Initial Retrocolic Endoscopic Tunnel Approach As an Ergonomic and Oncologically Apt Laparoscopic Technique for Resection of Malignant Right Colonic Lesions: An Experience from a University Hospital.

Introduction: Radical minimal access cancer surgery has demonstrated similar outcomes as open surgery of late, but with less morbidity, improving the quality of life especially in patients with colorectal cancer. Initial retrocolic endoscopic tunnel approach (IRETA) has been described in the literature by Palanivelu et al. as a laparoscopic technique for radical resection of malignant right colonic lesions (MRCL) following the modified concept of medial to lateral dissection. In this work, the authors present their experience of this ergonomic surgical technique. Materials and Methods: To begin with, retrocolic dissection was carried out to free and dissect the ascending colon up to hepatic flexure with the reflection of the peritoneum over the right colon along the white line of Toldt with abdominal wall kept intact initially to sustain intracorporeal specimen steadiness. Subsequently, the specimen is lifted medially in a distinct lymphovascular sheath, leading to high ligation of ileocolic, right colic, and the right branch of the middle colic vein with a consequent definite en bloc thorough removal of the lesion. The specimen was delivered through a transumbilical incision. Results: Ten patients (age 45.4 ± 5.6 years) underwent resection by the IRETA technique with a mean operating time of 185 ± 30 minutes and blood loss of 90 ± 20 mL. Mean hospital stay was 6 days. R0 surgical resection was achieved in all patients with proper marginal clearance. Ninety percent had adequate lymph nodal resection. One patient had an intraoperative complication and n = 3 patients developed postoperative ileus. Adjuvant chemotherapy was given and there is no recurrence on 28 months of average follow-up. Conclusion: With the increasing use of laparoscopic surgery for the management of colorectal cancers, the IRETA technique appears to be an ergonomic and oncologically robust procedure for the removal of MRCL. The presented data set needs to be increased with at least 5 years of follow-up to establish long-term surgical outcomes.

A prospective randomised control trial to compare the perioperative outcomes and ergonomic challenges between triangular versus midline port placement in total extra-peritoneal repair of uncomplicated unilateral inguinal hernia.

BACKGROUND: Routine TEP technique requires three skin incisions for placement of three trocars in the midline. Otherwise, this can be done by three-port triangular technique or two-hand technique. This study reports a randomised trial of perioperative outcomes and ergonomics characteristics of this procedure using two different techniques of port insertion. METHODS: N = 28 patients were randomised into two groups for triangular three-port (TTEP) versus midline three-port TEP (MTEP) hernioplasty after informed written consent in Department of Surgery, King George's Medical University UP between September 2016 and September 2017 after institutional ethical approval. Patient-related outcomes in terms of quality of life (QOL) and ergonomic evaluation of the technique were compared in double-blinded fashion. RESULTS: Postoperative pain score at 24 h post surgery (5.1 ± 0.6; 95% CI 4.9-5.3 vs. 4.8 ± 0.4; 95% CI 4.6-4.9) differed, while hospital stay, time to return to routine work, tolerance to oral feeds and intraoperative complications occurrence (OR 2.1; 95% CI 0.2-24.3) were comparable in both groups. Time to return to office work (5.5 ± 0.5; 95% CI 5.4-5.7 vs. 4.0 ± 0.8; 95% CI 3.7-4.3) and immediate postoperative sensation of mesh and pain score were significantly higher in MTEP compared to TTEP. Ergonomic parameters including visualization of landmark score, spreading of mesh score and total surgeon satisfaction score (TTEP 8.4 ± 0.7; 95% CI 8.1-8.6 vs. MTEP 7.0 ± 0.8; 95% CI 6.7-7.3), mental effort quotient (SMEQ score: TTEP 50.6 ± 12.7; 95% CI 45.9-55.3 vs. MTEP 70.8 ± 12.6: 95% CI 66.1-75.4) and physical effort quotient (LEDQ scores in wrist, hand, arm and shoulders) were also superior in triangular technique of port placement. CONCLUSION: Triangular three-port TEP hernioplasty is ergonomically feasible and enables a surgeon to perform surgery safely using basic principles of laparoscopy.

Mesopancreas: myth or reality?

CONTEXT: A recently published study hypothesized the concept of 'mesopancreas', defining it as a firm, well-vascularized structure extending from the posterior surface of the pancreatic head to behind the mesenteric vessels. OBJECTIVE: To verify and define mesopancreas from resection specimens obtained from fresh cadavers. DESIGN: Postmortem anatomical-pathological study. SETTING: Department of Surgery in conjunction with the Departments of Forensic Medicine and Pathology, Government Medical College and Hospital, Jabalpur, MP, India. PARTICIPANTS: Twenty fresh adult cadavers without any intra-abdominal injury or gross intra-abdominal pathology. INTERVENTIONS: Specimens containing the entire duodenum, pancreatic head and neck, gallbladder, cystic duct, common bile duct, superior mesenteric vessels, inferior vena cava and aorta were removed en-bloc. Gross and histopathological examinations of the specimens were carried out. MAIN OUTCOME MEASURES: To look for a fibrous sheath or fascia around the retropancreatic structure purported to be a mesopancreas. RESULTS: Loose areolar tissue, adipose tissue, peripheral nerve, nerve plexus, lymphatic and capillaries were found in the retropancreatic tissue, extending from the head, neck and uncinate process of pancreas to the aorto-caval groove but no fibrous sheath or fascia was found around these structures. CONCLUSIONS: The concept of 'mesopancreas' is anatomically unfounded.

Characterization of proteases in guts of Daphnia magna and their inhibition by Microcystis aeruginosa PCC 7806.

Many cyanobacteria produce peptides that inhibit mammalian proteases. The hypothesis that inhibitors of mammalian proteases produced by cyanobacteria also interfere with digestive proteases of natural cladoceran grazers was tested by comparing the effects of cyanobacterial protease inhibitors on digestive proteases from Daphnia magna and on commercially available bovine proteases. The major digestive proteases of D. magna are trypsins and chymotrypsins, which differ from those of bovine origin in substrate specificity and susceptibility to synthetic inhibitors. An extract from Microcystis aeruginosa strain PCC 7806 inhibited both types of D. magna proteases. Subsequent fractionation of the extract by high-performance liquid chromatography indicated that several inhibitors are produced by M. aeruginosa that differ in their specificity for the trypsins and chymotrypsins of D. magna. Two fractions differed in their inhibitory effect on proteases of D. magna and bovine origin; therefore, assessment of the impact of cyanobacterial protease inhibitors on natural communities requires the use of digestive proteases from ecologically relevant grazers.