Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial.

BACKGROUND: Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. METHODOLOGY: This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. RESULTS: Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. CONCLUSION: LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.

Endoscopic totally extraperitoneal repair for groin hernia: Experience from a tertiary care centre.

Background: Totally extra-peritoneal (TEP) and transabdominal preperitoneal (TAPP) repair are two established minimal access techniques of groin hernia surgery. TEP offers the advantage of avoiding violation of the peritoneal cavity. Aim: This study aims to describe the decade-long experience of TEP in groin hernia repair in a tertiary care teaching institute and the feasibility of the same in difficult scenarios. Materials and Methods: Retrospective analysis of the database of patients undergoing TEP repair for inguinal hernia in a single surgical unit at a tertiary teaching hospital between January 2008 and December 2019 was performed. Detailed pre-operative clinical details, operative duration, intraoperative and post-operative complications, including pain, length of post-operative hospital stay and hernia recurrence data were analysed. Results: Over 12 years' duration, 511 patients underwent endoscopic TEP mesh repair and the total number of hernias repaired was 614. Majority (97.45%) of patients were male. The mean age of the patient population was 51.3 years. Primary hernia was seen in 490 patients. The mean operating time for unilateral inguinal hernia repair was 56.8 ± 16 min and for bilateral repair 80.9 ± 25.2 min. TEP in previous lower abdominal/suprapubic surgical scars was attempted in 17 (3.3%) patients, with only one requiring conversion. The intraoperative peritoneal breach was the most common documented complication (34.8%). Seroma was seen in 9.4% of patients. Seventeen patients required conversion (14 TAPP and 3 open). Recurrence was seen in 4 (0.7) patients. Conclusion: TEP repair is an effective method of groin hernia repair and can be attempted in the majority of patients groin hernia, including patients with previous lower abdominal incisions.

Impact of bariatric surgery on urinary incontinence in morbidly obese individuals.

BACKGROUND: There is scanty evidence on the impact of bariatric surgery on urinary incontinence (UI) in the Asian population. METHODOLOGY: Patients who underwent bariatric surgery from June 2018 to June 2019 were screened using the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) questionnaire. Patients having UI were identified and followed until 1 year of surgery using the ICIQ-UI-SF. These were classified as having stress, urge, or mixed type of UI. The prevalence, change in scores, and the number of pads used were compared at baseline and at follow-up. RESULTS: A total of 148 patients underwent bariatric surgery of whom, 41 patients (M = 2, F = 39) had UI. Stress incontinence was seen in 70.7%, 19.5% had urge incontinence, and rest had the mixed type. Using logistic regression, it was found that female gender was the most important predictor of having UI (OR: 8.33). The prevalence of UI decreased from 27.7% at baseline to 8.1% at 6 months and 3.4% at 12 months. The mean ICIQ-UI-SF score improved from 8.76 (SD = 3.2) at baseline to 0.66 (SD = 2.1) at 12 months of follow-up. The proportion of patients with UI using any number of pads decreased from 92.7% at baseline to 9.8% at 12 months. There was a decrease in the number of patients having moderate to very severe UI from 35 (85.4%) at baseline to 2 (4.9%) at 12 months. Proportion of patients showing resolution was highest among the stress incontinence group at 96.5%. Presence or absence of comorbidities did not significantly influence the ICIQ-UI-SF scores. CONCLUSION: Bariatric surgery leads to profound improvement in UI in obese individuals which is well sustained until 1 year of follow-up. Resolution rates might be higher in Asian population.

Giant secretory multifocal adrenal myelolipoma: a diagnostic dilemma.

A 38-yearr-old man presented with erectile dysfunction and infertility. On examination, he was hypertensive and detected to have a left flank mass. Blood investigations were unremarkable except raised serum noradrenaline levels. Imaging revealed multiple well-defined fat-containing hypodense lesions in left suprarenal area with largest one measuring 14×16 cm, suggestive of left adrenal myelolipoma. Diagnostic dilemma was posed due to discordance between clinical, biochemical and imaging findings. Left adrenal mass resection was planned keeping the possibility of pheochromocytoma. However, histopathology revealed it to be adrenal myelolipoma. Hypertension was resolved in the postoperative period and serum noradrenaline levels were normalised. Final diagnosis of a secretary adrenal myelolipoma was made, which is an extremely rare entity.