Impact of cadaver training for learning abdominal wall reconstruction: our early experience.

PURPOSE: Assess the utility of a hands-on cadaver workshop for teaching abdominal wall reconstruction (AWR) using components separation technique. METHODS: Over a year, from June 2022 to July 2023, 112 surgeons participated in seven training courses focused on the eTEP technique for inguinal and ventral hernias. The workshops covered theoretical learning sessions followed by hands-on training using frozen human cadavers. An online survey was used to know the influence of our workshop on the clinical practice of the attendees. RESULTS: Out of 112 total participants, 70% (78) participants completed the survey. Among them, 58% (45) surgeons had over 10 years of experience. The workshop resulted in approximately 85% (66) of participants successfully adapting to eTEP. Confidence levels significantly increased for all steps of the technique after the workshop (p < 0.001, Rank-Biserial Correlation = -1.000). Participants expressed high satisfaction with the course. CONCLUSION: The cadaver model training program was found to be effective in reducing the learning curve and being replicable. This suggests its potential for widespread implementation as an introductory training model for learning the anatomy of abdominal wall and adapting this for treating hernias requiring AWR.

Fulminant amoebic colitis co-infection in a patient with COVID-19.

A woman in her 80s who presented with sudden abdominal pain and bloody stool associated with fever, dry cough and malaise, was found to be COVID-19 RT-PCR positive with fulminating necrotising amoebic colitis. She underwent right extended hemicolectomy with ileostomy and survived despite an unpredictable post-operative course, the need for aggressive intensive care and other major risk factors, and was discharged home after the twentieth day of her presentation.This case summarises the survival of a geriatric patient diagnosed with two lethal complications - amoebic colitis and COVID-19 respiratory infection with the aid of prompt surgical intervention and appropriate critical care.

Strategies for closing the posterior rectus sheath during enhanced view totally extraperitoneal Rives-Stoppa repair.

Introduction: The popularity of endolaparoscopic extraperitoneal repairs has been on the rise due to advantages such as sublay mesh placement and early return to daily activities. However, the procedure requires overcoming a learning curve, and with increased adoption, new complications have emerged. One significant complication is the rupture of the posterior rectus sheath (PRS). In this article, we present our modifications of the technique to reduce tension during PRS closure. Patients and Methods: The study included 105 patients who underwent endolaparoscopic extraperitoneal repairs for ventral hernias using two different techniques. Group A (n = 68) underwent the original technique, whereas Group B (n = 37) underwent the modified technique. The modifications in Group B included preserving the peritoneal bridge between the two PRS and the hernia sac, conducting a complete dissection of the space of Bogros and adopting a transverse or oblique closure of PRS along the lines of least tension. To assess the efficacy of these modifications in preventing PRS rupture, we compared the results of both groups. Results: Our findings indicate that following all the technical steps of the modified technique resulted in a reduced need for transversus abdominis release for PRS closure and a lower incidence of PRS rupture in the postoperative period. However, to further validate the effectiveness of these modifications, a larger follow-up period and a bigger sample size are required. Conclusions: The adoption of the modified technique can help achieve a tension-free PRS closure.

Postoperative Distal Enteral Tube Refeeding in Stoma Patients: A Comparative Analysis of Clinical Outcomes.

<b><br>Introduction:</b> Stoma surgery, which involves creating a diversion of the small intestine through an abdominal wall opening, poses challenges in managing fluid and electrolyte imbalances. Patients with high proximal stoma often rely on costly and risky parenteral nutrition (PN). Distal enteral tube feeding, a method of delivering nutrition to the small intestine, is intended to improve clinical outcomes and reduce complications. This study presents a comparative analysis of clinical outcomes between postoperative distal enteral tube refeeding and traditional enteral and PN approaches in stoma patients with distal mucous fistula.</br> <b><br>Aim:</b> To evaluate the effectiveness of distal enteral tube refeeding in improving postoperative outcomes after stoma surgery and to examine the impact of distal enteral tube refeeding on total hospitalization stay, ICU length of stay, TPN duration, and time to closure of the stoma.</br> <b><br>Material and methods:</b> The study is a retrospective, single-center trial involving 84 patients who had undergone stoma surgery. The patients were divided into two groups: those receiving postoperative distal enteral tube refeeding (n = 42) and the control group (n = 42), with standard mucous fistula creation. The data was collected retrospectively from January 2012 to January 2022 and the statistical analysis was performed using descriptive statistics, the chi-square test, and the t-test.</br> <b><br>Results:</b> The results of our study show that the patients who had undergone postoperative distal enteral tube refeeding had a significantly shorter total hospitalization stay (p = 0.0002), a significantly shorter ICU length of stay (p = 0.0006), a significantly shorter TPN duration (p= 0.0004), and a significantly faster time to closure (p = 0.0002).</br>.

Initial experience of radiofrequency ablation for the treatment of advanced haemorrhoidal disease.

Introduction: The ideal approach to the management of haemorrhoidal disease (HD) remains to be elucidated. A procedure that returns the anal cushions to their normal size without destroying them or damaging the surrounding tissues is sought. Radiofrequency ablation (RFA) overcomes many of the disadvantages of the previously described repairs and may be a valuable alternative in the management of advanced HD. Aim: To evaluate the efficacy and outcomes of the Rafaelo® technique for treatment of HD. Material and methods: A retrospective observational study was carried out between June 2019 and October 2020. The haemorrhoidal severity score (HSS), the Cleveland Incontinence Score (CIS), and the visual analogue scale (VAS) for pain were compared prior to and post procedure using a paired t-test. Results: Forty-seven patients were included in the study, with a mean age of 43 years. All individual symptom scores of HSS showed statistically significant improvement post RFA (p < 0.05). Minor complications like urinary retention (6.3%) and bleeding (12%) were noted. There were 2 instances of recurrence at 2 months. No major complications like anal stenosis or infections were observed. Conclusions: The RFA technique is a safe and effective treatment alternative for advanced HD. It results in a statistically significant improvement in the symptoms of HD and is associated with minimal discomfort to the patient with early return to normal activity.

A Novel Modification of Subcutaneous Onlay Endoscopic Repair of Midline Ventral Hernias With Diastasis Recti: An Indian Experience.

Introduction A ventral hernia is a common problem in the population. Many patients with umbilical/epigastric hernia often present with diastasis recti (DR) too. Diastasis recti is the thinning of the linea alba with an abnormal increase in the distance between the recti without a concomitant fascial defect. The presence of diastasis recti complicates the repair of the existing umbilical/epigastric hernia. Repair of only the umbilical/epigastric hernia in the presence of DR results in incomplete repair and predisposes to recurrence. There are various options available for the repair of umbilical hernia with diastasis recti. Open hernia repairs often have unsatisfactory cosmetic outcomes and, furthermore, involve complications frequently associated with large incisions such as surgical site occurrences (SSO), pain, dermal flap necrosis, and delayed postoperative recovery, to name a few. The era of minimal access surgery leaves us with a vast array of creative solutions to the same. Laparoscopic onlay repair has been given various names in literature, e.g., minimally invasive linea alba reconstruction (MILAR), pre-aponeurotic endoscopic repair (REPA), endoscopic linea alba reconstruction (ELAR), subcutaneous onlay laparoscopic approach (SCOLA), and totally endoscopic assisted linea alba reconstruction (TESLAR), with similar principles for all the procedures. The average rate of seroma formation in these procedures varies from 5% to 40%. SCOLA has been used in our study, with an added modification of the operating port and limiting the extent of lateral dissection with the aid of spinal needles, resulting in restrained dissection and creation of smaller lipocutaneous flaps, leading to reduced incidence of seroma formation. Methods Patients with symptomatic primary ventral hernia with concomitant diastasis recti were enrolled in the participating center from the period of May 2020 to December 2021. Thirty patients were enrolled for this prospective study. The patients underwent subcutaneous laparoscopic onlay repair of midline ventral hernia with diastasis recti, with plication of the defect and onlay placement of a polypropylene mesh. Results Six point sixty-six percent (6.66%) of the patients developed seroma and SSO. The incidence is congruent with the results available in current literature. None of the patients had necrosis of umbilical skin. There were no recurrences at the three months follow-up. Conclusion Our modification of SCOLA is an ergonomically favorable procedure and has comparable outcomes to other approaches, with minimal complications.

Are drains useful in eTEP ventral hernia repairs? An AWR surgical collaborative (AWRSC) retrospective study.

BACKGROUND: Drain practices in minimally invasive retromuscular ventral hernia repairs have largely been transferred over from open surgery without significant review. We wished to evaluate the role of drains in these repairs. METHODS: Using the Abdominal Wall Reconstruction Surgical Collaborative (AWRSC) registry, patients with ventral hernias who underwent enhanced-view totally extraperitoneal (eTEP) repairs between February 2016 and September 2019 were evaluated. Patients with contamination or active infection within the surgical field, those who underwent an emergent or hybrid repair, or received a concomitant procedure were excluded. Propensity score matching based on the defect size, previous hernia repair status, and the use of posterior component separation (PCS) was used to match patients with drains to patients without drains. We evaluated 180-day outcomes in terms of SSIs, SSOs, and recurrence. RESULTS: 308 patients met the inclusion criteria. After propensity score matching, 48 patients with drains and 72 without drains were included in the analysis cohort. Those with drains were older with a greater likelihood of an incisional hernia, but were broadly similar for other relevant demographic and hernia-related variables. While there was no difference in the incidence of SSOs and SSIs between the two groups, we report a higher risk of SSOs needing procedural intervention (SSOPI) and recurrence, with a lengthened hospital stay in the cohort that received surgical drains. CONCLUSION: The use of surgical drains in "clean" eTEP repairs of ventral hernias appears to be common, with a selection bias for more complex cases. Based on our analysis, we found the use of drains was associated with longer hospital stays. The use of drains did not change the likelihood of suffering an SSI or SSO. However, the incidence of SSOPIs was higher despite the use of drains, which raises questions about their protective role in these repairs.

Enhanced Drainage Protocol in Large Amoebic Liver Abscess.

Background Amebic liver abscess (ALA) contributes significantly to morbidity and mortality in patients of the developing world. Even though medical management is the primary modality of treatment, 15% of the cases are refractory and require intervention for drainage. Pigtail catheterization is inefficient and results in a long duration of hospital stay. So, we conducted a prospective observational study to determine the efficacy and safety of drainage of large ALA using a wide bore 24 French (Fr) drain compared with a conventionally used 10 Fr pigtail catheter. Materials and Methods A single center prospective observational study was conducted over a period of 5 years and data of 122 patients was collected. After starting empirical medical therapy, patients underwent drainage of ALA with either a 10 French pigtail or a 24 Fr drain. The primary outcome variables were resolution of clinical symptoms such as fever and pain in abdomen, length of hospital stay, and resolution of abscess on imaging at day 3. Secondary outcome was complications related to the procedures. Results Data of 122 patients was collected. Males constituted a vast majority (96%) of the study population and the fifth decade was the most common age group involved. Alcoholics had a higher chance of developing a large ALA. Sixty-eight patients underwent drainage of the ALA using a 24 Fr drain which resulted in faster resolution of symptoms (2.4 vs. 5.1 days, p -value 0.033), a shorter duration of catheter in situ (6.4 vs. 13.2, p -value 0.011), and a faster drainage of ALA (residual volume at day 3; 177 vs. 212 mL, p -value 0.021). Twenty-eight patients had a biliary communication of which 26 required therapeutic endoscopic retrograde cholangiopancreatography. Conclusion In patients with a large ALA, placement of a wide bore 24 Fr catheter hastens recovery of the patients when compared with drainage with a standard 10 Fr pigtail catheter. Placement of a biliary stent serves as a useful adjunct for their management and it may obliviate the need for a major biliary diversion surgery.

Hepaticocystic Duct in an Era of Laparoscopic Cholecystectomy.

The biliary tract is notorious for its variable anatomy. A persistent hepaticocystic duct with agenesis of common bile duct is a rare biliary anomaly that creates a diagnostic dilemma and can add to the operative difficulties. It is important to diagnose this anomaly preoperatively since the gallbladder forms an integral part of bilioenteric continuity and an inadvertent cholecystectomy can lead to a surgical catastrophe. If diagnosed, surgeons can plan definitive treatment in the form of biliary diversion. We present a case of a 22-year-old man, who presented to us with obstructive jaundice and cholangitis. The biliary system was decompressed initially with a percutaneous transhepatic biliary drainage and an endoscopic retrograde cholangiogram established the diagnosis of a type IV hepaticocystic duct preoperatively in our case. Since diagnosis was made prior to operative intervention, we were able to perform a cholecystojejunostomy to maintain biliary continuity. The patient was discharged with an uneventful postoperative course. To our knowledge, this is the first report of such a variation being diagnosed preoperatively. We are also presenting a brief review of literature about persistent hepaticocystic ducts and the embryological basis of their origin.

Role of Indocyanine Green to Mitigate Wound Complications in Component Separation Technique for Ventral Hernia Repair-Our Early Experience.

BACKGROUND: The ease of the anterior component separation technique (ACST) makes it an attractive surgical option for ventral hernia repairs (VHR). Incorporation of indocyanine green-fluorescence angiography (ICG-FA) to map soft tissue perfusion during open ACST is an effective way to minimize the wound complications. This study aims to evaluate the impact of adoption of ICG-FA on wound-related complications following open ACST in VHR. METHODS: We performed a retrospective review of patients who underwent VHR with the open ACST at a single centre between March 2018 and July 2020. The study comprised of consecutive cases of open ACST with onlay meshplasty done before (March 2018-April 2019) and after (May 2019 to July 2020) implementation of ICG-FA for intra-operative perfusion mapping of subcutaneous tissue and skin. RESULTS: The pre-ICG group and post-ICG group were similar in terms of baseline patient demographics and peri-operative details. The rate of surgical site occurrence's was higher in the pre-ICG group, but this result was not statistically significant (46% vs. 26%; p value 0.189). Skin necrosis, however, was observed in significantly less patients of the post-ICG cohort (29% vs. 5%; p value 0.045). CONCLUSION: This study demonstrates the effectiveness of perfusion mapping by the use of ICG angiography to determine potential areas of decreased perfusion and thereby minimize wound complications. Using ICG-FA to guide removal of at-risk tissue to minimize wound complications may substantially improve the patients outcome.

Complicated Ventral Hernia: A Perquisite for Perforated Peptic Ulcer-Unusual Clinical Scenario.

Introduction Peptic ulcer usually presents to the emergency in the form of an acute abdomen, which is usually diagnosed easily either clinically or radiologically. Although its incidence has decreased with the introduction on proton pump inhibitors it is still one of the most common emergencies encountered by a surgeon. Case Presentation A 60-year-old woman complained of epigastric swelling for 6 months which gradually increased and became irreducible over the last 2 months. The patient also complained of pain associated with vomiting. Radiological investigations revealed a epigastric hernia with omentum and stomach as content along with fluid collection in the right perihepatic region, with tiny air foci. The patient was explored for the same. Discussion Perforated peptic ulcer is a serious complication and carries high risk of morbidity and mortality. Early diagnosis with immediate resuscitation and surgical intervention is essential to improve outcomes. This is a rare case of perforated gastric ulcer which was masked under the complicated ventral hernia.

Decalogue of Transversus Abdominis Release Repair- Technical Details and Lessons Learnt.

Background Posterior component separation (PCS) via transversus abdominis release (TAR) technique overcomes the pitfalls of traditionally described repairs. We evaluate the safety and efficacy of this approach and present the lessons we have learnt in our experience with a large series of complex ventral hernias. We also evaluate the importance of pre-operative optimisation and the value of a dedicated abdominal wall reconstruction (AWR) team in improving the surgical outcomes. Study Design A retrospective review of all patients undergoing TAR at a specialised hernia centre in the 2016-2019 period was performed. Pertinent data collected included patient demographics, peri-operative details and post-operative complications. Primary outcome variables were surgical site occurrences (SSO) and hernia recurrence. A multivariate regression model was developed to determine significant predictors of SSO. Results In 92 consecutive patients, the mean age was 52 years with a mean body mass index of 27.9%. Major comorbidities included diabetes (41%), hypertension (23%), and chronic obstructive pulmonary disease (15%). The mean hernia defect was 13.2 cm and the average operative time was 232 minutes. Complete posterior sheath closure was achieved in 95.6% cases. There were 18 (19.5%) cases of SSO which were managed conservatively and no cases required mesh explanation. There were 2 (2.1%) recurrences which required a redo surgery. On multivariate analysis operative time (p value 0.047) was a significant predictor of SSO. Conclusions AWR using the TAR approach offers a robust repair with low overall morbidity. A holistic pre-operative optimisation strategy and a dedicated AWR team can further improve surgical outcomes.

Novel Use of Intraoperative Fluoroscopy in an Era of ICG for Complex Laparoscopic Cholecystectomy.

Background Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach specially in cases with an inflamed calots triangle. While use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. We propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD. Methods A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC at our institution. All patients were stented preoperatively and the stent was used for a much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct. Results The gall bladder was gangrenous in all the cases while two cases had evidence of end organ damage. This innovative use of CBD stenting allowed us to correctly delineate biliary anatomy in all of the cases and we report no instances of BDI despite a severely inflamed local environment. Conclusion This technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with a distorted biliary anatomy.

Tubular Ileal Duplication Causing Perforative Peritonitis in an Adult: A Rare Presentation.

Background Enteric duplication cysts are a rare congenital abnormality that present more commonly in children than adults. Clinical presentation varies from vague abdominal pain, abdominal lump, iron deficiency anemia to intestinal obstruction due to intussusception or mass effect. We report a tubular ileal duplication in an adult male presenting with an acute abdomen due to perforative peritonitis. Case A 20-year-old male presented to the emergency department with complains of right lower abdominal pain. On clinical examination and ultrasound scan patient was suspected to have a complicated acute appendicitis (rupture). However, a computed tomography scan was suggestive of perforation in the distal ileum. Emergency exploratory laparotomy revealed a perforated isolated ileal tubular duplication.

Surgical Mask-the Saviour: from its Invention to the COVID-19 Era.

The earliest available evidence attributes the discovery of droplets as a mode of transmission of disease to Carl Flügge, a German bacteriologist, a contemporary of Emil Kocher, in 1897. This finding was instrumental in the development of the gauze mask introduced by Johann von Mikulicz Radecki in the same year. A surgical mask has become an indispensable tool in the armamentarium to fight the COVID 19 pandemic. Surgical masks which were once limited to the confines of healthcare setups are now donned by the members of the general public. It has become imperative that a healthcare worker selects the right kind of respiratory protective equipment to protect himself and his patients. The surgical mask has become essential, in a way, for survival.

Antesternal colonic interposition for corrosive esophageal stricture.

Restoration of swallowing in a patient with dysphagia due to nondilatable corrosive stricture of esophagus remains a surgical challenge. Organs available for replacement are stomach, jejunum, or colon. Jejunum is useful to replace a small segment, whereas stomach and colon are required for a long-segment replacement. In cases where the stomach is also injured, colon remains the only option. The route of colonic interposition has also been a subject of debate over the years. Antesternal, retrosternal, or esophageal bed passage are the routes described. In the present series, the data of antesternal colonic interposition (ACI) performed for nondilatable benign esophageal strictures in 32 patients (1988-2011) have been retrospectively analyzed. The results indicate that ACI for corrosive strictures is a quick and simple procedure. Thoracotomy is avoided and anastomosis is easily performed in the neck, and mortality rate due to anastomotic failure or graft failure is diminished. This retrospective analysis discusses the ease, effectiveness, quality of life, morbidity, and mortality of ACI and compares the pros and cons of ACI with other procedures described in the literature.

Gastric cancer presenting with acute disseminated intravascular coagulation.

Patients presenting with acute disseminated intravascular coagulation (DIC) as the first symptom of malignancy are rare. A 68-year-old man presented with DIC. On evaluation, he was found to have adenocarcinoma of the stomach. Resection of the growth controlled the DIC for a few days, after which the patient developed altered coagulation parameters and sepsis, and succumbed.