Novel laparo-endoscopic hybrid technique of management of a rare case of duodeno-duodenal intussusception.

We herein report a rare case of duodeno-duodenal intussusception (IS) presenting with obstruction caused by tubulovillous adenoma in an adult with malrotation that was managed by a novel laparoendoscopic hybrid technique. This was done by passing transjejunal nasogastric tube (NG) through one of the ports and manoeuvring it towards the IS. Two hundred and fifty millilitre of saline was flushed by aseptosyringe with pressure connected to the NG. This hydrostatic reduction technique resulted in distension of the jejunal and duodenal loop achieving reduction of IS. Intraoperative endoscopy was performed to exactly localise the mass lesion. The duodenum was kocherised and was delivered through a 4-cm transverse incision. Anterior duodenotomy was performed; the mass was excised; and duodenotomy was closed transversely. An extensive literature search did not show any case report of duodenoduodenal IS being managed by this technique. The combination of novel retrograde decompression and intraoperative endoscopy helped us to manage this rare case by this novel technique.

Use real-time near-infrared fluorescence during Heller's cardiomyotomy for achalasia cardia.

Laparoscopic Heller's cardiomyotomy is the surgical procedure of choice in the management of oesophageal achalasia. It is critical to confirm the completeness of the myotomy and mucosal integrity at the conclusion of the procedure. This is conventionally achieved by intraoperative endoscopy and dynamic air leak test. Other modalities that can be used to confirm the myotomy and the integrity of the mucosa at the myotomy site are oesophageal manometry and a methylene blue dye study, respectively. Indocyanine green (ICG) has been in clinical use for more than six decades. The real-time integration of ICG fluorescence with laparoscopy is a relatively new breakthrough. Here, we present a novel method of using real-time near-infrared ICG fluorescence for confirming the completeness of the myotomy and mucosal integrity at the myotomy site post laparoscopic Heller's myotomy. This is the first report on the use of ICG in laparoscopic Heller's cardiomyotomy that we are aware of.

Fat clearance in the hepatocystic triangle during laparoscopic cholecystectomy: Fact or fad? An NIRF-based study.

INTRODUCTION: At present, the pre- and postdissection regions during laparoscopic cholecystectomy (LC) are uniformly described by the term "hepatocystic triangle" (HCT). It is unclear whether a distinction needs to be made. An observational study was undertaken to evaluate the predissection hepatocystic region (pre-HCR) and the postdissection hepatocystic region (post-HCR). Also, the dissection-related changes to the contents of the pre-HCR ("proper HCT") were evaluated. METHODS: A retrospective review of a prospectively maintained database was done. The operative videos of patients who underwent fluorescence-guided surgery from December 2021 to February 2022 were reviewed. Patients with gallstone disease without complications (GSD) were included in the study. Exclusion criteria were acute cholecystitis, choledocholithiasis, biliary pancreatitis, biliary fistulas, and gallbladder wall thickening of ≥3 mm on ultrasonography. RESULTS: Thirteen patients underwent LC for GSD using standard dissection methods. The boundaries of the pre-HCR were identified before dissection in all patients. The dissection resulted in a quadrangular space lateral to the "proper HCT" in all. The post-HCR contained the undissected "proper-HCT" and the quadrangular space in all. The post-HCR area was 4.4 times that of the pre-HCR (3.2-13.1). The peritoneum over the "proper HCT" was unbreached in all patients, and the target structures were delineated outside of it. A critical view of safety (CVS) was demonstrated outside of the "proper HCT" in all patients. CONCLUSION: During near-infrared fluorescence-guided LC for GSD, there is no fat clearance in the "HCT." The hepatocystic region before and at the conclusion were distinctly different. The uniform usage of the term "HCT" does not convey this change.

Laparoscopic splenectomy for massive splenomegaly: the "splenic no-touch" technique for hilar control by anterior lienorenal approach.

PURPOSE: Laparoscopic splenectomy is challenging in patients with massive splenomegaly. The paper describes a technique that overcomes the difficulties one faces while dealing with a massive spleen laparoscopically. METHODS: We describe our splenic no-touch technique through the anterior lienorenal approach in patients undergoing laparoscopic splenectomy for massive splenomegaly during a 10-year period from January 2010 to January 2020. RESULTS: During the study period, 14 patients underwent laparoscopic splenectomy for massive splenomegaly. Of these, 13 patients had successful laparoscopic completion of the procedure. One patient required conversion for bleed. There were no pancreatic tail injuries during splenic hilar stapling in any patient. The median operative time was 170 minutes (140-225). The median blood loss was 50 mL (20-600). Two patients required blood transfusions. There was no other morbidity or mortality. The median postoperative stay was 2 days. CONCLUSION: The splenic no-touch technique using the anterior lienorenal approach for laparoscopic splenectomy is safe and feasible in patients with massive splenomegaly. Preoperative imaging enables optimal port placement and procedure ergonomics.

The second 'gallbladder operation'.

Background: Subtotal cholecystectomy has been reported in 8% and 3.3% of patients undergoing open and laparoscopic cholecystectomy, respectively. According to a recent nationwide survey, the utilisation of subtotal cholecystectomy in the treatment of acute cholecystitis is on the rise. In 1.8% of subtotal cholecystectomies, a reoperation is required. Reoperations for residual gallbladder (GB), gallstones, and related complications accounted for half of the reoperations described in the literature after subtotal cholecystectomy. The purpose of this study was to evaluate the clinical profile, risk of complications, and feasibility of laparoscopic approaches and surgical procedures in patients with recurrent symptoms from a residual GB that necessitated a completion cholecystectomy. Methods: Patients who underwent surgery for residual GB with stones and/or complications between January 2007 and January 2020 were included in the study group. A prospectively maintained database was used to review patient information retrospectively. The demographic profile, operation details of the index surgery, current presentation, investigations performed, surgery details, morbidity and mortality were all included in the clinical information. Results: There were 13 patients who underwent completion cholecystectomy. The median age was 55 years (22-63 years). Prior operative notes mentioned subtotal cholecystectomy in only seven patients. The average time between the index surgery and the onset of symptoms was 30 months (2-175 months). A final diagnosis of residual GB with or without calculi was made by ultrasound (USG) in 11 patients and by magnetic resonance cholangiopancreatography (MRCP) in two others. Choledocholithiasis (n = 4, 30.7%), acute cholecystitis (n = 2, one with empyema and GB perforation) and Mirizzi syndrome (n = 1) were seen as complications of residual gallstones in seven patients. All 13 patients underwent successful laparoscopic procedures. A fifth port was used in all. A critical view of safety was achieved in 12 patients. Two patients required laparoscopic common bile duct (CBD) exploration for CBD stones. Intraoperative cholangiograms were done in eight patients (61.5%). There were no conversions, injuries to the bile duct or deaths. Morbidity was seen in one. The patient required therapeutic endoscopic retrograde cholangiography for cholangitis and CBD clearance on the fifth post-operative day. The median hospital stay was 4 days (3-7 days). At a median follow-up of 99 months, symptom resolution was seen in all 13 patients. Conclusion: Gallstones in the residual GB are associated with more complications than conventional gallstones. The diagnosis requires a high level of suspicion. MRCP is more accurate in establishing the diagnosis and identifying the associated complications, even if the diagnosis is made on USG in most patients. A pre-operative roadmap is provided by the MRCP. For patients with residual GB, laparoscopic completion cholecystectomy is a feasible and safe option.

Near-infrared fluorescence guided laparoscopic cholecystectomy in the spectrum of complicated gallstone disease.

ICG fluorescence (ICGF) guidance during laparoscopic cholecystectomy (LC) is gaining wider acceptance. While the accruing data largely addresses ICGF guidance during LC in patients with uncomplicated gallstone disease (UGS) and acute cholecystitis, there is a paucity of data related for complicated gall stone disease (CGS) such as choledocholithiasis, bilio-enteric fistula, remnant gall bladder, etc. The purpose of this study was to evaluate the role of ICGF during LC in the spectrum of CGS with state of the art 4 chip camera system. Retrospective review from a prospectively maintained database of all patients who underwent ICGF guided LC during the period June 1st, 2019 till December 30th, 2021 formed part of the study. Clinical profile and findings on ICGF during LC for CGS were studied. The data was studied to evaluate the potential roles of ICGF during LC for CGS. Of 68 patients, there were 29 males and 39 females. Among them were 32 and 36 in the uncomplicated and complicated gallstone disease groups, respectively. ICGF showed CBD visualization in 67(98.5%) and cystic duct in 62(91%). ICGF guidance helped in management of CGS, prior to, during and after completion of LC. It had novel application in patients undergoing CBD exploration. In our small series of patients with CGS, ICGF guidance enabled a LC and laparoscopic subtotal cholecystectomy in 94% and 6% of patients respectively. The study highlights potential roles and advantages with ICGF guided laparoscopic management for CBD stones, bilioenteric fistula, completion cholecystectomy and cystic duct stones. Large scale multicenter prospective studies are required to clarify the role of ICGF in the wide spectrum of CGS.

Laparoscopic Repair of Spontaneous Esophageal Perforation After Multiple Endoscopic Failures.

Spontaneous esophageal perforation (SEP) (Boerhaave syndrome) carries high morbidity and mortality. Delay in diagnosis, because of the non-specific complaints and the rarity of the condition, further increases the mortality. While patients diagnosed early can be managed by primary closure of esophageal perforation, those presenting beyond 24 hours often require an esophagectomy with salivary diversion and feeding access with a plan for the reconstruction of the alimentary tract at a later date. In a minority of patients with a controlled esophageal fistula and feeding access, source control could be achieved by endotherapy. Patients with mediastinitis and associated systemic sepsis would be better served by surgical intervention. We present a case of an SEP with a delayed diagnosis, who underwent three unsuccessful endotherapy attempts and decortication before referral for surgical repair. The patient had an established esophageal fistula. He underwent a laparoscopic repair of the fistula. Postoperative recovery was uneventful. At the one-year follow-up, the patient was asymptomatic and had gained weight. Though surgery is the treatment of choice, the optimal management of SEP with delayed diagnosis is not clearly defined. In the current era of advanced endotherapy, more cases are being managed endoscopically. However, they carry a high failure rate, resulting in increased morbidity among the patients. Early involvement of a surgical team in the decision-making is crucial for optimal outcomes of the disease.

Thoracoscopic pericardial patch repair of iatrogenic major bronchial injury during oesophagectomy.

Tracheobronchial injuries are rare but dreaded and potentially lethal complications of oesophagectomy. The reported literature on tracheobronchial injuries in thoraco-laparoscopic oesophagectomy is sparse. They may be detected either intraoperatively or in the post-operative period. Those tracheobronchial injuries detected intraoperatively usually need conversion to an open procedure for appropriate management. The surgical approaches and the methods employed for closure depend on the size and location of the rent. The methods of surgical repair include primary closure, gastric patch closure, pericardial patch, pleural patch, pedicled intercostal muscle flap, dural graft and synthetic polytetrafluoroethylene grafts. Herein, we report a thoracoscopic repair of a major bronchial injury encountered in a patient during thoracoscopic oesophagectomy using a pericardial patch. To the best of our knowledge, this is the first report of a thoracoscopic repair of a bronchial injury using a pericardial patch.

Laparoscopic management of Crohn's disease-related complex enterovesical, enterocutaneous and enteroenteric fistula: A case report.

The management of Crohn's disease is medical, with surgery reserved for emergencies and complications. Fistulizing Crohn's disease can present with either an internal or external fistula. Internal fistulae are common in patients with ileocolonic disease. Enterovesical fistulae form a very small part of these internal fistulae. An ileovesical fistula with other concomitant internal or external fistulae is a complex fistula. A patient with an ileovesical fistula further compounded by an enteroenteric fistula and an enterocutaneous fistula is a difficult surgical patient to manage because of the resultant dense inflammation. Here we report a case of complex ileovesical fistula (concomitant enterocutaneous fistula and enteroenteric fistula) managed by a laparoscopic approach.

Rare variant of type V choledochal cyst masquerading as a biliary cystadenoma.

Cystic lesions of the liver are commonly encountered in routine clinical practice with a reported prevalence of 15%-18%. They may range from a benign simple developmental cyst to a malignancy. Therefore, an accurate diagnosis is essential for adequate management. Cystic tumors of the liver are classified based on the content (mucin containing or not), presence of ovarian stroma, and biliary communication. Biliary cystadenoma are a group of hepatobiliary neoplasia which by definition must be multilocular, lined by a columnar epithelium, and have a densely cellular ovarian stroma. We report a case of a cystic lesion in the hilar region of the liver, which had features of biliary cystadenoma on the preoperative imaging. However, on exploration was found to be a diverticular variant of type V choledochal cyst arising from both hepatic ducts. We have discussed the preoperative imaging features, intraoperative cholangiogram, and the management of this cystic lesion.

How to do a laparoscopic repair of a post-hysterectomy rectovaginal fistula?

The exact incidence of iatrogenic post-hysterectomy rectovaginal fistula is unknown. The overall surgical management for this group of patients is different from rectovaginal fistula in general. These are high fistula presenting with a diversion stoma in situ and are characterised well on a rectal contrast pelvic computed tomography (CT). We have described the laparoscopic repair of these fistulae.

Surgery Complicated by Self-Expandable Metallic Stents (SEMS) Tracheal Stent in a Congenital H-type Tracheo-Esophageal Fistula.

A congenital tracheo-esophageal fistula of the H-type is a rare variant. The diagnosis is usually missed because of mild symptoms. A long history of coughing during liquid intake and nocturnal cough may aid in the diagnosis. A delay in the diagnosis may have a deleterious effect on the lung because of recurrent infections. Surgery is the cornerstone of management. Self-expandable metallic stents (SEMS) do not have a role in the management of these fistulae. We report a case of a missed diagnosis of a congenital H-type fistula managed as an acquired tracheo-esophageal fistula with two attempts at conservative management with a tracheal self-expandable metallic stent. The difficulties and disadvantages of using self-expandable metallic stents for the management of benign tracheo-esophageal fistulae are also discussed.

Metastatic Sigmoid Colon Malignancy With a Synchronous Carcinoma Breast: Is Cure Possible?

Malignancies developing in two organs or more in the same patient are called multiple primary malignancies. They can be synchronous or metachronous based on the time of diagnosis of second cancer from the first. We encountered a synchronous stage IV sigmoid colon cancer (resectable liver metastasis) and breast cancer in a lady. The clinical dilemmas that arose with multiple primary malignancies and how they were tackled in our case have been discussed. A second malignancy should not deter the management or alter the clinical decision-making. Multidisciplinary teams are crucial to the management of these rare occurrences. We could successfully manage a synchronous breast and colon cancer with resectable liver metastasis at presentation.

LigaSure Vessel Sealing System for Small Bowel Transection During Roux Limb Construction.

Roux limb construction is an essential part of several major reconstructive hepatobiliary and upper gastrointestinal surgeries. This can be achieved with a stapling device or suturing. For over two decades, the LigaSure vessel sealing systems (Medtronic, MN, USA) have been in use for omental division, mesenteric transection, and sealing of vessels. We used the LigaSure vessel sealing system with a ForceTriad energy platform (Medtronic) for transection of the bowel during the formation of the Roux limb for a Roux-en-Y reconstruction. Between July 2019 and December 2020, patients who had Roux limb construction as part of a pancreato-enteric anastomosis in surgery for chronic pancreatitis were analysed. The data was reviewed from a prospectively maintained database. Fifteen patients had undergone surgery for chronic pancreatitis. The mentioned technique takes approximately eight minutes to construct a Roux limb. There was no bleeding from the gut ends that had been transected. There was no breach in the bowel's seal. The field was free of enteric contamination. In the post-operative course of these individuals, there was no Roux limb-related morbidity. This procedure is useful because it is cost-effective, time-saving, dependable, and prevents contamination and blood loss. It is also simple to learn and apply.

A Rare Occurrence of Spontaneous Closure of a Sigmoid Loop Colostomy and an Inevitable Ventral Hernia.

An intestinal stoma is an opening of the intestinal tract onto the anterior abdominal wall. It is a commonly performed surgical procedure done for various benign and malignant pathologies. The construction of the stoma is temporary or permanent. Loop stoma is usually performed to divert the faecal stream for protection of the downstream anastomosis. They are usually reverted once the purpose of their creation is served. Spontaneous closure is a rare event that could result from a gradual stomal retraction. However, a normal bowel with no distal obstruction would be a prerequisite for it to be asymptomatic. Here, we report a case of spontaneous closure of a diversion loop sigmoid colostomy which had a delayed presentation. This is the second case of spontaneous closure of a sigmoid loop colostomy and the first report on the management of ventral hernias following spontaneously closed stoma in the English literature to the best of our knowledge.

Considerations in laparoscopic resection of giant pancreatic cystic neoplasms.

Background: Laparoscopic distal pancreatectomy (LDP) with (LDPS) or without splenectomy for cystic tumours in the body and tail has become the standard of care. Data on patients with large tumours of the body and tail of the pancreas are sparse. Patients and Methods: A retrospective analysis of a prospectively maintained database of patients who were managed with laparoscopic surgery for pancreatic cystic neoplasm since 2010 was done. Patients with cysts more than 8 cm were analysed. Clinical presentation, imaging, details of the surgical procedure and the outcomes were looked into. Results: Five patients of giant pancreatic cystic neoplasm (GPCN) were managed with LDPS. Four patients were female, mean age was 45 years (range 15-69 years). The mean cyst size was 11.2 cms (range 8-15 cm). The splenic vein was either stretched or thrombosed in all patients. Three patients had sinistral portal hypertension. All patients were operated with a modified five-port placement. None of the patients required conversion. Mean operative duration was 3½ h, blood loss was 80 ml approximately and none required a blood transfusion. One patient had a biochemical leak. All patients were discharged from the hospital by 3rd postoperative day. Drain removal was done before discharge except in the patient with biochemical leak (removed on day 6). On a median follow-up of 89 months (range 1-120 months), two patients developed diabetes. There has been no Overwhelming post-splenectomy infections (OPSI). Conclusion: Laparoscopic distal pancreatectomy is feasible in patients with GPCN and offers the all the short-term benefits, namely lesser pain, no wound infections, early return of bowel activity, early return to orals and early discharge and early return to work. Splenectomy was required in all patients because of splenic vein thrombosis and portal hypertension in three and for technical reasons in the rest.