Expanding the horizon of robotic surgery to large pelvic paraganglioma.

INTRODUCTION: Paragangliomas are the most common extra-adrenal pheochromocytoma. Symptomatic and growing tumors demand surgical extirpation. Minimally invasive techniques allow surgeons to perform the procedure without wide exposure and mobilization of intra-abdominal organs. To our knowledge, we present the fourth case of robotic excision of a large retroperitoneal paraganglioma. MATERIALS AND METHODS: An 18-year-old unmarried female presented with occipital headache for past 3 years. She also had palpitations and sweating. Ultrasound abdomen revealed a presacral mass of 4 × 4 × 3 cm, and on further evaluation, CECT abdomen characterized 5 × 3.2 × 4 cm well-defined heterogenous mass with intense enhancement in retroperitoneum near presacral region. Functional work-up revealed increased normetanephrine of 3723 mcg/dl and metanephrine of 273 mcg/dl. Patient underwent transperitoneal robot-assisted excision of the mass by fourth-generation da Vinci robotic system. After locating the mass of size 7 × 5 × 3 cm in the presacral region, dissection was carried out all around the mass. Intra-operative hypertensive episodes were managed by esmolol infusion. Feeding vessels were identified, clipped and cut. Resected mass was entrapped in specibag and retrieved intact. RESULTS: Blood loss was around 50 ml and operative duration was 120 min. In the postoperative period, her blood pressure became normal. Patient was discharged on POD 4. Histopathology was confirmatory of paraganlioma. CONCLUSION: Presacral tumors, especially those growing anterior, can be successfully removed with the da Vinci robotic system, and this approach can become the standard for manipulation of this kind of tumor irrespective of its size and malignancy.

Early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery-a randomized controlled trial.

OBJECTIVE: This prospective randomized controlled trial was conducted to compare the safety, tolerability and outcome of early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery. METHODS: A total of 120 consecutive patients who underwent elective open bowel surgeries were randomized into either early feeding (n = 60) or traditional feeding group (n = 60). Patients in the early feeding group were started on oral fluids on post-operative day 1, while those in the traditional feeding group were started orals after the resolution of ileus. Patient characteristics, surgical procedures, co-morbidity, first flatus, first defecation, time of starting solid diet, complications and length of hospitalization were assessed between the two groups. RESULTS: The two groups were similar in demographic and baseline data. The number of days to first flatus (p < 0.0001), first defecation (p < 0.0001), length of post-operative stay (p = 0.011) and time of starting solid diet (p < 0.0001) were significantly earlier in the early feeding group. Anastomotic leak, wound infection, fever, vomiting, abdominal distention and other complications were similar. Multivariate analysis showed that patients in the early oral feeding group were discharged 3.4 days earlier (p = 0.037). CONCLUSION: In patients undergoing elective open bowel surgeries, early post-operative feeding is safe, is well tolerated and reduces the length of hospitalization.