First ever reported case of right-sided rupture of eventration of the diaphragm: Thoraco-laparoscopic approach.

ABSTRACT: Diaphragmatic eventration (DE) is an abnormal condition where a portion or the entire hemidiaphragm elevates due to insufficient muscle or nerve function while maintaining its anatomical attachments. On the other hand, congenital diaphragmatic hernias occur due to the abnormal development of muscular entities of the diaphragm, resulting in the displacement of abdominal contents into the thorax. The difference between diaphragmatic hernia and eventration is important as there is no true defect in DE. Ruptured eventration of the diaphragm is a rare entity, with only three cases reported in adults in literature till date, all on the left side. We report the first case of ruptured eventration of the diaphragm on the right side, which was repaired by a combination of laparoscopy and thoracoscopy and with double-mesh placement.

The use of indocyanine green and near-infrared imaging in laparoscopic completion cholecystectomy for the management of stump cholecystitis: A case series.

Introduction: Stump cholecystitis is managed by performing a completion cholecystectomy, which can be done either laparoscopically or by an open method. The use of indocyanine green (ICG) is known to improve the identification of the biliary tree anatomy, facilitating Calot's triangle dissection and shortening surgery, thereby reducing the risk of bile duct injuries and making laparoscopic cholecystectomy safer. Patients and Methods: A retrospective analysis was performed of prospectively collected data from 15 patients at our institution from March 2016 to March 2021. Magnetic resonance cholangiopancreatography was performed in all 15 cases, showing remnant gall bladder in all cases with calculi within. Four cases had a dilated common bile duct (CBD) with CBD calculi. Endoscopic retrograde cholangiopancreatography (ERCP) and stone removal followed by CBD stenting were performed in the four patients with CBD calculi. These four cases were scheduled for surgery 4 weeks post-ERCP. All 15 patients underwent laparoscopic completion cholecystectomy. The mean operating time was 80 min. Results: The post-operative period of all cases was uneventful, and the patients were discharged on post-operative day 2 or day 3. All patients remained asymptomatic during 1-5 years of follow-up. Conclusion: Laparoscopic completion cholecystectomy was performed safely in cases of stump cholecystitis and resulted in symptom relief during short-term follow-up. The use of ICG and near-infrared imaging in such cases helps identify the biliary anatomy, may contribute to the safety of laparoscopic completion cholecystectomy and might reduce the duration of surgery.

Life-Threatening Intracerebral Hemorrhage in Adult with ITP: Challenging Entity.

Intracerebral hemorrhage (ICH) is a rare and fatal complication of immune thrombocytopenia. ICH is more common in children than in the adult population. A 30-year-old male patient, a known case of immune thrombocytopenia, presented with sudden onset severe headache and vomiting. Computed tomography scan showed a large right frontal intracerebral hematoma. His platelet counts were low, and he received multiple transfusions. Though he was initially conscious, his neurological condition progressively deteriorated, so the decision was taken for an emergency craniotomy. Despite multiple transfusions, his platelet counts were 10,000/µL, so craniotomy was very risky. He underwent an emergency splenectomy and received one unit of single donor platelets. Subsequently, his platelets count increased a few hours after, and he underwent successful evacuation of intracerebral hematoma. He eventually had an excellent neurological outcome. Though intracranial hemorrhage carries significant morbidity and mortality, a timely decision of emergency splenectomy followed by craniotomy can result in an excellent clinical outcome.

Post-laparoscopic sleeve gastrectomy, intrathoracic sleeve migration and its management: A case series and review of literature.

De novo or persistent gastro-oesophageal reflux disease which may or may not be associated with injury of the oesophageal mucosa is now a known complication in post-sleeve gastrectomy patients. Repair of hiatal hernias to avoid such circumstances has been commonly performed, although recurrences may occur resulting in migration of gastric sleeve into the thorax, which is now a well-known complication. We report four cases of post-sleeve gastrectomy patients who presented with reflux symptoms, with their contrast-enhanced computed tomography abdomen showing intrathoracic sleeve migration and had hypotensive lower oesophageal sphincter with normal body motility on their oesophageal manometry. A laparoscopic revision Roux-en-Y gastric bypass surgery with hiatal hernia repair was performed for all four of them. No post-operative complications were seen at 1-year follow-up. Laparoscopic reduction of migrated sleeve with posterior cruroplasty and conversion to Roux-en-Y gastric bypass surgery can be safely performed for patients presenting with reflux symptoms in cases of intra-thoracic sleeve migration with good short-term outcomes.

Efficacy of near-infrared fluorescence cholangiography using indocyanine green in laparoscopic cholecystectomy: A retrospective study.

Context: While laparoscopy has been the standard procedure for gallstone treatment, recent advances including the use of indocyanine green (ICG) in laparoscopic cholecystectomy have made it easier to understand the biliary tree and reduce the risk of bile duct injury. Aims: In this retrospective study, we aim to determine the efficacy of ICG in near-infrared fluorescence cholangiography (NIRFC) for visualising biliary anatomy. Settings and Design: A total of 90 patients with the symptoms of cholelithiasis were enrolled for this retrospective study. Subjects and Methods: All the patients underwent cholecystectomy approximately 53.8 min (40-90 min) after the intravenous administration of mean volume 1.6 ml (1-2 ml) ICG. The surgeons used NIRFC along with ICG for real-time visualisation of biliary anatomy. Results: The mean operative time for the surgery was 65.7 min (25-120 min) with no post-surgical complications observed in the patients. The average length of stay was 2 days (1-3 days). ICG usage with NIRFC enabled identification of cystic duct, common hepatic and common bile duct, the junction between common hepatic and bile duct, right and left hepatic duct in 87.7%, 94.4%, 80% and 14.4% of cases, respectively. Conclusions: ICG fluorescence allowed successful visualisation of at least 1 biliary structure in 100% of cases.

Antibiotic-associated Gut Dysbiosis.

The human gut microbiota plays a crucial role in maintaining overall health. However, the widespread use of antibiotics has raised concerns about its impact on the microbial ecosystem. This review explores the multifaceted relationship between antibiotics and gut dysbiosis, highlighting the mechanisms underlying these interactions and their implications for human health. Antibiotics, while invaluable in treating infections, disrupt the gut microbiota by indiscriminately targeting both harmful and beneficial microorganisms. This disturbance leads to a reduction in microbial diversity, altered metabolite production, and compromised immune responses, resulting in a state referred to as dysbiosis. Broad-spectrum antibiotics tend to induce more severe dysbiosis compared to narrow-spectrum agents. Antibiotic-induced dysbiosis has been linked to the onset and progression of these disorders, emphasizing the far-reaching consequences of microbial imbalance. The review highlights various strategies to mitigate the adverse effects of antibiotics on gut health, like probiotics, fecal microbiota transplantation (FMT), and phage therapy, as promising approaches to restore and maintain a balanced gut microbiota. How to cite this article: Ramakrishna BS, Patankar R. Antibiotic-associated Gut Dysbiosis. J Assoc Physicians India 2023;71(11):62-68.

Life-threatening perforating brain injury by a rusty iron rod - A case report.

Background: When an object traverses through the cranium leaving behind both an entry and exit wound, it is called perforating brain injury. Perforating open brain injury is rare. A paucity of published literature on such cases and a lack of a standard management protocol pose significant challenges in managing such cases. Case Description: We present a case of a 24-year-old man who worked as a carpenter at the construction site. He slipped while working and fell from a height of 13 feet onto a rusty, vertically placed 3 feet iron rod located on the ground. Iron rod entered his body from the right upper chest, came out from the neck, and again re-entered through the right upper neck medial to the angle of the mandible and finally came out from the posterosuperior surface of the right side of the head. He presented to the emergency department in a conscious state, but his voice was heavy and slow-paced, and he showed signs of lower cranial nerve palsy on the right side. He underwent numerous radiological investigations. The iron rod was removed in the operation theater under strict aseptic precautions. On day 7 after surgery, he developed right lobar pneumonia, and on day 21, he developed an altered sensorium, followed by a loss of consciousness. He did not regain consciousness and, unfortunately, succumbed after 30 days of sustaining the injuries. Conclusion: Perforating open brain injuries are rare, especially in civilian society, and are usually associated with significant morbidity and mortality. Due to a lack of standard guidelines for managing such severe injuries and limited knowledge, many patients with these injuries do not survive. Although each case presents differently, certain management principles must be followed.

Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: Follow-up in the Indian population.

CONTEXT: Obstructive defecation syndrome (ODS) is a poorly understood cause of constipation. In selected patients not responding to conservative management, surgical options may be offered. Laparoscopic ventral mesh rectopexy (LVMR) is another surgical option which gained popularity in the past decade. AIM: This study aims to identify the efficacy of LVMR in the Indian population. SETTING AND DESIGN: It is a retrospective analysis of prospectively collected data of patients who underwent LVMR from January 2015 to January 2017 at a tertiary centre in India. SUBJECTS AND METHODS: Thirty patients fulfilled the inclusion criteria. Patients were periodically followed for 2 years. Pre- and post-operative modified Longo's ODS scores were recorded and compared. Furthermore, other complications were noted and evaluated. STATISTICAL ANALYSIS USED: Relevant statistical tests were used to analyse the collected data. RESULTS: Thirty patients (28 females, 2 males, mean age: 52.4 years) underwent LVMR for ODS due to anatomical abnormality like rectorectal intussusceptions (RRIs) (36.7%), rectocele (13.3%), or combined RRI with rectocele (50%). The mean pre-operative modified Longo's ODS score was 23.17 ± 4.82 which decreased to 2.37 ± 1.59 at the end of 6 months and 1.23 ± 1.14 and 1.57 ± 1.14 at the end of 12 months and 2 years, respectively. The mean modified Longo's ODS score showed a significant fall of 94.7% at 12-month follow-up and 93.2% fall on 2-year follow-up. The mean operative time was 115 min and the average hospital stay of patients who underwent LVMR was 3.26 days. CONCLUSION: LVMR is a safe surgical procedure with minimal complications and good functional results for ODS patients due to rectal anatomical abnormality. Further larger studies are required to decide the best treatment modality for ODS.

Quantitative assessment of crural closure for laparoscopic anti-reflux surgeries: A novel technique to reduce post-operative dysphagia.

BACKGROUND: Long-term dysphagia is a known complication of laparoscopic anti-reflux surgery (LARS). Of the several factors, inadequate hiatal closure is one of the major reasons for its occurrence. The aim of this study is to develop a technique for the quantitative assessment of crural closure during LARS to reduce dysphagia. MATERIALS AND METHODS: It is an analysis of prospectively collected data of 109 patients who underwent LARS at a tertiary healthcare centre in India. To identify the adequacy of hiatal closure intraoperatively, a 7 French Fogarty catheter was used, and its balloon was inflated with 1 cc air at the repaired hiatus. This inflated balloon in the repaired hiatus following cruroplasty gives an accurate quantitative assessment of the adequate closure and adequate space for food bolus to pass without causing mechanical obstruction after hiatus repair. Pre- and post-operative 12 months' DeMeester scores and lower oesophageal sphincter (LES) pressures were calculated. RESULTS: The patients had a significant reduction in DeMeester scores postoperatively from a mean of 68.5-12.3 (P < 0.0001). None of the patients had long-term dysphagia or the need for long-term proton-pump inhibitors. The mean LES pressures on post-operative manometry showed increase to 15.1 mmHg from a mean of 6.4 mmHg, which was statistically significant (P = 0.0001). None of the patients had a recurrence of hiatus hernia. CONCLUSION: Quantitative assessment of adequacy for crural closure during LARS using a 7 French Fogarty catheter balloon is a novel technique which may decrease the incidence of post-operative dysphagia or intrathoracic wrap migration or recurrence of hiatus hernia.

Laparoscopic loop cystojejunostomy: An alternative to Roux-en-Y cystojejunostomy for pancreatic pseudocyst.

Surgical internal drainage of pancreatic pseudocyst can be done into the stomach, duodenum or jejunum depending on the anatomic relation of pseudocyst with hollow viscera. For cystojejunostomy, a Roux-en-Y loop is preferred over loop cystojejunostomy as former is thought to avoid the reflux of jejunal contents into the cyst cavity. This study presents our experience with laparoscopic loop cystojejunostomy showing loop cystojejunostomy for the pseudocyst of the pancreas can be safely performed laparoscopically with simpler technique with no complications including reflux.

Laparoscopic modified lateral transabdominal preperitoneal approach for Spigelian hernia repair: An easier approach to a rare condition.

INTRODUCTION: Both laparoscopic and open approaches are well accepted for spigelian hernia (SH) repair. Several techniques for SH repair are described in literature. In our study, eight patients underwent laparoscopic SH repair. A modified lateral TAPP approach was used in four cases and then compared with the conventional TAPP approach. METHODS: From January 2015 to January 2017, eight cases of SH were treated using the laparoscopic TAPP approach. Four cases underwent surgery by the conventional laparoscopic TAPP approach (group I). For the other four, modified lateral approach transabdominal preperitoneal technique was used (group II). Postoperative pain, operative time, length of hospital stay, and complications were compared between the groups. Patients were followed up for a minimum period of 1 year. RESULT: Among the eight cases, the mean age was 52 years in group I and 50 years in group II, mean defect size was 23 mm in group I and 28 mm in group II, mean length of hospital stay was 1.50 days in group I and 1.25 days in group II, and operative time was 61 minutes in group I and 51 minutes in group II. There was no remarkable difference in complications or length of hospital stay between the groups. The groups were comparable in all other parameters, but the lateral approach was ergonomically better for the surgeon. CONCLUSION: Of the approaches described for laparoscopic SH repair, the modified lateral TAPP approach is more convenient because it provides better and more adequate lateral and inferior space access and is ergonomically better for surgeons.

Real-Time Visualization of Ureters Using Indocyanine Green During Laparoscopic Surgeries: Can We Make Surgery Safer?

Background. Intraoperative ureteral injury is rare, but a grave complication during laparoscopic surgery. Several methods for intraoperative localization of ureters are described with their own pitfalls. Intraoperative localization using near-infrared (NIR) fluorescence with indocyanine green (ICG) is an easier and assured method during laparoscopic pelvic surgeries. Method. From September 2017 to December 2017, patients undergoing laparoscopic pelvic surgeries were administered cystoscopic-guided intraureteral ICG immediately preoperatively with tip of a 6-Fr ureteral catheter. The fluorescence of ureters was visualized in the NIR mode of the camera system, localizing the ureters precisely and in real time. Results. This technique was used to visualize ureters in 30 surgeries. Median age of the patients was 46.7 years with median body mass index of 23.2 kg/m2. Mean duration between administration of dye and insertion of trocar was 10 minutes. Mean duration for insertion of cystoscopically guided intraureteral ICG was 7 minutes. Ureteral fluorescence was visualized in all cases with some variation in intensity of the brightness perceived depending on surrounding fat. Duration of the lengthiest surgery was 240 minutes, and fluorescence was appreciated till the end. There were no intraoperative or postoperative complications attributed to ICG administration. In 10 patients (33%), there was difficulty in identifying the ureters on conventional white light mode, in which ICG localization was extremely helpful. Conclusion. ICG-stained ureteral visualization under NIR light is a safe and feasible method that provides real-time ureteral demarcation. This easily replicable, sensitive, and specific method of ureteral visualization can make complex laparoscopic pelvic surgeries safer.

Combined laparoscopic and perineal approach for the management of recurrent tailgut cyst.

Tailgut cyst is an uncommon developmental anomaly arising from the embryonic hindgut in the retrorectal space. The patient frequently is asymptomatic or has vague perineal complaints that pose a diagnostic dilemma. Moreover, the patient is often misdiagnosed and therefore mismanaged. MRI is the investigation of choice for diagnosis. After the diagnosis is established, complete surgical excision is required to alleviate patient discomfort and to prevent complications such as infection, malignant transformation, and recurrence. Proper clinical examination and imaging not only establish the accurate diagnosis but also help in determining the best surgical approach for the patient (anterior abdominal, posterior sacral perineal, or combined approach). We hereby report a case of recurrent tailgut cyst managed with a combined anterior laparoscopic and perineal approach.

Percutaneous ultrasonography-guided nephroscopic evacuation of hydatid cyst in posterior segment of liver.

Hydatid disease commonly affects liver and treatment of choice is surgery. Ultrasound examination is helpful to diagnose, classify and plan management of the cyst. Surgical treatment is done using a conventional open technique or minimal access technique. We report our experience of using ultrasound-guided percutaneous nephroscopic approach to treat liver hydatid cyst.

Redo Laparoscopic Heller's Cardiomyotomy for Recurrent Achalasia: Is Laparoscopic Surgery Feasible?

BACKGROUND: Achalasia cardia is an esophageal motor disorder with raised lower esophageal sphincter (LES) pressure. Minimally invasive procedures have become the procedure of choice compared with conventional open surgery. After the primary surgery, recurrence or persistent symptoms have been noted in almost 10%-20% of cases. MATERIALS AND METHODS: In this case series, we share our experience with a series of 7 patients who presented to us from January 2010 to January 2017 for recurrent symptoms, following Heller's myotomy for achalasia cardia. RESULTS: Commonest symptom of recurrence was dysphagia with mean duration of recurrence of 17.9 months between primary and redo surgery. Revisional Heller's myotomy with Dor's fundoplication was performed in all patients laparoscopically. Mean duration of surgery was 150 minutes. Incomplete gastric myotomy and fibrosis at previous myotomy scar were the main causes of recurrence. Mean duration of hospital stay was 3.5 days. Mean follow-up period was 23.5 months. All the patients were symptomatically better following the redo surgery. Subsequent manometry was performed at the end of 3 months with mean reduction in LES pressure of 7.5 + 1.2 mmHg. CONCLUSION: Laparoscopic redo Heller's cardiomyotomy is a possibly reasonable option with good long-term results and minimal postoperative complications in expert hands.

Perineal Stapled Prolapse Resection.

Perineal stapled prolapse resection is a new technique for external rectal prolapse introduced in 2007. We have done stapled perineal resection for 12 patients with full thickness rectal prolapse between January 2010 and April 2012. Elderly patients with comorbidities and young patients who want to avoid risk of nerve damage, with rectal prolapse up to 8-10 cms were included prospectively for perineal stapled rectal prolapse resection. Functional outcome, complications, operating time, and hospital stay were assessed in all patients. Perineal stapled prolapse resection was performed without major complications in a median operating time of 45 (range, 40-90) min and median Hospital stay was 3 days (3 to 11 days). Preoperative severe fecal incontinence and constipation improved postoperatively in 90 and 66 % of the patients, respectively, and there was no incidence of de novo onset or worsening of constipation in any of the patient. One patient developed small extra peritoneal collection which was managed by conservative treatment. No other complications occurred. At median follow-up of 36 months, all patients were well and showed no early recurrence of prolapse. Perineal stapled rectal prolapse resection is a new surgical procedure for external rectal prolapse, which is safe, easy, and quick to perform.

Enteritis Cystica Profunda Presenting as Recurrent Sub Acute Intestinal Obstruction-NOT ALL Cases of IC Strictures are Koch's! A Case Report.

A 13-year-old girl presented with recurrent colicky abdominal pain and distension. She was treated for abdominal Koch's for 4 months without any relief. She underwent diagnostic laparoscopy which revealed cicatrized cecum and multiple strictures in ileum. Laparoscopy-assisted (extracorporeal) resection of affected bowel (terminal ileum and cecum) and ileoascending anastomosis were performed. Histopathological examination of the specimen diagnosed it as enteritis cystica profunda. Laparoscopy can be successfully used as a diagnostic and therapeutic modality in cases with doubtful diagnosis.

Laparoscopic sleeve gastrectomy for a large gastrointestinal stromal tumor.

The biological behavior of gastrointestinal stromal tumor (GIST) makes resection of the tumor with adequate margins, a mode of curative treatment. GIST does not have lymphatic permeation. Hence, the goal of therapy is complete resection of visible and microscopic disease, which can be achieved by adequate tumor-free margins. Laparoscopic management of large GIST tumors is discouraged because of the fear of spillage of the tumor or rupture of the tumor capsule while handling a large tumor and thus causing metastasis.

Laparoscopic release of median arcuate ligament.

Median arcuate ligament (MAL) syndrome, also known as the celiac axis compression syndrome, is rare. It is a diagnosis of exclusion, characterised by the clinical triad of postprandial abdominal pain, weight loss and vomiting. Computed tomographic angiography is the gold standard for making the diagnosis of MAL and colour Doppler is essential to confirm the diagnosis. The classic management involves the surgical division of the MAL fibres. We report successful management of two patients diagnosed as MAL syndrome and treated by laparoscopic release of the MAL.