Thoracoscopic and endovascular management of retained haemothoarx associated with an intercostal artery pseudoaneurysm.

Intercostal artery pseudoaneurysm (IAP) is a rare entity and may complicate a percutaneous intervention through an intercostal space or follow thoracic trauma. Its rupture into the pleural space can give rise to haemothorax, which if untreated may lead to a retained haemothorax (RH). Traditionally both the IAP and the RH are managed by a thoracotomy. We report a patient who developed an IAP with haemothorax following a trauma. The diagnosis was established by computed tomography. The patient was treated by endovascular embolisation of the IAP followed by thoracoscopic decortications of the RH.

Ventral hernia repair in India: a Delphi consensus.

PURPOSE: While research on inguinal hernias is well-documented, ventral/incisional hernias still require investigation. In India, opinions on laparoscopic ventral hernia repair (LVHR) techniques are contested. The current consensus aims to standardize LVHR practice and identify gaps and unfulfilled demands that compromise patient safety and therapeutic outcomes. METHODS: Using the modified Delphi technique, panel of 14 experts (general surgeons) came to a consensus. Two rounds of consensus were conducted online. An advisory board meeting was held for the third round, wherein survey results were discussed and the final statements were decided with supporting clinical evidence. RESULTS: Experts recommended intraperitoneal onlay mesh (IPOM) plus/trans-abdominal retromuscular/extended totally extraperitoneal/mini- or less-open sublay operation/transabdominal preperitoneal/trans-abdominal partial extra-peritoneal/subcutaneous onlay laparoscopic approach/laparoscopic intracorporeal rectus aponeuroplasty as valid minimal access surgery (MAS) options for ventral hernia (VH). Intraperitoneal repair technique is the preferred MAS procedure for primary umbilical hernia < 4 cm without diastasis; incisional hernia in the presence of a vertical single midline incision; symptomatic hernia, BMI > 40 kg/m2, and defect up to 4 cm; and for MAS VH surgery with grade 3/4 American Society of Anaesthesiologists. IPOM plus is the preferred MAS procedure for midline incisional hernia of width < 4 cm in patients with a previous laparotomy. Extraperitoneal repair technique is the preferred MAS procedure for L3 hernia < 4 cm; midline hernias < 4 cm with diastasis; and M5 hernia. CONCLUSION: The consensus statements will help standardize LVHR practices, improve decision-making, and provide guidance on MAS in VHR in the Indian scenario.

Breakage of fascial closure device during laparoscopic surgery.

Breakage of instruments during laparoscopic surgery is rare. However, when it does occur, locating and retrieving the broken part of the instrument can be cumbersome. Moreover, inability to do so may carry serious medicolegal implications. We report a patient in whom the tip of a fascial closure device broke during laparoscopic surgery. This was located by intraoperative fluoroscopy and retrieved from the extraperitoneal plane via a small incision. The paper discusses the probable factors responsible for breakage of the fascial closure device in our patient and reviews the previously reported cases of the rare complication of breakage of instruments during laparoscopic surgery.

Benign cystic peritoneal mesothelioma.

The well defined but rare entity of benign cystic mesothelioma is reported. The aetiology of this neoplasm remains obscure. The presenting features make a precise preoperative diagnosis difficult; information provided by computed tomography and cytology may help. A firm diagnosis can only come from electron microscopic or immunohistochemical examination of the tumour. Diagnostic accuracy and diligent follow up are essential because, although the tumour is considered benign, it does tend towards local recurrence.

Laparoscopic drainage of a peripancreatic tuberculous abscess.

A 28-year-old woman presented with abdominal pain, anorexia, low-grade pyrexia, and a palpable abdominal lump. An abdominal CT scan revealed a mass in the region of the pancreatic head comprised of enlarged lymph nodes interspersed with loculi of pus. Because a fine-needle aspiration failed to establish a diagnosis, the abscess was drained laparoscopically and biopsy specimens were obtained; the specimens confirmed lymph nodal tuberculosis. Postoperatively, the patient received a 9-month course of antitubercular therapy; she remains asymptomatic on follow-up. To the best of our knowledge, this is the first report describing the use of laparoscopy for the drainage of a peripancreatic tuberculous abscess.

Laparoscopic ureterolysis and reconstruction of a retrocaval ureter.

A 32-year-old man was investigated for repeated episodes of right-sided flank pain. Ultrasonography showed a dilated right pelvicalyceal system and upper ureter as well as multiple gallstones; subsequent intravenous urogram demonstrated a retrocaval ureter. At surgery, a right-sided double-J ureteric stent was placed under fluoroscopic guidance. Initially, three laparoscopic ports were used. The dilated pelvis and upper ureter were mobilized, followed by the lower ureter. The pelvis was transected and transposed anterior to the inferior vena cava. Reconstruction was carried out with an intracorporeally sutured anastomosis over the double-J stent. A fourth port was added for completion of cholecystectomy. The patient had an uneventful recovery and was discharged on the third day. Fourteen months later he remains well, with a recent intravenous urogram showing regression of hydronephrosis. We review the previously reported cases of laparoscopic and retroperitoneoscopic reconstruction of retrocaval ureter to compare and contrast these minimal access approaches.

Intrahepatic subcapsular hematoma complicating laparoscopic cholecystectomy.

A 64-year-old woman underwent endoscopic retrograde cholangiopancreatography for bile duct stones, followed 2 days later by an uneventful laparoscopic cholecystectomy. She presented after 10 days with upper abdominal discomfort, nausea, and pyrexia. Investigations revealed a decrease in hemoglobin, and computed tomography identified a large intrahepatic subcapsular hematoma in segments V and VI. There was no intraabdominal collection and the rest of the viscera were normal. The collection was drained percutaneously under ultrasound guidance and a wide-bore catheter placed. She was treated with intravenous antibiotics and the catheter was removed 14 days later upon cessation of drainage. Serial ultrasonographic examinations showed a reduction in the size of the hematoma and complete resolution at 4 months. She remained well and asymptomatic at follow-up 16 months later. We report this case due to its rarity and review the previously documented cases of this complication.

Laparoscopically guided transperitoneal percutaneous nephrolithotomy for calculi in pelvic ectopic kidneys.

Although percutaneous nephrolithotomy is a well-established endourological modality for the management of calculi in the normally placed kidney, it is not easy to apply in the management of calculi in pelvic ectopic kidneys. We report the cases of three patients who were found to have large calculi in pelvic ectopic kidneys and subsequently underwent laparoscopically guided transperitoneal percutaneous nephrolithotomy, all with successful outcome. In all patients, complete stone clearance was achieved in a single operation with no intraoperative or postoperative morbidity. They remain asymptomatic and recurrence-free at a follow-up ranging from 2 to 38 months. Laparoscopic guidance allows the transperitoneal route to be used safely for percutaneous nephrolithotomy in patients with calculi in pelvic ectopic kidneys. We believe it to be a feasible, safe, and valid minimally invasive management option for this uncommon but challenging urological condition.

Port-site infection with Mycobacterium chelonei following laparoscopic appendicectomy.

We report a 14-year-old girl who developed port-site infection with Mycobacterium chelonei following laparoscopic appendicectomy. She was treated with local exploration and excision of sinuses that developed at the site, followed by antibacterial agents for six months. She has had no recurrence of infection at two years.

Laparoscopic gastropexy for chronic intermittent gastric volvulus.

The traditional surgical treatment of chronic gastric volvulus involves laparotomy for derotation of the stomach and its fixation to the patients. We describe a 36-year-old man with organoaxial gastric volvulus who was treated successfully with laparoscopic gastropexy. He is asymptomatic four months later.

Laparoscopic cholecystectomy in India.

The first 100 cases of laparoscopic cholecystectomy carried out in a "developing country" are studied. There were 77 females and 23 males. The mean age was 48 years (24-82 years). There was no mortality and 2% morbidity. The mean operative time was two hours and 15 minutes in the first 50 cases, one hour and 50 minutes in the subsequent 50. Twelve cases were converted to open surgery, nine within the first 50 cases, three in the subsequent 50. In developing countries the challenge of financial constraints as also a different spectrum of abdominal pathology calls for greater efforts of innovation and improvization. However, the rewards of laparoscopic cholecystectomy as compared to open cholecystectomy are significant in developing countries in terms of shorter hospitalisation (3.6 vs. 13 days), early return to work (12 vs. 36 days), better hospital bed utilization, and reduced expense.

Laparoscopic management of complicated ventriculoperitoneal shunts.

Intra-abdominal migration of the catheter and formation of a cerebrospinal fluid pseudocyst are both rare complications of a ventriculoperitoneal shunt. Traditionally, each condition is treated by a formal laparotomy. Laparoscopic management of the complications in two patients is described.

Laparoscopic biopsy in patients with abdominal lymphadenopathy.

BACKGROUND: Abdominal lymphadenopathy (AL) - a common clinical scenario faced by clinicians - often poses a diagnostic challenge. In the absence of palpable peripheral nodes, tissue has to be obtained from the abdominal nodes by image-guided biopsy or surgery. In this context a laparoscopic biopsy avoids the morbidity of a laparotomy. AIM: This retrospective analysis of prospectively collected data represents our experience with laparoscopic biopsy of abdominal lymph nodes. MATERIALS AND METHODS: Between October 2000 and November 2005, 28 patients with AL underwent laparoscopic biopsy. Pre-operative radiological imaging studies had identified a nodal mass in 20, a solitary node in 1, a cold abscess in 1 and a mesenteric cystic lesion in 1 patient. In five patients with chronic right lower abdominal pain and normal ultra-sonographic findings mesenteric nodes were identified and biopsied during diagnostic laparoscopy. RESULTS: The sites of biopsied lymph nodes included para-aortic (10), mesenteric (8), external iliac (3), left gastric (2), obturator (1), aorto-caval (1) and porta hepatis (1). One patient with enlarged peripancreatic nodes mass and another with a mesenteric cystic mass had cold abscesses drained in addition to biopsy. There were no perioperative complications and the median postoperative stay was 2 days (range 1-4 days). Histopathology revealed tuberculosis in 23 patients, reactive adenitis in 2, lymphoma in 1 metastatic carcinoma in 1, and a retroperitoneal sarcoma in 1. CONCLUSIONS: In patients with AL, laparoscopy provides a safe and effective means of obtaining biopsy. It is of particular value in patients in whom (a) the nodes are small or present in locations unsuitable for image-guided biopsy, (b) adequate tissue cannot be obtained by image-guided biopsy or (c) previously undiagnosed lymphadenopathy is encountered during diagnostic laparoscopy.

Carcinoma of the breast at the site of migrated pacemaker generators.

We report two patients in whom breast malignancy developed in the proximity of 'migrated' pacemaker generators. These cases and the similar ones reported in the literature raise concerns whether this association is merely coincidental or whether the pacemaker generator is responsible for the occurrence in some inexplicable manner. We urge for a routine, careful examination in all patients with implanted pacemaker generators at follow-up visits. This would help in (a) timely detection of migration of the pacemaker generators and (b) earlier diagnosis of any mass developing close to the migrated generators.

Quest for continence: surgery for ulcerative colitis and familial adenomatous polyposis.

In the past decade pelvic pouch procedure (restorative proctocolectomy) has become the surgical treatment of choice for ulcerative colitis and most cases of familial adenomatous polyposis. It is an operation that eradicates disease yet restores gastrointestinal continuity and maintains continence.