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.

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.

Pararectal angiomyxoma: a diagnostic dilemma.

Clinical diagnosis of pararectal masses remains a challenge to this day. Despite the availability of advanced imaging facilities, we often fail to reach a definitive diagnosis and have to resort to surgery. We describe a case of a 60-year-old female with a painless perianal swelling gradually increasing in size for 6 months with spontaneous reduction on assuming a supine position. Clinical examination of this patient was suggestive of a pelvic floor hernia. However, radiological investigations were suggestive of an ischiorectal abscess. In view of lack of radiological corroboration of clinical findings, patient underwent diagnostic laparoscopy which ruled out a hernia. A wide local excision of the mass was performed, which on histopathology with immunohistochemistry examination revealed an aggressive pararectal angiomyxoma.

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.

Multiple endocrine neoplasia type 1 syndrome: single centre experience from western India.

Multiple endocrine neoplasia type 1 syndrome (MEN1) is a rare autosomal dominant familial cancer syndrome affecting multiple endocrine glands. Published literature on MEN1 from Indian subcontinent is scarce. We report here a case series of MEN1 patients (n = 18) from 14 unrelated families. Retrospective study describing the clinical profile of MEN1 patients from endocrine unit of a tertiary care hospital from western India. Additionally clinical profile of primary hyperparathyroidism (PHPT) in MEN1 patients was compared with that of apparently sporadic PHPT cohort from our centre. Eighteen patients (10 males, 8 females) diagnosed as MEN1 were included. Mean age at diagnosis was 31.5 ± 10.6 years (range 17-54). Incidence of primary hyperparathyroidism (PHPT), pituitary adenoma (PA), and gastro-entero-pancreatic neuroendocrine tumor (GEP-NET) was 94.4, 72.2, and 72.2 %, respectively. GEP-NET was the commonest presenting lesion (33.3 %), followed by PA (27.7 %), PHPT (16.6 %), thymic carcinoid (5.5 %), while 16.6 % cases were identified on family screening. PHPT manifestations (clinical and biochemical) in MEN1 were less severe as compared to those of sporadic PHPT. Contrast enhanced computed tomography (CECT) and (68)Ga-DOTANOC PET/CT were equally sensitive (64.7 vs. 63.5 %) in identifying multiglandular parathyroid disease. Non functioning tumors (NFT) were the most common GEP-NET, followed by insulinoma (5/13, two were metastatic). (68)Ga-DOTANOC PET/CT had higher sensitivity in detecting GEP-NET lesions than CECT (100 vs. 62.5 %). The most common pituitary lesion was prolactinoma, and all were cabergoline responsive. Genetic analysis was available in 13 patients and 11 patients showed mutation in MEN1 gene. The clinical profile of MEN1 in Asian Indian patients is largely comparable to that reported in other cohorts. Peculiar findings of our cohort are predominance of GEP-NET as a presenting manifestation and relatively higher prevalence of insulinoma with higher occurrence of metastatic insulinoma. Clinical and biochemical profile of MEN1 associated PHPT is less severe than that of our sporadic PHPT.

Laparoscopic excision of infra-renal PEComa.

Perivascular epitheloid cell tumors (PEComas) are rare tumors of malignant potential. There is no normal cell variant to these cells. The family is large and includes angiomyolipoma, clear cell "sugar" tumor amongst others. Imaging modalities are not very diagnostic. The diagnosis hence is often postoperative. A 55-year old female presented to us with ultrasonographic diagnosis of solid mass in the right infrarenal region. Contrast-enhanced computerized sonography (CECT) suggested paraganglioma or a soft tissue retroperitoneal tumor. Laparoscopic excision was successful. The rarity of this pathology and laparoscopic modality of excision prompted us to publish this report.

Massive Liver Trauma-Multidisciplinary Approach and Minimal Invasive Surgery can Salvage Patients.

Management of massive liver trauma (grades IV-VI) is associated with high morbidity and mortality. It can pose serious challenges to treating physician and requires multimodality interventions. For a successful outcome, timing of intervention is crucial. We report a case of grade V hepatic injury treated successfully with angioembolization, laparoscopic lavage, and endoscopic stenting during a time period from admission to discharge on the 24th day. Angioembolization was performed at admission after resuscitation as CT scan showed active extravasation in the arterial phase. Laparoscopic lavage and drainage was performed on the fifth day as abdominal inflammatory response failed to respond to medical management. There was biliary component of abdominal fluid noticed during laparoscopy, which manifested by postoperative localized biliary fistula; hence endoscopic stenting of the bile duct was performed on the seventh day. The patient recovered well with timely minimal invasive approach and was fine at 1 year follow-up.

Coexistence of pheochromocytoma/praganglioma and renal artery stenosis.

Renal artery stenosis (RAS) often coexists with pheochromocytoma (Pheo)/paraganglioma (PGL) and often alters the management of patients with Pheo/PGL. We have studied the prevalence of RAS in our Pheo/PGL patients. The study included 70 consecutive, histopathologically proven Pheo/PGL patients from a tertiary health care center. In 60 patients, tumors were limited to adrenal glands (54 unilateral and 6 bilateral) while other 10 patients had extra-adrenal abdominal tumors. Five patients had RAS with an overall prevalence of 14%. Only two out of 60 patients with Pheo had RAS with a low prevalence of 3.3% while three out of 10 patients with extra-adrenal abdominal PGL had RAS with a prevalence of 30%. To conclude, RAS commonly coexists with Pheo/PGL, more often with extra-adrenal PGL.

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 excision of hepatoduodenal ligament cyst.

Hepatoduodenal ligament cysts are rare. These may be confused with hepatic cysts even on advanced investigative modalities like Computerized tomography scanning or Magnetic Resonance Imaging. Diagnosis is often an intraoperative surprise. Laparoscopic treatment of such hepatoduodenal cysts is not described in available medical literature. We report one such case treated laparoscopically.

Laparoscopic excision of a giant mesothelial omental cyst.

A 42-year-old patient presented with right-sided abdominal discomfort. Investigations revealed a 19 × 21 centimetres large cystic lesion occupying nearly the entire right side of the abdomen. It was situated between ascending colon and right kidney and extended from the liver to the pelvic inlet supero-inferiorly. Laparoscopic excision was planned. The cyst was aspirated completely and dissected from the surrounding structures. It was eventually found to be arising from the right free edge of the greater omentum. Due to its size and weight it was lodged behind the ascending colon. Post-operative course was uneventful. Histology revealed a mesothelial omental cyst. Omental cysts are rare abdominal tumours. Complete excision is the treatment advised to prevent recurrence. Laparoscopic excision can be safely performed taking care to ascertain diagnosis and not to damage any structures intra-operatively.

Thoracoscopic removal of impacted denture: Report of a case with review of literature.

Impacted foreign bodies in the oesophagus are common. Because of their large size, rigidity and pointed edges, dentures get frequently impacted in the oesophagus and are difficult for endoscopic retrieval. Traditional thoracotomy for retrieval of impacted foreign bodies in the thoracic oesophagus is associated with significant morbidity. We present a case of impacted denture in the mid-oesophagus successfully removed using minimal access thoracoscopic procedure.

Laparoscopic Heller's cardiomyotomy in cirrhosis with oesophageal varices.

Surgical intervention in cirrhosis of liver with portal hypertension is associated with increased morbidity and mortality. This is attributed to liver decompensation, intra-operative bleeding, prolonged operative time, wound related and anaesthesia complications. Laparoscopic surgery in cirrhosis is advantageous but is associated with technical challenges. We report one such case of hepatitis C cirrhosis with oesophageal varices and symptomatic achalasia cardia, who was successfully treated by laparoscopic cardiomyotomy after thorough preoperative workup and planning. In the review of literature on pubmed, no such case is reported.

Has experience changed the scenario in laparoscopic adrenalectomy?

BACKGROUND: Laparoscopic adrenalectomy (LA) is a relatively uncommon operation performed by surgeons with a specific interest in endocrine surgery as well as advanced laparoscopic surgery. LA is technically difficult and it is recommended to tackle small glands first till adequate experience is reached [1]. A minimum of 30 cases are required to master the technique [2]. The present study reviews data of 60 laparoscopic adrenalectomies comparing the later results with the first 30 cases. MATERIAL AND METHODS: Starting 2001, patients diagnosed to have adrenal disorders were subjected to laparoscopic approach in a graded manner. A database was maintained with respect to age, sex, duration of symptoms, co-morbid conditions, diagnosis, size of tumor, weight of tumor, blood loss, duration of surgery, conversion to open, in-hospital stay, referral pattern, morbidity (both early and late) and mortality. The database was divided into two groups. First 30 patients constituted Group A, Group B constituted the next 30 adrenalectomies and deviation in the two was noted. Statistical analysis was performed to determine the importance of deviation of factors. RESULTS: Sixty adrenalectomies were performed in 49 patients (11 being bilateral) between February 2001 and July 2008. Age group varied from 12-54 years with mean of 30.73 years, Twenty four were males. Thirty-one right and 29 left LA were performed. The comparison of factors in relation to the two groups (Group A and B respectively) revealed an increase in number of adrenalectomies performed (0.4 v/s 0.76) in relation to timeline, increased incidence of pheochromocytoma (6 v/s 18) and incidentalomas (zero v/s 8), larger tumor size (4.17 cm v/s 6.6 cm), comparable blood loss (72 cc v/s 98.3 cc) and duration of surgery (122 min v/s 112 min), increased conversion to open surgery (1 v/s 6) leading to increased in-hospital stay (2.8 days v/s 3.37 days) but a comparable morbidity (2 v/s 1) and no mortality. CONCLUSION: Though technically difficult, with increasing experience and focused approach, laparoscopic skills in adrenalectomy improves. The spectrum of indications broadens, thus making laparoscopic interventions for vascular and large adrenal glands safe and patient friendly.

Effectiveness of box trainers in laparoscopic training.

RATIONALE AND OBJECTIVES: Various devices are used to aid in the education of laparoscopic skills ranging from simple box trainers to sophisticated virtual reality trainers. Virtual reality system is an advanced and effective training method, however it is yet to be adopted in India due to its cost and the advanced technology required for it. Therefore, box trainers are being used to train laparoscopic skills. Hence this study was undertaken to assess the overall effectiveness of the box-training course. STUDY PROCEDURE: The study was conducted during six-day laparoscopic skills training workshops held during 2006. Twenty five surgeons; age range of 26 to 45 years, of either sex, who had not performed laparoscopic surgery before; attending the workshop were evaluated. Each participant was given a list of tasks to perform before beginning the box-training course on day one and was evaluated quantitatively by rating the successful completion of each test. Evaluation began when the subject placed the first tool into the cannula and ended with task completion. Two evaluation methods used to score the subject, including a global rating scale and a task-specific checklist. After the subject completed all sessions of the workshop, they were asked to perform the same tasks and were evaluated in the same manner. For each task completed by the subjects, the difference in the scores between the second and first runs were calculated and interpreted as an improvement as a percentage of the initial score. STATISTICAL ANALYSIS: Wilcoxon matched-paired signed-ranks test was applied to find out the statistical significance of the results obtained. RESULTS: The mean percentage improvement in scores for both the tasks, using global rating scale, was 44.5% ± 6.930 (Mean ± SD). For task 1, using the global rating scale mean percentage improvement was 49.4% ± 7.948 (Mean ± SD). For task 2, mean percentage improvement using global rating scale was 39.6% ± 10.4 (Mean ± SD). Using Wilcoxon matched-paired signed-ranks test, 2-tailed P-value<0.0001 which is extremely significant. CONCLUSION: This study confirms that a short-term, intensive, focused course does improve laparoscopic skills of trainees. Box-trainers can be used to change the present day didactic training into objective and competency-based. Global rating scale and checklist provide an inexpensive and effective way of objective assessment of performance of laparoscopic skills.

Laparoscopic transmesocolic excision of paraganglioma in the organ of Zuckerkandl.

Extra-adrenal pheochromocytomas (paragangliomas) are rare. We report the case of a 20-year-old female at 15 weeks gestation, who was detected to have a large paraganglioma (6.5 x 5 cm) in the organ of Zuckerkandl during an antenatal visit. After medical termination of the pregnancy, successful laparoscopic excision of the paraganglioma was performed.

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.

Breast gangrene as a complication of puerperal sepsis.

Gangrene of the breast, although rare, has been reported following anticoagulant treatment, trauma, and infection. Two cases of breast gangrene due to puerperal sepsis have been reported. We report a case of right breast gangrene as a complication of puerperal sepsis in a female patient.