Surgical Cholecystectomy Score (SCS) for grading the difficulty of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic gall stone disease. A good scoring system is necessary to standardize the reporting. Our aim was to develop and validate an objective scoring system, the Surgical Cholecystectomy Score (SCS) to grade the difficulty of LC. METHODS: The study was conducted in a single surgical unit at a tertiary care hospital in two phases from January 2017 to April 2021. Retrospective data was analysed and the difficulty of each procedure was graded according to the modified Nassar's scoring system. Significant preoperative and intraoperative data obtained was given a weightage score. In phase II, these scores were validated on a prospective cohort. Each procedure was classified either as easy, moderately difficult or difficult. STATISTICAL ANALYSIS: A univariate analysis was performed on the data followed by a multivariate regression analysis. Bidirectional stepwise selection was done to select the most significant variables. The Beta /Schneeweiss scoring system was used to generate a rounded risk score. RESULTS: Data of 800 patients was retrieved and graded. 10 intraoperative parameters were found to be significant. Each variable was assigned a rounded risk score. The final SCS range for intraoperative parameters was 0-15. The scoring system was validated on a cohort of 249 LC. In the final scoring, cut off SCS of > 8 was found to correlate with difficult procedures. Score of < 2 was equivalent to easy LC. A score between 2 and 8 indicated moderate difficulty. The area under ROC curve was 0.98 and 0.92 for the intraoperative score indicating that the score was an excellent measure of the difficulty level of LCs. CONCLUSION: The scoring system developed in this study has shown an excellent correlation with the difficulty of LC. It needs to be validated in different cohorts and across multiple centers further.

Effect of positive end expiratory pressure on atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia: A lung ultrasonography study.

Postoperative pulmonary complications vary in major upper abdominal surgery. The objective of this study was to assess the effect of positive end expiratory pressure on the incidence of atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia using lung ultrasound. The patients were randomised into receiving either no positive end expiratory pressure (Group I) or positive end expiratory pressure of 5cm H2O (Group II). Lung ultrasound was performed at various time points - baseline, 10 minutes, 2 hours after induction, during closure of skin and 30 minutes post extubation. The lung aeration as assessed by Total Modified Lung Ultrasound Score was worse in the Group I as compared to the Group II at 2 hours post induction. Driving pressure in Group II was significantly reduced compared to Group I. Application of positive end expiratory pressure, as minimal as 5cm H2O, as a single intervention, helps in significantly reducing the Total Modified Lung Ultrasound Score after a duration of more than 2 hours and also attaining low driving pressures during intraoperative mechanical ventilation.

Comparison of extended totally extra peritoneal (eTEP) vs intra peritoneal onlay mesh (IPOM) repair for management of primary and incisional hernia in terms of early outcomes and cost effectiveness-a randomized controlled trial.

BACKGROUND: There are no randomized controlled trials comparing the eTEP with IPOM repair and this randomized study was designed to compare the two techniques in terms of early pain, cost effectiveness, and quality of life. METHOD: This was a prospective randomized trial with intention to treat analysis. The primary outcome was immediate post-operative pain scores. Operative time, conversions, peri operative morbidity, hospital stay, return to daily activities, incremental cost effectiveness ratio and quality of life (WHO-QOL BREF) were secondary outcomes. RESULTS: Sixty patients were randomized equally. Early post-operative pain scores and seroma rates were significantly lower and with a significantly earlier return to activity in eTEP group (p value < 0.05). With negative costs and positive effects, eTEP group was 2.4 times more cost effective. CONCLUSION: eTEP repair is better in terms of lesser early post-operative pain, earlier return to activities and cost effectiveness in small and medium size defects.

Timing of intraoperative crystalloid infusion may decrease total volume of infusate without affecting early graft function in live related renal transplant surgery: A randomized, surgeon-blinded clinical study.

INTRODUCTION: Early graft function is crucial for successful kidney transplantation. Intravascular volume maintenance is paramount in ensuring reperfusion of transplanted kidney. This study was planned to compare whether the timing of fluid infusion can help to decrease amount of fluid given without altering early graft function during renal transplantation. MATERIALS AND METHODS: The present study included forty recipients, randomized into standard (Group-S) or targeted fluid therapy (Group-T). Group S received fluid according to conventional fasting deficit while Group T received at 1 ml/kg/h from the start of surgery till start of vascular anastomosis after which fluid infusion rate in both group was increased to maintain a central venous pressure of 13-15 mm of Hg till reperfusion. Primary outcome measured was serum creatinine level on first postoperative day while secondary outcomes were IV fluid given, perioperative hemodynamics, onset of diuresis, graft turgidity, urine output, and renal function during first 6 postoperative days. RESULTS: The study showed Group T postoperatively had early fall in serum creatinine (day 3) than S (day 6) although this difference was not statistically significant. Group T had received significantly less fluid per kg of dry weight (T-42.7 ± 9.7 ml/kg, S-61.1 ± 11.1 ml/kg, P < 0.001), had early diuresis, better graft turgidity and urine output than Group S. CONCLUSION: Targeted hydration significantly decreases the total amount of fluid infused during the intraoperative period without altering early graft function. Targeted hydration during vascular anastomosis produced stable hemodynamics and early diuresis without any side-effects pertaining to hypo or hyper-volemia.Clinical trial identifier number-CTRI/2016/07/007111.

Optimum time of LMA ProSeal removal in adult patients undergoing isoflurane anesthesia: A randomized controlled trial.

BACKGROUND AND AIMS: Optimum timing of laryngeal mask airway (LMA) removal after general anesthesia with isoflurane is debatable. The objective was to investigate the potential benefits of removing LMA ProSeal at ≤0.4 Minimum alveolar concentration (MAC) isoflurane over awake and "deep plane" extubation after short duration laparoscopic gynecological surgery. MATERIAL AND METHODS: In this prospective randomized trial 90 adult female patients undergoing elective laparoscopic surgery under general anesthesia using LMA ProSeal™ as airway device were included. At the end of surgery, LMA ProSeal™ was removed when the patient was awake, could open mouth following verbal command (Group A); at MAC ≤0.4 (Group B); or at MAC of 0.6 (Group C). Adverse airway events like nausea, vomiting, airway obstruction, coughing, bucking, laryngospasm were noted. Statistical analyses were done by SPSS statistical software (IBM SPSS Statistics for Mac OS X, Version 21.0. IBM Corp, Armonk, NY). RESULTS: Baseline demographic characteristics were comparable in all three groups. Coughing or bucking at the time of LMA removal was higher in group A (P = 0.004). Snoring and airway obstruction after LMA removal was significantly higher in group C compared to group A and group B (P = 0.002 and P = 0.011, respectively). There was significant change in mean arterial pressure and heart rate between before and after LMA removal on group A (P = 0.008 and P < 0.001, respectively) but not in other groups. CONCLUSION: MAC ≤0.4 can be considered optimum depth of anesthesia for removal of LMA Proseal in adult patients undergoing isoflurane anesthesia.

Colonic interposition for oesophageal replacement surgery in a patient with left broncho-oesophageal fistula: anaesthetic management.

Management of an uncorrected broncho-oesophageal fistula in the perioperative period is a challenge for the anaesthesiologist. Positive pressure ventilation which is inevitable during surgery will lead to gastric insufflation and there is a high risk of aspiration of gastric contents. In this case report, we discuss how we used a double lumen tube to occlude a pericarinal broncho-oesophageal fistula. This method was quite effective as it obviated the need for isolating the lung as well as ensured smooth delivery of positive pressure ventilation during the surgery.

Haemodynamic responses following orotracheal intubation in patients with hypertension---Macintosh direct laryngoscope versus Glidescope®videolaryngoscope.

BACKGROUND AND AIMS: Glidescope®videolaryngoscope (GVL) is a video intubation system with 60° angle blade that provides excellent laryngeal view, does not require alignment of oral, pharyngeal, and laryngeal axes for visualisation of glottis, thus causing less stimulation of orolaryngopharynx. The aim of this study was to compare haemodynamic responses (blood pressure and heart rate) and airway morbidity using the Macintosh direct laryngoscope (MDL) and the Glidescope®videolaryngoscope (GVL) in hypertensive patients. METHODS: Fifty patients with hypertension controlled on antihypertensive medications scheduled for elective surgery under general anaesthesia were randomly assigned to group GVL (n = 25) or group MDL (n = 25). Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) were recorded at baseline, after induction, pre-intubation, at intubation, 1, 2, 3, 4, and 5 min after intubation. Time to intubation, number of attempts, complications during intubation, and postoperative airway complications (sore throat, hoarseness, dysphagia, and cough) were also recorded. RESULTS: There was a statistically significant increase in SBP, DBP, and MBP at intubation [(P = 0.003, 0.013, 0.03), 1 min (P = 0.001, 0.012, 0.02), 2 min (P = 0.04, 0.02, 0.04), and 3 min (P = 0.02, 0.01)] in the MDL group as compared to GVL group. The time to intubate was significantly greater in the GVL group as compared to MDL group (P = 0.0006). There was no significant difference in the incidence of intraoperative and postoperative airway complications. CONCLUSION: In the hands of an experienced anaesthesiologist, the use of GVL in controlled hypertensive patients is associated with less haemodynamic response as compared to Macintosh Laryngoscope without any increase in airway complications.

A three-arm randomized study to compare sexual functions and fertility indices following open mesh hernioplasty (OMH), laparoscopic totally extra peritoneal (TEP) and transabdominal preperitoneal (TAPP) repair of groin hernia.

BACKGROUND: With evolving technology, the focus of groin hernia repair has shifted to sexual function and fertility outcomes. METHODS: This three-arm randomized study was conducted in tertiary care hospital from 1st July 2017 to 30th March 2019. Consecutive patients of groin hernia were randomized into 3 groups, TAPP (Group 1), TEP (Group 2), and OMH (Group 3). Demographic profile and hernia characteristics were assessed preoperatively. Sexual functions (using BMSFI) and fertility (using surrogate fertility indices, viz., semen analysis and anti-sperm antibodies (ASA)) were assessed preoperatively at 3 months after the surgery. RESULTS: A total of 121 patients were included in the study with 41 patients in TAPP (Group 1) and 40 each in TEP (Group 2) and OMH (Group3) group. All the 3 groups were comparable in terms of demographic profile, hernia characteristics, intra-operative and early post-operative outcomes. Significant improvement was found in most of the domains of BMSFI score in the study population (p value < 0.001) with no intergroup difference. There was significant increase of anti-sperm antibody level in OMH group as compared to TAPP and TEP (p = 0.001), however, the levels were within normal limit. CONCLUSIONS: In conclusion, this study has shown that inguinal hernia repair whether open or laparoscopic (TEP or TAPP) leads on to improvement in sexual functions and fertility indices and can have a significant impact on pre-op counseling of the patient in terms of choice of repair, depending on the available expertise in a given center.

Coronavirus disease 2019 and laparoscopic surgery in resource-limited settings.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, the use of laparoscopy has been discouraged by the Intercollegiate General Surgery because of its potential for aerosol generation and infection. In contrast, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association of Endoscopic Surgery recommend continuing to use laparoscopy but with devices to filter released CO2 aerosol particles. However, commercially available systems are costly and may not be readily available. Herein, we describe a custom-made system to safely remove surgical smoke and CO2 , as well as a case of laparoscopic cholecystectomy in which we used it. MATERIALS AND SURGICAL TECHNIQUE: The patient had had multiple episodes of biliary pancreatitis and required urgent cholecystectomy during the COVID-19 pandemic. Although India was in complete lockdown, it was decided to operate with precaution. A system was designed using underwater seal chest tube drainage and an electrostatic membrane filter with a viral retention function greater than 99.99%. The system was connected to an extra port for continuous controlled egression of CO2 pneumoperitoneum. A regular four-port cholecystectomy was performed at an intra-abdominal pressure of 12 mm Hg. The gas flow rate was 10 L/min. CO2 for pneumoperitoneum, surgical aerosol, and effluents passed through the system before collecting in the suction apparatus. The exchange of operating instruments through the ports was kept to a minimum. It was done after the abdomen was temporarily desufflated using this system. DISCUSSION: The system we designed appears safe and is cost-effective. In resource-limited settings, it will be handy in patients requiring laparoscopic surgery both during and after the COVID-19 pandemic.

Anaesthetic considerations in a child with methylmalonic acidemia and its literature review.

Methyl malonyl coenzyme A mutase deficiency is a rare autosomal inherited inborn error in branched-chain amino acid metabolism characterised by the accumulation of methylmalonic acids. There is relative paucity of literature regarding anaesthetic management of these children presenting for incidental major abdominal surgery. Preoperative management includes goal-directed correction of dehydration, metabolic acidosis and hyperammonemia. Anaesthetic goals include avoidance of factors that can trigger metabolic crisis like hypercapnia, hypothermia, hypoxia, surgical stress, hypovolaemia, hypotension and so on. Herein, we are reporting the anaesthetic management of a 17-month-old child with methylmalonic acidemia (MMA) posted for a major upper abdominal surgery for excision of an adrenal mass, which was incidentally diagnosed during admission for an episode of metabolic crisis. We aim to highlight the specific nuances of pathophysiology of the disease, preoperative optimisation, anaesthetic considerations, role of advanced monitoring and regional anaesthesia and current literature on the management of patients with MMA.

Successful Pregnancy Outcomes After Laparoscopic Management of Pheochromocytoma.

Background: Pheochromocytoma is a rare cause of hypertension in pregnancy, which is often overlooked; especially in late pregnancy because of more prevalent pre-eclampsia. It has been associated with significant morbidity and mortality rates in both mother and fetus, if not diagnosed and treated in time. Minimally invasive surgery has been infrequently used for surgical management of pheochromocytoma in pregnancy, with <20 reported cases in English literature. Case Presentation: A 26-year-old pregnant woman presented at 9 weeks of gestation with complaints of palpitations, sweating, and headache; with past history of first trimester spontaneous abortion caused by accelerated hypertension. She was found to have hypertension and diabetes, but no pedal edema, weight gain, or proteinuria. Ultrasonogram and MRI of abdomen revealed a left adrenal mass and 24 hours urinary catecholamines levels were increased, suggesting a pheochromocytoma. After preoperative optimization in consultations with obstetricians, endocrinologists, and anesthetists, she underwent laparoscopic left adrenalectomy during 15th week of gestation. Perioperative hospital course was uneventful for both mother and the fetus. After adrenalectomy, her diabetes was cured and hypertension was controlled with single antihypertensive. She was readmitted at 31 weeks of gestation with accelerated hypertension and underwent emergency caesarean for impending eclampsia at 32 weeks, and delivered a healthy female baby. 131I-meta-iodobenzylguanidine (MIBG) scan and 68Ga-[1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-NaI(3)-octreotide positron emission tomography-CT (68Ga-DOTANOC PET-CT) scan was obtained in postpartum period to rule out any extra-adrenal pheochromocytoma, both of which did not reveal any abnormality. At 1 year follow-up, she is normoglycemic and hypertension controlled on single antihypertensive. Conclusion: Pheochromocytoma in pregnancy is a rare but potentially lethal condition, and high index of suspicion is required for early diagnosis. Multidisciplinary coordination is required for effective management of this rare condition. Laparoscopic adrenalectomy is safe in second trimester of pregnancy for both mother and fetus.

Long-term Outcomes Following Primary Closure of Common Bile Duct Following Laparoscopic Common Bile Duct (CBD) Exploration: Experience of 355 Cases at a Tertiary Care Center.

INTRODUCTION: Primary closure of common bile duct (CBD) after laparoscopic common bile duct exploration (LCBDE) is now becoming the preferred technique for closure of choledochotomy. Primary CBD closure not only circumvents the disadvantages of an external biliary drainage but also adds to the advantage of LCBDE. Here, we describe our experience of primary CBD closure following 355 cases of LCBDE in a single surgical unit at a tertiary care hospital. MATERIALS AND METHODS: All patients undergoing LCBDE in a single surgical unit were included in the study. Preoperative and intraoperative parameters including the technique of CBD closure were recorded prospectively. The postoperative recovery, complications, hospital stay, antibiotic usage, and postoperative intervention, if any, were also recorded. RESULTS: Three hundred fifty-five LCBDEs were performed from April 2007 to December 2018, and 143 were post-endoscopic retrograde cholangiopancreatography failures. The overall success rate was 91.8%. The mean operative time was 98±26.8 minutes (range, 70 to 250 min). Transient bile leak was seen in 10% of patients and retained stones in 3 patients. Two patients required re-exploration and 2 patients died in the postoperative period. Follow-up ranged from 6 months to 10 years, with a median follow-up of 72 months. No long-term complications such as CBD stricture or recurrent stones were noted. CONCLUSIONS: Primary closure of CBD after LCBDE is safe and associated with minimal complications and no long-term problems. The routine use of primary CBD closure after LCBDE is recommended based on our experience.

Randomized controlled trial to compare outcomes with and without the enhanced recovery after surgery protocol in patients undergoing radical cystectomy.

INTRODUCTION: Very few randomized controlled trials are available globally to support routine use of enhanced recovery after surgery (ERAS) protocol after radical cystectomy (RC), and none so far has been conducted in the Indian subcontinent. The aim of the present study was to evaluate hospital stay and 30-day perioperative outcomes following RC with the implementation of the ERAS protocol. MATERIALS AND METHODS: Fifty-four patients undergoing open RC were randomized to ERAS versus conventional surgical care (CSC) at our center from April 2017 to May 2018. Key interventions included avoidance of mechanical bowel preparation, early nasogastric tube removal, early enteral feeding, and early obligatory ambulation. Follow-up was done till 30-day postoperatively or till discharge, whichever longer. RESULTS: Twenty-seven patients in each group were analyzed. The demographic profile of the groups was similar. Length of stay in each group (8 days [5-57] ERAS vs. 9 days [5-31] CSC group, P = 0.390) was similar, with time to recovery of bowel function being significantly less in ERAS group (12 h [12-108] vs. 36 h [12-60] for bowel sounds [P = 0.001], 48 h [12-108] vs. 72 h [36-156] for passage of flatus [P = 0.001], and 84 h [36-180] vs. 96 [60-156] for passage of stools [P = 0.013]). Perioperative complication rate (12 patients (44.4%) vs. 14 (51.9%), P = 0.786) was similar. CONCLUSIONS: ERAS protocol leads to faster bowel recovery compared to conventional care in patients undergoing open RC but fails to demonstrate a shorter length of stay and lower complication rate.

Open surgery for pheochromocytoma: Current indications and outcomes from a retrospective cohort.

INTRODUCTION: Minimally invasive approaches are the current standard of care for pheochromocytoma/paraganglioma (PC/PG) surgery. However, a number of patients still undergo open surgery for these tumors. We evaluated the current indications and outcomes of open surgery for PC/PG to define the role of this approach. METHODS: Data of patients undergoing PC/PG surgery between July 2008 and July 2017 were retrieved from our prospectively maintained electronic database and hospital records. Tumor characteristics, operative and recovery parameters, and complications were evaluated for indications of open procedure and outcomes. RESULTS: During the study period, 106 patients underwent 124 procedures for PC/PG, including 18 simultaneous bilateral procedures. Surgeries included 102 adrenalectomies, 18 PG excisions, one partial adrenalectomy, and three partial cystectomies. Twenty-five (23.6%) patients (mean age 38.2 ± 16.1 years) underwent an open procedure, including four bilateral procedures. This included 16 adrenalectomies and 9 PG excisions. The indications for open surgery were unilateral large tumours (5; size 8-16, mean 11 cm), bilateral large tumours (2; size 6-10, mean 8.2 cm), retrocaval tumour extension (4), inter aortocaval PGs (8), Retro-mesenteric PG (1), concomitant procedures (3), and conversion from laparoscopy (2). Mean operative time was 217 ± 63.8 min, blood loss was 868 ± 734.2 ml, 11 patients required blood transfusion, and hospital stay was 6.44 ± 2.4 days. All these parameters were higher than for minimally invasive surgery (MIS) in this cohort. Three patients (12%) suffered a postoperative complication, and the rate of complications was not higher than MIS cohort (16%). CONCLUSIONS: Open surgery was most often indicated for large tumors or those located in the inter-aortocaval region. Most such procedures require large incisions and possible hepatic mobilization on the right side. The procedures can be safely completed with few complications.

Changes in blood pressure, blood sugar, and quality of life in patients undergoing pheochromocytoma surgery: a prospective cohort study.

INTRODUCTION: Pheochromocytoma surgery is associated with significant hemodynamic and metabolic changes that require post-operative monitoring. We prospectively evaluated the trends of blood pressure, blood sugar, body mass index (BMI), and quality of life (QoL) changes in a cohort of patients undergoing pheochromocytoma surgery to determine the minimum duration of monitoring and assess factors that could predict these changes. MATERIALS AND METHODS: Consecutive patients undergoing surgery for pheochromocytoma over a 20-month period were included in this ethics review board-approved, prospective cohort study. Blood pressure and sugar levels were serially monitored using a fixed protocol in the perioperative period and subsequently at 3 months after surgery. BMI and QoL (using World Health Organization Quality of Life [WHOQOL-BREF] questionnaire) were recorded at baseline and 3 months. Changes were compared and assessed for the predictive factors. RESULTS: Twenty-six patients undergoing 31 procedures were included in the study of whom 8 (30%) developed hypotension and 4 (15%) developed hypoglycemia after surgery. All hypotension episodes occurred within 6 hours of surgery. However, while 3 of the 4 patients who developed hypoglycemia manifest in the first 4 h after surgery, one occurred after 12 h. Occurrence of hypotension correlated with preoperative 24-h urinary vanillylmandelic acid (VMA) levels (P = 0.02) and the total daily dose of prazosin (P = 0.04). Out of 21 hypertensive patients, 7 (33%) had persistent hypertension (HTN) at 3 months and this was associated with age (P = 0.04) and diabetes mellitus (DM) at presentation (P = 0.04). Among six diabetic patients, 1 (16%) had persistent DM. There was significant increase in the BMI (P < 0.0001) and in WHOQOL-BREF scores postoperatively. CONCLUSIONS: Hypotension occurs in 30% patients and hypoglycemia in 15% after pheochromocytoma surgery. Hypotension occurs immediately but hypoglycemia may manifest upto 12h after surgery. Older, diabetic patients are more likely to have persistent HTN. Surgery results in increase in BMI and improvement in QoL.

Bougie-associated bronchial injury complicated by a nephropleural fistula after percutaneous nephrolithotomy: a tale of two complications.

We present a case of bronchial injury following bougie-assisted endotracheal intubation in a patient with difficult airway scheduled to undergo right percutaneous nephrolithotomy under general anaesthesia. The patient developed pleuritic pain along with right pleural effusion on the third postoperative day which was diagnosed by the anaesthesiologist who was following up the patient for airway trauma-associated complications. However, the patient was diagnosed to have a nephropleural fistula, a rare complication of supracostal access to percutaneous nephrolithotomy, which was managed successfully.

Proparacaine-Induced Mydriasis During Strabismus Surgery.

AIM: To evaluate the mydriatic effect of proparacaine hydrochloride (PH) in children undergoing strabismus surgery under general anesthesia (GA). METHODS: This was a pilot, prospective, non-randomized, self-controlled interventional study. Nine children with esotropia or exotropia undergoing horizontal muscle squint surgery under GA at a tertiary eye care center were included. The six Group 1 patients underwent both eye surgeries, while the three Group 2 patients underwent single eye surgery. PH was instilled in one eye of Group 1 patients and both eyes of Group 2 patients. Change in pupil diameter (PD) was analyzed as the main outcome measure. RESULTS: Mean age of the patients was 4.67 ± 2.64 years. In the study eyes, mean average baseline PD was 1.59 ± 0.40 mm (range: 1.06-2.37), while postoperative average PD was 3.99 ± 1.34 mm (range: 1.79-6.02). The mean baseline PC had increased from 5.51 ± 1.09 mm to 12.6 ± 3.58 mm at the end of the surgery. PD and PC increased in all of the study eyes while no change in PD or PC was seen in the control eyes of either of the groups. The dilated pupil was skewed horizontally towards the muscle being operated upon in all of the study eyes. CONCLUSIONS: PH has a mydriatic effect of its own. It penetrates through the bare sclera and leads on to skewed dilation of the pupil. Surgeons should consider this effect while judging pupil alignment at the end of the surgery.