Intraperitoneal Onlay Mesh (IPOM Plus) Repair Versus Extended-View Totally Extraperitoneal Rives-Stoppa (eTEP-RS) Repair in Primary Ventral Hernias: Experience With 50 Cases in a Tertiary Care Hospital.

Background Primary ventral hernias are abnormal protrusions of abdominal viscera through the areas of weakness in the fascia of the abdominal wall. The aim of this study was to compare the benefits and complications, and the overall outcome in the Extended-View Totally Extraperitoneal Rives-Stoppa (eTEP-RS) repair versus Intraperitoneal Onlay Mesh (IPOM Plus) repair in the management of primary ventral hernias. Methods After obtaining institutional ethical committee clearance, this prospective comparative study between IPOM Plus and eTEP-RS was conducted in a tertiary care hospital from December 2020 to January 2022. A total of 50 patients presenting with primary ventral hernias were included in the study, of whom 25 underwent IPOM Plus and 25 underwent eTEP-RS repairs. Group selection was done by simple randomization using the lottery method. Patients more than 18 years of age with primary ventral hernias presenting with a hernial defect width less than 6 cm, consenting to the study, were included in the study. Patients who did not fulfill the inclusion criteria, strangulated/obstructed hernias, recurrent/incisional hernias, connective tissue disorders, skin infections, enterocutaneous fistulas, pregnancy, morbid obesity, and parastomal hernias were exclusion factors. Results The mean intraoperative duration in the eTEP-RS group (192.3 ± 16.20 min) was significantly higher than in the IPOM Plus group (102.6 ± 16.78min, p=0.001). The mean duration of hospital stay in the IPOM Plus group (5.9 ± 2.19 days) was longer than in the eTEP-RS group (4.6 ± 3.17 days, p=0.02). The mean postoperative pain scores, from the Visual Analogue Scale (VAS), on days 1, 7, and 90 were 3.2 ± 1.11, 2.64 ± 1.11, and 1.68 ± 1.46 in the IPOM Plus group and 1.84 ± 0.688, 0.76 ± 0.66 and 0.08 ± 0.40 in the eTEP-RS group, respectively (p=0.001). Conclusion Despite being a technically easy procedure requiring less intraoperative time, IPOM Plus had several disadvantages, such as increased postoperative pain, longer duration of hospital stays, higher chances of wound site seromas, and higher rates of postoperative paralytic ileus. On the other hand, eTEP-RS was a more challenging procedure requiring more intraoperative time; however, it had several advantages: less postoperative pain, less duration of hospital stay, early recovery, and fewer chances of seromas and paralytic ileus. However, more robust data is required to compare and validate the differences between both procedures' short- and long-term outcomes.

Endoscopic Thyroidectomy: A 6-Year Experience from a Tertiary Care Teaching Hospital in Western India.

Background: Minimally invasive and endoscopic surgical techniques have surpassed the conventional open thyroidectomy for the treatment of thyroid nodules. Trans-axillary, Unilateral Axillo-Breast Approach (UABA), Bilateral Axillo-Breast Approach, and Trans-Oral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) are the most common endoscopic procedures performed currently. This article highlights our experiences with UABA and TOETVA over a period of 6 years. Materials and Methods: Between January 2015 and December 2020, we retrospectively analyzed our experience in Endoscopic thyroidectomy with 119 patients using UABA (n = 72) and TOETVA (n = 47) in our tertiary care teaching hospital. Both approaches used the standard three-port technique. Real time angiography was performed intraoperatively using Indocyanine Green dye to delineate the vessels in all patients. Results: The mean operative time for UABA and TOETVA was 90 and 110 minutes, respectively. Estimated blood loss was 18 mL in the former and 20 mL in the latter. Temporary Recurrent Laryngeal Nerve palsy and Hypoparathyroidism were minimal with TOETVA (5 patients versus 4 patients and 7 patients versus 2 patients). Shorter duration of hospital stay was observed with UABA (3 days versus 5 days). Cosmetic satisfaction was better with TOETVA. Conclusion: Based on our 6-year experience, we propose "JJ Hospital Criteria," which we currently follow to decide which surgical approach will yield best results. UABA and TOETVA are safe, feasible, and give exceptional cosmetic satisfaction. Both approaches should be seen as complementary rather than competitive.

Endoscopic sistrunk using bilateral axillo-breast approach - A minimal access technique for thyroglossal duct cysts.

Sistrunk procedure for thyroglossal duct cyst (TGDC) includes removal of the thyroglossal cyst, middle portion of the hyoid bone and the tract towards the foramen caecum. Endoscopic approaches have surpassed the traditional open approaches for the treatment of benign thyroid swellings and TGDCs. Endoscopic Sistrunk procedure using bilateral axillo-breast approach is a safe and better alternative for the successful treatment of TGDC and provides excellent cosmetic results.

Minimally Invasive Management of Hemorrhagic Pheochromocytoma-A Rare Case Report.

Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells. The diagnosis is usually suggested by its classic history, presence of a strong family history, or discovery of an incidental mass on imaging in an asymptomatic patient. Hemorrhage into an occult pheochromocytoma is a rare complication with ∼1 to 2 per 100,000 individuals diagnosed annually. We report a case of a 29-year-old woman, who presented with abdominal pain (with no other significant history) due to a right hemorrhagic pheochromocytoma. Computed tomographic imaging and magnetic resonance imaging revealed the source of retroperitoneal hemorrhage as the right adrenal mass. They lacked the typical features of a pheochromocytoma which was eventually proven by the biochemical tests. The patient underwent preoperative stabilization with α and ß adrenergic receptor blockers for 7 days following which laparoscopic adrenalectomy was performed successfully with an uneventful postoperative period. This is the eighth reported case in literature managed laparoscopically. Histopathology confirmed it as pheochromocytoma. The treacherous and deceptive nature of pheochromocytomas and its hemorrhage make it crucial to detect and treat it promptly; otherwise, it will almost certainly be fatal from cardiovascular complications or metastasis.

Laparoscopic versus Open Appendectomy: A Prospective Comparative Study and 4-Year Experience in a Tertiary Care Hospital.

Background The aim of this study was to validate the pros of laparoscopic appendectomy (LA) over open appendectomy (OA) and to compare various primary outcome measures in the management of acute and recurrent appendicitis. Study Design Prospective comparative study. Place and Duration Between June 2015 and October 2019 in JJ Hospital, Mumbai. Materials and Methods Total of 60 patients with acute and recurrent appendicitis were included in the study. Thirty patients underwent OA and 30 underwent LA. Both groups were comparable clinicopathologically and demographically. Various intraoperative and postoperative parameters were compared. Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. Mann-Whitney U test was used to compare continuous variables and chi-squared test was used to compare categorical variables. p -Value≤0.001 was considered to be statistically significant. Results The median age of patients undergoing OA and LA was 24.9 and 25.2 years ( p = 0.221), respectively. Female: male ratio in OA and LA was 1.30 and 1.14, respectively ( p = 0.795). Mean operative duration in LA and OA group was 47.17 ± 14.39 minutes and 36.9 ± 12.33 minutes ( p = 0.001), respectively. Mean length of postoperative stay in LA and OA group was 3.69 ± 0.71 days and 5.28 ± 0.63 days ( p = 0.000), respectively. Median visual analogue scale score in LA and OA group was 3.5 and 5 ( p = 0.001), respectively. Mean time to return to normal activity in LA and OA group was 8.13 ± 1.33 days and 10.10 ± 2.20 days ( p = 0.000), respectively. About 6.66% patients in LA group and 13.33% in OA group had postoperative wound infection ( p = 0.652). Mean scar scale scoring done on 30th postoperative day was 4.23 in LA and 8.23 in OA ( p = 0.000). Discussion and Conclusion LA is more promising than OA in the management of acute and recurrent appendicitis. LA offers lesser operative site pain in the postoperative period, shorter postoperative hospital stays, earlier recovery, and return to normal activities and cosmetically better scars on 30th day follow-up. No conversions or significant difference in wound related complications were seen in both groups. Prolonged intraoperative duration was the only drawback of LA.

Wandering parasite: endoscopic management of hydatid cysts of abdomen encroaching thorax.

BACKGROUND: Minimal access surgery has opened avenues of hybrid approach for abdominal hydatid cysts extending into thorax. This approach of combined laparoscopy and thoracoscopy should be evaluated for its feasibility and efficacy. AIM: Present prospective study was designed to highlight the feasibility and utility of endoscopic approach in the management of complex hydatid cyst of the liver and spleen extending into the thorax. MATERIAL AND METHODS: Patients undergoing combined Laparoscopy and thoracoscopy for abdominal hydatid cysts extending into thorax over a period of 4 years were included in the study. Their clinical features, investigations, imaging, treatment and duration of hospital stay were studied. Clinical outcomes were assessed with respect to morbidity and mortality using Calvien Dindo scale. RESULTS: A total of 15 patients were studied. All patients had thoracic hydatid cysts with liver involvement in 12, splenic involvement in 2, and both liver and spleen in 1 patient. The most common symptom was pain in the abdomen in 11 patients (73.3%) followed by lump in the abdomen in 2 patients (13.33%), and dyspnoea in 2 patients (13.33%). Computed Tomography was diagnostic in all patients. Most common type was Gomez type 1 (7 patients) followed by Gomez type II (3 Patient) and Gomez type III (2 patient). The mean operative time was 120 min. Mean hospital stay was 10 days. Pleural effusion being the commonest postoperative sequelae. CONCLUSION: This endoscopic approach for liver and splenic hydatid cyst extending into thorax is feasible and averts morbidities of thoracotomy.

Management of thymomatous myasthenia gravis - Case report of a rare Covid19 infection sequelae.

INTRODUCTION: SARS CoV19 infection can predispose to many autoimmune and neurological conditions, thymomatous myasthenia gravis being one of them. The rarity of these case poses therapeutic dilemmas about their further management. PRESENTATION OF CASE: A 61 year old gentleman who had covid19 infection 2 months back, presented with new onset myasthenia gravis and an anterior mediastinal mass. He was diagnosed as a case of anti acetyl choline receptor antibody positive thymomatous myasthenia gravis. The patient was posted for video assisted thoracoscopic excision of thymoma. The procedure was uneventful and patient was discharged with improvement in myasthenic symptoms. Histopathological examination confirmed the diagnosis of WHO Type A Spindle cell thymoma. DISCUSSION: SARS CoV19 infection is associated with an array of autoimmune disorders due to various proposed phenomenon including molecular mimicry and loss of immune tolerance. Post infectious thymomatous myasthenia gravis is extremely uncommon, and can be managed with open, minimally invasive or robotic approach. CONCLUSION: This is the first documented case of post covid19 infection thymomatous myasthenia gravis to the best of our knowledge, managed with minimally invasive thoracoscopic surgery. Further research is required for documentation of the natural history of the disease and therapeutic outcomes.

Umbilical Hernia with Evisceration. Two Cases and a Review of the Literature.

BACKGROUND: Evisceration of umbilical hernias is an uncommon occurrence whereby the hernial contents break through the skin overlying the sac and skin. Irrespective of cause, sudden evisceration of an umbilical hernia is associated with deterioration and a poor outcome. CASE REPORTS: Our first case was a 42-year-old woman who presented with sudden outpouring of fluid from the umbilicus with omental evisceration. Further evaluation revealed hepatic decompensation caused by hepatitis C infection belonging to Child-Turcotte-Pugh class C. After stabilizing her hemodynamically, she underwent a partial omentectomy with primary repair of umbilical defect. The patient's postoperative course was challenging. She died of septicemia and acute renal failure after 5 days. Our second case was a 40-year-old man who suffered from alcohol-induced cirrhosis, presenting with omental evisceration, belonging to Child-Turcotte-Pugh class C. We performed a primary repair of the hernial defect with peritoneovenous shunting for his intractable ascites. Upper gastrointestinal endoscopy revealed grade I esophageal varices. The patient succumbed to acute variceal hemorrhage with acute renal failure 18 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In an emergent setting with multiple factors influencing final surgical outcome, it is imperative that management be tailored for each patient. Those with severe encephalopathy or cardiovascular instability must be stabilized before surgical intervention. Central venous and blood pressures need to be closely monitored during resuscitation, as fervent fluid administration may predispose to variceal hemorrhage. It may be prudent to follow the principle of hypotensive resuscitation as in acute trauma cases.