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.

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.

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.

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.

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.