant difference in terms of distribution of p16 and p53 with stage (χ2 = 7.017, P = 0.037 and χ2 = 5.861, P = 0.033) respectively. CONCLUSIONS: The present study shows the expression of molecular markers Her2 neu, p53, p16, survivin, COX-2, and EZH-2 in GBC. Now the time has come, and it is also the need of the day to establish early biomarkers of this highly lethal malignancy. It can be used in future for the detection of disease in the early phase and targeted therapy.

Demographic and clinicopathological Profile of Gall Bladder Cancer Patients: Study from a tertiary care center of the Sub-Himalayan region in Indo-Gangetic Belt.

INTRODUCTION: Gall bladder cancer (GBC) accounts for 80%-95% of biliary tract malignancies in the world. There is however striking variability in the global incidence of gallbladder cancer, reaching epidemic levels for some regions and ethnicities. The aim of this study was to evaluate the demographic and clinicopathological profile of the gallbladder cancer patients. MATERIALS AND METHODS: All patients of carcinoma gall bladder presenting to department of surgery in hepatopancreaticobiliary unit from July 2017 to November 2020 were included in this study. A proforma containing all the relevant details including history, examination, blood, radiology, and pathological investigations was filled. RESULTS: A total of 326 patients of GBC were analyzed. The majority (75%) were found to be females with a mean age of 55 years. Pain abdomen was the most common presenting symptom in 81% of patients. The most common stage of presentation was stage IV and only 6 were in stage I. Two hundred and thirty three (71.4%) patients had metastatic disease at presentation. Liver infiltration at the time of diagnosis was present in 89% of patients. The most common site of metastasis was found in the liver (23.3%). GBC was more common in patients with A blood group. Baseline serum albumin levels were found to be significantly associated with the staging of GBC. CONCLUSIONS: Due to the non specific symptoms patients of GBC present at very advanced stages, high index of suspicion and health education seems to play an important role in early detection and improvement of survival.

Role of carbohydrate antigen 19-9, carcinoembryonic antigen, and carbohydrate antigen 125 as the predictors of resectability and survival in the patients of Carcinoma Gall Bladder.

INTRODUCTION: Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) have been reported in previous studies to assess the prognosis of gall bladder cancer (GBC) individually and in combination. However, the evidence of utility of preoperative CA 19-9, CEA and carbohydrate antigen 125 (CA 125) in determining the resectability and prognosis of GBC is still lacking. In the present study we correlated the serum levels of tumor markers CA 19-9, CEA and CA 125 individually and combined to determine the resectability and prognosis of the GBC. MATERIALS AND METHODS: Seventy one diagnosed patients of GBC between January 2018 and September 2019 were included in the present study. Serum CA 19-9, CEA and CA 125 were determined by chemiluminescence. Receiver operating characteristic (ROC) curve was used to evaluate the role of tumor markers in determining the resectability of GBC. The Kaplan Meier survival curves were made and log rank analysis was performed to assess the prognostic role of tumor markers in terms of overall median survival. RESULTS: All the three tumor markers CA19-9, CEA and CA 125 showed high discriminatory power in determining the resectability with respective area under curve of 0.76, 0.68 and 0.78 as determined by ROC. Median survival in patients with high serum CA 19-9, CA 125 was significantly lower than patients with normal serum CA 19-9, CA 125 whereas no significant difference was observed in case of CEA. CONCLUSION: The present study suggested that CA 19-9, CEA and CA 125 can predict resectability in GBC and raised levels of CA 19-9 and CA 125 can predict poor prognosis in patients with elevated levels.

Symptom Palliation in Advanced GallBladder Cancer: An Institutional Experience.

AIM: Palliation of symptoms of patients with advanced carcinoma gallbladder (GB). MATERIALS AND METHODS: Sixty-two newly diagnosed patients of unresectable advanced and metastatic GB cancers were enrolled, and following clinicoradiological assessment patients were considered for palliative symptom management. RESULTS: The most common presenting symptom was pain in 57 (92%) patients. Obstructive jaundice was observed in 29 (46.7%) patients. Patients were considered for percutaneous biliary drainage/internal stenting, therapeutic ascitic tapping, and pain control. Patients with good performance status were considered for palliative chemotherapy. CONCLUSION: Patients with advanced carcinoma GB were managed with various palliative procedures with the aim to improve the quality of life of patients because of jaundice, loss of appetite, nausea, pain, etc. Symptoms are distressing for patients.

Review of Mesenteric Ischemia in COVID-19 Patients.

The new coronavirus (COVID-19) infection, first detected in Wuhan, China in 2019 has become a pandemic that has spread to nearly every country in the world. Through October 11, 2021, more than 23 billion confirmed cases and 4.8 million fatalities were reported globally. The bulk of individuals afflicted in India during the first wave were elderly persons. The second wave, however, resulted in more severe diseases and mortality in even younger age groups due to mutations in the wild virus. Symptoms may range from being asymptomatic to fatal acute respiratory distress syndrome (ARDS). In addition to respiratory symptoms, patients may present with gastrointestinal symptoms such as stomach pain, vomiting, loose stools, or mesenteric vein thrombosis. The frequency of patients presenting with thromboembolic symptoms has recently increased. According to certain studies, the prevalence of venous thromboembolism among hospitalized patients ranges from 9 to 25%. It was also shown that the incidence is significantly greater among critically sick patients, with a prevalence of 21-31%. Although the exact origin of thromboembolism is unknown, it is considered to be produced by several altered pathways that manifest as pulmonary embolism, myocardial infarction, stroke, limb gangrene, and acute mesenteric ischemia. Acute mesenteric ischemia (AMI) is becoming an increasingly prevalent cause of acute surgical abdomen in both intensive care unit (ICU) and emergency room (ER) patients. Mesenteric ischemia should be evaluated in situations with unexplained stomach discomfort. In suspected situations, appropriate imaging techniques and early intervention, either non-surgical or surgical, are necessary to avert mortality. The purpose of this article is to look at the data on acute mesenteric ischemia in people infected with COVID-19.

Malignant pleural effusion from a case of squamous-cell carcinoma of the oral cavity: Cytological detection of a rare outcome.

Distant metastases from carcinomas of the oral cavity are rare. Detection of these metastasis are essential for staging and management of the patient. These tumours may metastasize to lung, liver, brain and bone; but pleural involvement by squamous-cell carcinoma is distinctly rare. We present a case of bilateral pleural effusion arising from distant metastasis of squamous-cell carcinoma detected on cytology.

Pancreatic tuberculosis mimicking as pancreatic malignancy: Surgeon's dilemma.

Pancreatic tuberculosis is a rare form of Tuberculosis (TB) which requires a high index of suspicion to diagnose. Here, we report a case of middle-aged gentleman presenting with abdominal pain and constitutional symptoms who was diagnosed with pancreatic tuberculosis on imaging, which was confirmed by Fine Needle Aspiration (FNA) from the lesion. The patient was given Anti-Tubercular Treatment (ATT) as per conventional protocol. Follow-up showed recovery from the entity. A review of patient presentation, patho-physiology, diagnosis, and management of pancreatic tuberculosis is mentioned in this article.

Laparoscopic Retrieval of a 13-Year-Old Retained Iatrogenic Metallic Foreign Body from the Pelvis: An Uncommon Case Report.

Retained surgical foreign bodies are unanticipated events culminating from inadvertent operating room errors and may cause severe medical and legal problems between the patient and the doctor. Here, we report detecting a surgical instrument fragment 13 years after an open abdominal hysterectomy in a quadragenarian during her evaluation of a month-old complaint of lower abdominal and right thigh pain. A computed tomography scan of the abdomen demonstrated a radio-opaque linear foreign body traversing the right obturator foramen with extension into the pelvis cranially and the adductor compartment of the right thigh caudally. The metallic foreign body, identified as a fragmented handle of a uterine tenaculum forceps with a slender sharp-tip hook, could be removed laparoscopically from the pelvis after a diagnostic laparoscopy, preventing significant complications. The minimally invasive approach enabled a smooth recovery, and the patient could go home on the second postoperative day.

Silica coating of polymer nanowires produced via nanoimprint lithography from femtosecond laser machined templates.

In this paper we report on the fabrication of regular arrays of silica nanoneedles by deposition of a thin layer of silica on patterned arrays of polymer nanowires (or polymer nanohair). An array of high-aspect-ratio nanoscale diameter holes of depths greater than 10 µm was produced at the surface of a fused silica wafer by an amplified femtosecond laser system operated in single-pulse mode. Cellulose acetate (CA) film was imprinted into the nanoholes and peeled off to form a patterned array of standing CA nanowires, a negative replica of the laser machined nanoholes. The cellulose acetate replica was then coated with silica in a chemical vapor deposition process using silicon tetrachloride vapor at 65 °C. Field emission scanning electron microscopy, focused ion beam sectioning, energy dispersive x-ray analysis and Fourier-transform infrared spectroscopy were used to characterize the silica nanoneedles. Precisely patterned, functionalized arrays of standing silica nanoneedles are useful for a number of applications.

The Friend Turned Foe: A Rare Presentation of Bilateral Empyema Secondary to the Perforated Appendix.

Acute appendicitis is one of the most common surgical emergencies encountered. Although studies have reported a rise in the number of cases over the past decade in Western countries, appendicitis is comparatively lower in Asian countries, mainly due to the prevailing dietary habits. Acute appendicitis can further complicate as either appendicular abscess or an appendicular lump or culminate into peritonitis following gangrene/rupture. Almost one-third of the patients with appendicitis present to the hospital with a ruptured appendix. Management of complicated appendicitis is complex, and the diagnosis itself becomes tricky when it presents unusually. Here, we describe the management of one such rare manifestation in a middle-aged female who had concomitant gangrenous appendicitis and bilateral pyothorax. This case report emphasizes that abdominal pathology can lead to bilateral intrathoracic collection without any preexisting thoracic pathology.

Negative pressure wound therapy in surgical practice: an Institutional experience from a tertiary centre of North India.

<b>Introduction:</b> Negative pressure wound therapy (NPWT) has been suggested as a gold standard for managing complex wounds and to reduce the time of healing and overall morbidity and mortality of the patient. </br></br> <b>Aim:</b> We have done a retrospective study to observe the outcome in patients managed with negative pressure wound therapy for varied etiologies. </br></br> <b> Methods:</b> Patients with complicated wounds including lower limb wounds post-debridement, upper limb wounds post-debridement, postoperative abdominal wound dehiscence, abdominal and chest abscess wounds post-debridement and amputation stumps, managed with negative pressure wound therapy were studied on the basis of wound outcome, total hospital stay, days of NPWT application and pressure and mode of NPWT. </br></br> <b>Results:</b> A total of 42 patients with complicated wounds were included in the study. Mean hospital stay was 16.2 days and mean NPWT application time was 8.29 days with NPWT being applied on average for 3.91 days post-procedure like debridement or amputation or after wound dehiscence in which debridement was not done. As many as 41.5% of wounds were closed with suturing, 48.8% healed by secondary intention and 9.8% were covered with split-thickness skin grafts. A significant observation was made for lower pressure being used for abdominal wound dehiscence (75 mmHg) compared to other wounds on limbs (mean 98.33 mmHg) (P < 0.001). Re-debridement after the 1st cycle of NPWT was needed in 40% of wounds managed with intermittent mode compared to 6.2% in continuous mode (P = 0.028). </br></br> <b>Conclusion:</b> NPWT can reduce and manage wound complications with improvement in the quality of life of patients when used at an appropriate time with knowledge of its mechanism and functionality.

Artificial intelligence: A new tool in surgeon's hand.

Artificial intelligence (AI) is the future of surgery. Technological advancements are taking place at an incredible pace, largely due to AI or AI-backed systems. It is likely that there will be a massive explosion or "Cambrian explosion" of AI in our everyday life, largely aided by increased funding and resources spent on research and development. AI has also significantly revolutionized the medical field. The concept of machine learning and deep learning in AI is the crux of its success. In surgical practice, AI has numerous applications in the diagnosis of disease, preoperative planning, intraoperative assistance, surgical training and assessment, and robotics. The potential automation of surgery is also a possibility in the next few decades. However, at present, augmentation rather than automation should be the priority. In spite of the allure of AI, it comes with its own price. A robot lacks the "sixth sense" or intuition that is crucial in the practice of surgery and medicine. Empathy and human touch are also inimitable characteristics that cannot be replaced by an AI system. Other limitations include the financial burden and the feasibility of using such technology on a wide scale. Ethical and legal dilemmas such as those involving privacy laws are other issues that should be taken under consideration. Despite all these limitations, with the way technology is progressing, it is inevitable that AI and automation will completely change the way we practice surgery in the near future. Thus, this narrative review article aims to highlight the various applications and pitfalls of AI in the field of surgery.

Clinical spectrum and management outcome in gallbladder perforation-a sinister entity: Retrospective study from Sub-Himalayan region of India.

Objectives: Gallbladder perforation is an infrequent entity seen among surgical patients. Rare occurrence owes to difficulty in diagnosing gallbladder perforations. The aim of the present study was to determine the optimal management strategy that may decrease the morbidity and mortality associated with this potentially life-threatening condition. Material and Methods: This was a retrospective study from hospital health records wherein the experience of 40 consecutive patients with gallbladder rupture, either spontaneous or secondary to both benign conditions and malignancy, was noted at a tertiary care hospital over 48 months from February 2017 till January 2021. The etiology, clinical presentation, and treatment given were analysed. Results: Out of 40 patients included, 23 were females and the majority of patients were more than 45 years of age. Twelve patients responded to intravenous antibiotics and analgesics alone while five required an ultrasound-guided pigtail catheter drainage due to non-improving clinical condition. The failure of expectant management led to a delayed laparotomy in seven patients while four patients required emergency laparotomy because of generalized peritonitis. An elective cholecystectomy was offered to 12 patients with cholecystoenteric fistulae after diagnostic laparoscopy in the same admission. Thirty-eight patients were discharged in stable condition and doing well at 30-day follow-up. Conclusion: Gallbladder perforation is seen more commonly in acute calculous cholecystitis compared to other conditions. It is more evident when the treatment of acute calculous cholecystitis is delayed by more than 6-8 weeks. The spectrum of clinical presentation varies from mild pain and vomiting to generalized peritonitis. The patient often requires a step-up approach to control the ongoing sepsis for an improved outcome.

Adult Left Colocolic Intussusception Successfully Managed by Left Hemicolectomy and Primary Anastomosis.

Intussusception, although quite common in children with the classic triad of cramping abdominal pain, bloody diarrhea, and palpable masses, is a rare cause of acute abdomen with myriad presentations in adults. It is defined as the telescoping of a proximal segment of the gastrointestinal (GI) tract, called the intussusceptum, into the lumen of the adjacent distal segment of the GI tract, called intussuscipiens. Due to its different manifestations and time course, adult colonic intussusception often poses a diagnostic challenge for emergency doctors. The treatment of colonic intussusception in adults typically involves surgery, often with bowel resection and anastomosis followed by a defunctioning loop ileostomy. We report a case of left-sided colocolic intussusception secondary to a tubular adenoma as the lead point, which was successfully treated by resection and primary anastomosis. The pathological diagnosis of the lesion was reported as adenocarcinoma and resected bowel margins were found free of the tumor.

Stentolith in Bile Duct: A Neglected Entity-Case Report with Review of Literature.

Stentolith is a forgotten stent that acts as a nidus for stone formation leading to a stone-stent complex. Once the planned procedure is completed, these stents should be removed within 4 to 6 weeks, but if they are required for a longer period, then they should be replaced every 3 to 6 months. Devastating complications may ensue -such as cholangitis, biliary stricture, or secondary biliary cirrhosis. Management primarily comprises surgical intervention with common bile duct exploration or endoscopic clearance. The majority of patients eventually develop symptoms that lead to their diagnosis and subsequent management. This article, however, details the case of a silent stentolith and how it may have led to disastrous complications if surgical intervention was not done promptly.

Large retroperitoneal cystic lymphangioma mimicking mesenteric cyst: a case report.

Cystic lymphangioma is a benign tumour that occurs secondary to obstruction of lymphatic channels. Its appearance in the paediatric age group is quite common, but adulthood presentation is infrequent. Common locations are head and neck areas, whereas intra-abdominal occurrence is rare. To date, a few retroperitoneal cystic lymphangioma cases have been reported. A pre-operative clinical detection is always confusing, and most often, the diagnosis rests over the intraoperative findings and histopathological examination. The cyst's complete surgical resection remains the treatment of choice in patients with bulky, rapidly growing lesions or symptoms. Herein, we report a large retroperitoneal cystic lymphangioma that mimicked the mesenteric cyst clinically.

Risk factors of surgical site infection in elective laparotomy in a tertiary care center: an observational study.

INTRODUCTION: Surgical site infections (SSI) encompass 20-25% of all hospital-acquired infections with their prevalence ranging from 2.5 to 41.9% across the world. Prevalence and risk factors of SSI vary greatly between countries and between healthcare institutions within a country. There is limited data on the pattern and risk factors of SSI in the Indian healthcare scenario. This study is an attempt to identify risk factors of SSI in patients who underwent elective laparotomy in the general surgery department of a tertiary care hospital in India. METHODOLOGY: This is an observational cross-sectional retrospective study, conducted over 5 years from January 1, 2015, to December 31, 2019. A total of 112 patients who underwent elective laparotomy in the department of general surgery, were enrolled in the study. Data collection was done from hospital case records and discharge summaries of patients. RESULTS AND DISCUSSION: Out of the 112 patients, a total of 16 patients (14.29%) developed surgical site infections. Preoperative serum total protein (W-465.500, P 0.012) and length of hospital stay (W=1235.000, P≤0.001) were found to have a significant association with surgical site infection. Age, gender, smoking, comorbidity, class of surgical wound and, preoperative albumin did not show any significant association with the development of SSI. Escherichia coli was the predominant organism isolated in culture. CONCLUSION: Measures to curtail SSI can only be adopted after a thorough understanding of its prevalence and predictors. The characteristics and pattern of SSI will help identify prevalent organisms, their resistance pattern and will aid in formulating antibiotic policy tailor-made for the healthcare institution.

A Series of Biliary Tract Cancer With Coexistent Non-biliary Second Malignancy From Sub-Himalayan Region of India.

Background When researching female patients with breast or ovarian neoplasms, our research will sensitize oncologists to the prevalence of biliary tract cancers such that early cancers are not overlooked. Depending on different inherited, environmental, and iatrogenic risk factors, patients diagnosed with cancer have a risk of harboring another de novo malignancy. The additional primary identification of late has increased mainly due to progress in both diagnosis and treatment modalities, improvement in life expectancy, and understanding. Methods This is a descriptive study of retrospectively collected data from health records over 15 months, of patients who had biliary tract cancer and incidentally detected coexisting second non-biliary malignancy, from July 2018 to September 2019 at a tertiary care hospital. Details such as age, sex, smoking history, family history, occupation, body mass index (BMI), the organ involved, levels of tumor markers, treatment, and outcome were recorded. Results Six consecutive patients with biliary tract cancer presented during this duration and incidentally detected the second primary was ovarian cancer in three (50%) patients, breast carcinoma in two (33%) patients, and urinary bladder carcinoma in the remaining one patient (17%). The median age at diagnosis was 52.5 years with a range of 40-65 years. All patients were females (100%), non-smokers, homemaker, and without any history of cancer in family members. Only two patients who had a resectable disease were alive at one year's follow-up. Conclusion The mechanisms of carcinogenesis in multiple primary malignancies are mainly genetic, epigenetics, and immunological. Prognosis, as well as the intent of treatment, depends on the respective stages of the two malignancies. In our study, most of the patients were in an advanced stage that demanded palliative care.