Comparison of short-term outcomes of video-assisted thoracoscopic (VATS) plication of diaphragmatic eventration - a six-year prospective cohort study.

Diaphragmatic eventration is one of the rarest conditions characterized by elevation of the hemidiaphragm while maintaining its normal attachments. In recent years, video-assisted thoracoscopic surgery (VATS) has gained popularity for diaphragmatic surgery. In this study, we share our experience over six years with VATS plication of diaphragmatic eventration. We conducted a prospective study at our institute for six years from April 2016 to March 2021, which included 37 symptomatic patients with diaphragmatic eventration. The sample size reported in this study is one of the largest to date for VATS diaphragmatic plication. Of these, 18 patients underwent combined stapler and suture plication, and 19 patients underwent single modality approach (10-stapled resection, 9-suture alone plication). All patients were followed-up for a minimum of 2 years. Comparative analysis of the combined approach and the single modality approach was performed. The mean operative time was significantly longer with the combined approach (p value < 0.01). However, there was no difference in postoperative pain (p value = 0.50), analgesia requirement (p value = 0.72), or pleural drainage (p value = 0.32) between the two approaches. Although not statistically significant, the combined approach had fewer post-operative complications (p value = 0.32). Besides, the Single modality approach resulted in one recurrence (p value = 0.32) and one mortality (p value = 0.32). VATS diaphragmatic plication using staplers and/or sutures is safe and efficacious in the management of diaphragmatic eventration. Surgeons should consider using both staplers and sutures whenever possible, rather than selecting one over the other.

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.

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.

Minimally invasive extended thymectomy for thymoma associated with pure red cell aplasia.

Anaemia characterised by near absence of red cell precursors in the bone marrow is referred to as "pure red cell aplasia (PRCA)." It has an unusual and intriguing association with thymoma and auto-immunity. Here, we report such a case which was successfully treated with extended thymectomy by minimally invasive approach. A 68-year-old anaemic lady presented to our institute with weakness and exertional dyspnoea for almost a year. She was transfused with blood for the same periodically but remained transfusion dependent. Apart from pallor, her systemic examination was unremarkable. Peripheral smear showed reduced haemoglobin (Hb) mass and reduced reticulocytes. Bone marrow biopsy implied PRCA. High-resolution computed tomography (HRCT) of thorax revealed a well-defined soft tissue lesion in the anterior mediastinum suggesting thymoma. Biopsy showed lymphocyte-rich type thymoma. Thymus along with fibrofatty tissue was resected completely using video-assisted thoracoscopic surgery (VATS) approach. Histopathological examination of the resected specimen revealed World Health Organisation (WHO) type B1-thymoma. Immediate post-operative period was uneventful. However, a fall in Hb which required blood transfusions necessitated initiation of immunosuppression with corticosteroids. Patient was given 6 weeks of adjuvant immunosuppression with corticosteroids. After 8 months post-thymectomy, she was leading a symptom-free life and no longer in need for blood transfusions. VATS thymectomy is a safe and feasible approach for the treatment of thymoma-induced PRCA with added advantage of minimal invasive approach. Long-term complete remission is possible with adjuvant immunosuppression.

Use of indocyanine green-aided real-time angiography in laparoscopic mesenteric cyst excision - A safer approach.

Mesenteric cysts are rare abdominal lesions in the mesentery of the intestine. Complete surgical excision is the only treatment which can be done by an open laparotomy or laparoscopic technique. Application of indocyanine green dye during the surgery helps in identification of the mesenteric vasculature, prevention and early repair of inadvertent iatrogenic vascular and bowel injury.

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.

Intra-operative enteroscopic polypectomy-An innovative hybrid approach using straight sticks.

BACKGROUND: Peutz-Jeghers Syndrome (PJS) is an uncommon intestinal polyposis disorder. Bowel obstructions are a recurring problem in PJS and as many as 50% of these patients require surgery. The current standard of care for these patients is to perform a flexible enteroscopic polypectomy. The traditional push-pull enteroscopy however, might be unavailable or unsuitable in an emergency setting. Alternatively, repeated laparotomies with multiple small bowel resections can lead to short bowel syndrome. METHODS: In our series, we describe an innovative technique where a short midline laparotomy permitted sufficient access to reduce the intussusception(s) and perform a bowel walk. Rigid laparoscopic instruments were introduced within the small bowel lumen via enterotomies, to perform polypectomies along the entire small bowel length. This precludes the need for small bowel resections which can thwart the development of short bowel syndrome. RESULTS: Two patients with PJS presenting with acute small bowel obstruction underwent surgery using the described approach. Another two patients with PJS having multiple intussusceptions on CT underwent an elective prophylactic polypectomy using the same approach. We were able to run the bowel in its entirety and a maximum of 41 polyps were retrieved from the port site enterotomy. The operating times were modest and no unique complications pertaining to this technique were encountered. CONCLUSION: Small bowel polypectomy using rigid instrumentation employing a limited midline laparotomy is an attractive option for both emergency and elective settings in patients with PJS.

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.

Bailing out the bowel and bladder - A rare case report of rectal impalement injury with iatrogenic bladder rupture.

INTRODUCTION AND IMPORTANCE: Rectal perforations due to foreign body impalement are infrequently encountered in practice. Accidental or intentional foreign body insertions pose a diagnostic challenge to surgeons and put them in demanding circumstances for successful extraction. CASE PRESENTATION: We report a case of a 60-year-old male with alleged history of accidental foreign body insertion into the rectum. Radiographs showed a linear metallic foreign body with crooked end. Computed Tomography (CT) with rectal contrast revealed contrast extravasation indicating anterior wall perforation of upper rectum. Patient was taken urgently for exploration and foreign body removal. Intra-operatively, bladder was injured inadvertently. Primary repair of enterotomy and loop sigmoid-ostomy was done besides bladder repair. Patient tested positive for COVID-19. Patient was observed in critical care unit for two days. Post-operative period was unremarkable apart from midline abdominal wound gape for which secondary closure was done. Patient was discharged with urinary catheter in-situ. Patient followed-up with a normal cystourethrogram and a well-functioning stoma. Stoma closure after two months was uneventful. CLINICAL DISCUSSION: A thorough history and clinical examination is required and one should raise a high index of suspicion of perforation in patients with rectal foreign bodies, which should be managed appropriately and promptly to prevent sepsis and multi-organ dysfunction. Inadvertent bladder injuries are common with lower-midline incisions. However, give good results when repaired suitably. CONCLUSION: The rationale behind this report is to explicate the complexity and hurdles in the surgical management of rectal foreign bodies causing impalement injury.

Endoscopic parathyroidectomy: a retrospective review of 27 cases.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disorder with adenomas being the most frequent cause. The condition is conventionally treated by a bilateral neck exploration through a cervical incision with removal of the affected glands. Intra-operative parathyroid hormone (IOPTH) monitoring and pre-operative Tc99m MIBI scans are facilitating focused approaches like minimally invasive video-assisted parathyroidectomy (MiVAP) and totally endoscopic parathyroidectomy (TOEP). METHODS: Patients with primary hyperparathyroidism were tested for location of diseased gland and accordingly selected for endoscopic parathyroidectomy by either trans-vestibular or trans-axillary approach. Those having undergone prior neck surgery or irradiation and those with an enlarged thyroid were excluded. All patients underwent IOPTH measurement to confirm the completeness of diseased gland resection. RESULTS: Eleven cases meeting selection criteria underwent endoscopic trans-vestibular parathyroidectomy and 16 cases underwent endoscopic trans-axillary parathyroidectomy. The mean operative time and blood loss were 104 min and 34 mL in trans-vestibular approach, respectively, while they were 47 min and 68 mL for the trans-axillary approach. All patients had post-operative resolution of hypercalcaemia. A single conversion to cervical approach was performed due to unsatisfactory IOPTH fall. A single patient suffered transient recurrent laryngeal nerve palsy which resolved with steroids. CONCLUSION: Endoscopic parathyroidectomy is a safe and feasible surgical procedure when combined with pre-operative imaging and intra-operative parathyroid hormone monitoring. There is a steady rise in the number of patients with primary hyperparathyroidism, a majority of whom have solitary gland affliction. Focused exploration is the current standard, wherein endoscopic surgery can be an important tool to improve outcomes.

A rare case report of large B cell lymphoma in adult presentation as intussusception.

Adult intussusception represents 5% of all intussusceptions. Primary gastro-intestinal lymphoma comprises 1%-4% of all gastro- intestinal malignancies 90% of them are B-cell non-Hodgkin's lymphoma (NHL). Most common NHL is diffuse large B-cell lymphoma accounts for 30-40%. Most common lymphoma causing intussusception is diffuse large B-cell lymphoma (DLBCL). We herein report a rare case of ileo-colic intussusception due to DLBCL in a 50- years-old male. Computed tomography showed ileo-colic intussusception with possibility of neoplastic etiology as a lead point. Hemicolectomy with ileo-colic anastomosis was done laparoscopically with post-operative chemotherapy. Subsequently, whole body positron emission tomography-computed tomography verified complete resolution of the malignancy. This study aims to present a rare case of ileo-colic intussusception due to non- Hodgkin's B-cell lymphoma in a patient with unusual clinical course and highlight the importance of not only the timely surgical intervention but also the significance of strict adherence to follow up and chemotherapy will completely eradicate the malignancy.

Combined laparoscopic and thoracoscopic approach for tension gastrothorax in a foramen of Bochdalek hernia.

INTRODUCTION: The incidence of Bochdalek hernias in adults is much more than previously reported. Though most of these are asymptomatic. Tension gastrothorax is a rare complication of these. Literature about the endoscopic management of a tension gastrothorax is extremely sparse. In this case report, we describe how we combined laparoscopy and thoracoscopy in an emergency setting to manage a case of tension gastrothorax with an underlying Bochdalek hernia defect in an adult. PATIENT PROFILE: A 27 year old male presented to our emergency with tension gastrothorax and a gastric volvulus with an underlying Bochdalek hernia defect, exhibiting the classical Borchardt's triad. The patient underwent an emergency surgery, through a minimally invasive approach wherein the herniated contents were reduced, the gastric volvulus detorted and a repair of the diaphragmatic defect was performed. His post-operative course was uneventful. DISCUSSION: Tension gastrothorax, is a diagnostic challenge as an air-fluid level in the thorax on radiology with worsening respiration causes as many as 38% of these cases to be misdiagnosed as tension pneumothorax, hydro-pneumothorax, hemothorax, empyema, effusion or pneumonia. Various techniques of decompression have been described in literature but, employing those, in case of a misdiagnosis may have catastrophic outcomes. CONCLUSION: We strongly recommend employing a combined laparoscopic and thoracoscopic approach for an emergency repair of a tension gastrothorax in a hemodynamically stable patient as, it poses all the advantages of minimal access surgery and is available, at smaller centres, even in an emergency.

Laparoscopic lateral pancreaticojejunostomy: an evolution to endostapled technique.

BACKGROUND: Chronic pancreatitis (CP) is a debilitating condition resulting in severe pain with progressive deterioration of pancreatic function. "Tropical" pancreatitis represents a variant of the disease with widely dilated ducts, numerous calculi, and few strictures. Traditionally, modified Puestow's procedure has been the treatment of choice for a dilated pancreatic ductal system. However, it has only recently been adapted to laparoscopic approach which is a technically demanding procedure primarily due to need for extensive intra-corporeal suturing. METHODS: Symptomatic cases of CP presenting at our center with minimum 8 mm mean ductal diameter at body and head were selected for laparoscopic modified Puestow's procedure. Those with prior pancreatic surgery, pancreatic head masses, endoscopic pancreatic stenting, and portal hypertension were excluded. Twenty-eight cases meeting selection criteria underwent a laparoscopic procedure. RESULTS: Seven patients (25%) underwent a stapled pancreaticojejunal anastomosis, 17 (60.7%) received a sutured anastomosis. Four patients (14.3%) were converted to open surgery due to failure to localize the pancreatic duct with percutaneous needle aspiration. Of those patients who underwent a successful laparoscopic procedure, a single patient developed a pancreatic fistula which resolved spontaneously; another patient had a difficult post-operative course with prolonged intensive care. We suffered no mortality within the series and no patient had any long-term disability. Anastomotic patency rates of 100% were achieved by the third post-operative month. CONCLUSION: Lateral pancreaticojejunostomy is an effective surgical management for CP with a dilated ductal system. Its laparoscopic adoption is the rational next surgical step. It allows effective duct decompression with low mortality and morbidity. The procedure demands an advanced surgical skill set with an emphasis on intra-corporeal suturing. Those patients suffering from tropical CP with wide ductal dilatation greater than 12 mm are suited to an endostapled anastomosis which helps significantly reduce operative time without any corrosion of outcomes.

Role of indo-cyanine green (ICG) fluorescence in laparoscopic adrenalectomy: a retrospective review of 55 Cases.

BACKGROUND: Indo-Cyanine Green Fluorescence is an emerging technology with more frequent use in laparoscopic and robotic surgery. It relies on near-infrared (NIR) fluorescence to demonstrate tissue perfusion with demarcation of tissue planes and vascular pedicles. The aim of the study is to evaluate the role of this technology in laparoscopic adrenalectomy (LA). METHODS: 55 patients underwent laparoscopic adrenalectomy using NIR Fluorescence enabled laparoscope. All cases received a standard initial dose of 5-mg dye to aid tissue visualization. Surgery proceeded with "fluorescence mode" demonstrating real-time NIR images superimposed on standard white-light imaging. The timing, number of doses were dictated by the operating surgeon, which were recorded and correlated with intra-operative fluorescence visualization. RESULTS: 54 patients underwent successful LA, with one conversion in a case of large pheochromocytoma due to difficult hemostasis. The lag between ICG administration and visualization of adrenal fluorescence varied between 30 and 75 s. The total duration of adrenal parenchymal fluorescence after a single dose did not exceed 15 min in our series. Average total administered dose was 14.4 mg. We suffered no mortality. There were no adverse effects due to the dye. 5 patients suffered Grade I complications, with one patient suffering Grade II and IV complication each, as per Clavien-Dindo Classification. Final histopathology demonstrated pheochromocytoma, adrenocortical adenoma, adrenocortical carcinoma, cushing's adenoma, aldosteronoma, and myelolipoma. CONCLUSION: We describe our initial positive experience with ICG fluorescence in LA, with a detailed description of dye administration in our study. The technology offers real-time differentiation of tissues and identification of vascular structures, providing immediate guidance during surgery. Further evaluation of its role in adrenocortical malignancy is warranted. NIR fluorescence is a safe, useful addition in laparoscopic adrenalectomy which will undergo further refinement over time.

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.

When a cure becomes the pathology: mechanical bowel obstruction due to herbal pharmacobezoar. A case report with review of literature.

Bezoars are intra-luminal concretions of ingested material which accumulate within the bowel. They are termed pharmacobezoars when the constituent material is drugs. We report a 64-year-old female with abdominal pain and obstipation for 3 days. Patient had completed anti-tuberculous combination therapy for suspected abdominal tuberculosis 25 years ago. She exhibited features of shock with a right iliac fossa lump. Abdominal X-ray displayed multiple air-fluid levels with densely cluttered radio-opacities in the right lower quadrant. Laparotomy revealed a palpable mid-ileal intra-luminal lump, adherent to the ascending colon and proximal ileum necessitating resection. Ex vivo examination of resected specimen revealed numerous tablets aggregating proximal to an ileal stricture. The patient post-operatively confirmed the tablets resembled the herbal laxatives she had been consuming. Pharmacobezoars can lead to subacute intestinal obstruction. Numerous drugs have been implicated. Patients with partial gastrectomy and vagotomy are at risk. CT is the pre-eminent diagnostic modality. The treatment options for pharmacobezoars include lavage, endoscopic retrieval, in addition to surgery. Pharmacobezoars need a high index of suspicion for pre-operative diagnosis. A detailed history and correlation with radioimaging can offer important cues. One can prevent pharmacobezoars by abstaining from unwarranted medications and identifying those at risk.

Triorchidism: Presenting as Undescended Testis in a Case of Indirect Inguinal Hernia.

Triorchidism is the commonest variety of polyorchidism, an entity with more than two testis is an extremely rare congenital anomaly of the testis. Although excision of the abnormal testis is a safer alternative proposed, recent literature suggests more conservative approach in normal testes with watchful regular follow up to screen for malignancy. This case presented as a left inguinal swelling diagnosed as indirect left inguinal hernia. The left side testis was of smaller size (about half) with normal sperm count, morphology and motility. Intraoperatively indirect inguinal hernia was noted with supernumerary testis at deep ring in addition to normal left testis in left scrotal sac. The ectopic testis were small (2.5×2.5×1 cm) lacking epididymis and with short vas deferens. An evident normal semen analysis and varied anatomy, the decision for orchidectomy of ectopic testis was taken. The histopathological finding was consistent with arrest in germ cell development.

Large Epiphrenic Diverticula: A Rare Case Presentation.

A 70-year old female was admitted to hospital with heartburn and chronic halitosis since 5 years. She was on proton pump inhibitors for the same. Her complaints worsened during the last one-year. Workup comprising of esophago-gastro-duodenoscopy, esophageal manometry, 3D computed tomography scan showed right-sided epiphrenic diverticula measuring 10x10 cm with wide mouth about 5 cm with hypertensive lower esophageal sphincter. Patient underwent a video assisted thoracoscopic surgery for esophageal diverticulectomy using two 45 mm staplers. On day 5, the patient developed leak, which was managed by a covered esophageal stent placement. Patient started on oral feeds from day 3 and the esophageal leak healed completely within 2 weeks. Literature suggests that esophageal leaks treated conservatively took approximately 30-40 days on an average for healing. Literature search did not reveal esophageal leak managed by stent with faster recovery (2 weeks). This is one of the largest epiphrenic diverticuli reported in literature.

Anterior mandibular ameloblastoma.

Ameloblastoma is a benign odontogenic tumor. These are usually asymptomatic until a large size is attained. Ameloblastoma has tendency to spread locally and has a high recurrence rate. Majority of ameloblastomas (80%) arise from the mandible. Ameloblastoma arising from anterior mandibular region (symphysis-menti) is rare. Very few cases of midline anterior ameloblastomas are reported in the literature. They often require wide local excision. Reconstruction of mandible in these cases is challenging. We present a case of mandibular ameloblastoma arising from symphysis-menti. Patient underwent wide surgical excision of the tumor followed by immediate reconstruction using free fibular vascular flap, stabilized with titanium reconstructive plates. A brief case report ands review of literature is presented.