Feasibility of thoracoscopic approach for retrosternal goitre (posterior mediastinal goitre): Personal experiences of 11 cases.

INTRODUCTION: Posterior mediastinal goitres constitute of a unique surgical thyroid disorder that requires expert management. Occasionally, they require thoracic approach for the completion of thyroidectomy. In this paper, we describe the feasibility and utility of a novel thoracoscopic approach for such goitres. MATERIALS AND METHODS: This is a retrospective study conducted at a tertiary care endocrine surgery department in South India over a period of 5 years from January 2010 to December 2014. We developed a novel thoracoscopic technique for posterior mediastinal goitres instead of a more morbid thoracotomy or sternotomy. All the clinical, investigative, operative, pathological and follow-up data were collected from our prospectively filled database. Statistical analysis was done with SPSS 15.0 version. Descriptive analysis was done. Operative Technique of Thoracoscopic Thyroidectomy: Single lumen endotracheal tube (SLETT) was used of anaesthetic intubation and general inhalational anaesthesia. Operative decubitus was supine with extension and abduction of the ipsilateral arm. Access to mediastinum was obtained by two working ports in the third and fifth intercostal spaces. Mediastinal extension was dissected thoracoscopically and delivered cervically. RESULTS: Out of 1,446 surgical goitres operated during the study period, 72 (5%) had retrosternal goitre. Also, 27/72 (37.5%) cases had posterior mediastinal extension (PME), out of which 11 cases required thoracic approach. We utilised thoracoscopic technique for these 11 cases. The post-operative course was uneventful with no major morbidity. There was one case of recurrent laryngeal nerve (RLN) injury and hoarseness of voice in the third case. Histopathologies in 10 cases were benign, out of which two had subclinical hyperthyroidism. One case had multifocal papillary microcarcinoma. CONCLUSIONS: We opine that novel thoracoscopic technique is a feasibly optimal approach for posterior mediastinal goitre, especially for benign and non-invasive malignant goitres.

Laparoscopic repair of adult diaphragmatic hernias and eventration with primary sutured closure and prosthetic reinforcement: a retrospective study.

BACKGROUND: Diaphragmatic hernias may be congenital or acquired (traumatic). Some patients present in adulthood with a congenital hernia undetected during childhood or due to trauma, known as the adult-onset type. The authors present their series of adult-onset type diaphragmatic hernias managed successfully by laparoscopy. METHODS: This study retrospectively investigated 21 adult patients between 1995 and 2007 who underwent laparoscopic repair at the authors' institution, 15 of whom were symptomatic. Laparoscopic repair was performed with mesh for 18 patients and without mesh for three patients who had Morgagni hernia. RESULTS: In this series, Bochdalek hernia (n = 12), Morgagni hernia (n = 3), eventration (n = 3), and chronic traumatic hernia (n = 3) were treated. Intercostal drainage was required for 14 patients, whereas in three cases the hypoplastic lung never reinflated even after surgery. The time of discharge was in the range of postoperative days 4 to 9. The complication rate was 19%, and mortality rate was 4.5%. One case of recurrence was noted after 10 months. CONCLUSION: The controversies involved are the surgical approach, management of the hernial sac, whether or not to suture the defect, and choice of prosthesis. Although laparoscopic and thoracoscopic approaches are comparable, the laparoscopic approach seems to have certain distinct advantages. The authors prefer not to excise the hernial sac and favor suturing the defects before mesh reinforcement. Regarding the type of mesh used, composite, expanded polytetrafluoroethylene (ePTFE), or polypropylene are the available options. Laparoscopic repair is feasible, effective, and reliable. It could become the gold standard in the near future.

Unique presentation of Meckel diverticulum in the form of cocoon managed successfully by laparoscopic surgery.

We report a case of complicated Meckel diverticulum presenting with subacute intestinal obstruction in a 21-year-old man managed successfully by laparoscopic surgery. Despite a diagnostic laparoscopy and laparotomy performed elsewhere in the past, main pathology was missed. Diagnostic laparoscopy in our center revealed a fusiform mass arising from terminal ileum, which was treated by laparoscopic-assisted resection and end-to-end ileo-ileal anastomosis. Gross and microscopic examination revealed an encapsulated localized cocoon containing 40 cm of ileum entangled around an inflamed Meckel diverticulum. His intestinal obstruction and hematochezia got relieved.

Laparoscopic management of choledochal cysts: technique and outcomes--a retrospective study of 35 patients from a tertiary center.

BACKGROUND: Choledochal cysts are congenital dilations of the biliary tree. The accepted mode of treatment is total excision with hepaticojejunostomy. In this retrospective study, we present our technique and results of laparoscopic choledochal cyst excision. STUDY DESIGN: We retrospectively studied 35 patients who had undergone laparoscopic choledochal cyst excision in our institute from 1996 to 2008. Data about age, gender, type of choledochal cyst, symptoms, surgical technique, conversion rate, morbidity, and mortality were analyzed. RESULTS: There were Type 1B choledochal cysts in 27 patients (77%) and Type IVA in 8 patients (23%). An anomalous pancreatobiliary junction was found in 40%. Mean operative time was 295 minutes. Total cyst excision could be done in 26 patients. The conversion rate in our series was 8.5%. The overall morbidity rate was 14.3%, the reoperation rate was 8.5%, the mortality rate was 0%, and the incidence of carcinoma was 8.5%. CONCLUSIONS: To minimize the risk of malignancy, total excision of the cyst is ideal, but a small proximal cuff of cyst is retained for small-size ducts to aid in the hepaticojejunostomy anastomosis. A slit on one end of the small ducts will render the anastomosis in an oblique orientation, widening the lumen. Dissecting the posterior cyst wall from the underlying portal vein is the most crucial part of the procedure. Morbidity and mortality rates after laparoscopic management are comparable with published results of the open procedure. Laparoscopic surgery for choledochal cysts is feasible, safe, and even advantageous.