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   Table of Contents - Current issue
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October-December 2017
Volume 13 | Issue 4
Page Nos. 243-326

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REVIEW ARTICLE  

Robotics in general surgery: A systematic cost assessment Highly accessed article p. 243
Ioannis D Gkegkes, Ioannis A Mamais, Christos Iavazzo
DOI:10.4103/0972-9941.195565  PMID:28000648
The utilisation of robotic-assisted techniques is a novelty in the field of general surgery. Our intention was to examine the up to date available literature on the cost assessment of robotic surgery of diverse operations in general surgery. PubMed and Scopus databases were searched in a systematic way to retrieve the included studies in our review. Thirty-one studies were retrieved, referring on a vast range of surgical operations. The mean cost for robotic, open and laparoscopic ranged from 2539 to 57,002, 7888 to 16,851 and 1799 to 50,408 Euros, respectively. The mean operative charges ranged from 273.74 to 13,670 Euros. More specifically, for the robotic and laparoscopic gastric fundoplication, the cost ranged from 1534 to 2257 and 657 to 763 Euros, respectively. For the robotic and laparoscopic colectomy, it ranged from 3739 to 17,080 and 3109 to 33,865 Euros, respectively. For the robotic and laparoscopic cholecystectomy, ranged from 1163.75 to 1291 and from 273.74 to 1223 Euros, respectively. The mean non-operative costs ranged from 900 to 48,796 from 8347 to 8800 and from 870 to 42,055 Euros, for robotic, open and laparoscopic technique, respectively. Conversions to laparotomy were present in 34/18,620 (0.18%) cases of laparoscopic and in 22/1488 (1.5%) cases of robotic technique. Duration of surgery robotic, open and laparoscopic ranged from 54.6 to 328.7, 129 to 234, and from 50.2 to 260 min, respectively. The present evidence reveals that robotic surgery, under specific conditions, has the potential to become cost-effective. Large number of cases, presence of industry competition and multidisciplinary team utilisation are some of the factors that could make more reasonable and cost-effective the robotic-assisted technique.
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ORIGINAL ARTICLES Top

Hand-assisted laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis p. 256
Pengcheng Zhu, Chungen Xing
DOI:10.4103/jmas.JMAS_230_16  PMID:28695880
Introduction: In this study, we aimed to evaluate the feasibility and safety of undergoing restorative proctocolectomy through ileal pouch-anal anastomosis (RPC-IPAA) with hand-assisted laparoscopic (HALS) in patients with ulcerative colitis (UC). Patients and Methods: We reviewed 40 consecutive patients who underwent RPC-IPAA with HALS or open technique for treatment of UC between 2010 and 2013. Moreover, the intra-/post-operative outcomes were compared. Results: We found the median operative time was significantly longer in the HALS group while the blood loss was significantly less in patients with HALS than with open surgery. In the HALS group, the median duration of bed rest and the length of hospital stay were significantly shorter. Moreover, the rate of early post-operative complications in the HALS group was significantly less than that in the open surgery group, among which one patient died in the 30th day after surgery for the extensive use of steroids before the operation. Conclusion: These findings clearly show that HALS RPC is safe and less invasiveness. HALS can become a more comfortable and standardised procedure for UC with the adoption of evolving technologies.
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Laparoscopic excision of the choledochal cyst in adult patients: An experience p. 261
Hirdaya Hulas Nag, Kshitij Sisodia, Pushap Sheetal, Hari Govind, Som Chandra
DOI:10.4103/jmas.JMAS_159_16  PMID:28872095
Background: Laparoscopic choledochal cyst excision (LCCE) in adult patients is not common. Aims: The aim is to report our experience of LCCE in adult patients. Patients and Methods: This study includes a retrospective review of twenty adult patients (age >18 years) with choledochal cyst (CC) who underwent LCCE by a single surgical team from February 2011 to April 2016. Results: The mean age was 45.5 years. Nineteen (95%) patients had Type-I CC, and one patient (5%) had Type-IV CC (Todani's classification). Fifteen patients (75%) presented with pain in the abdomen, and five patients (25%) presented with jaundice and/or cholangitis. LCCE was successful in 16 (80%) patients, whereas four patients (20%) required conversion to open method. The reason for conversion was technical difficulty due to the initial learning curve, adhesion and inflammation. The mean blood loss, operation time and post-operative stay were 117.5 ml, 299.5 min and 8.15 days, respectively. Bilioenteric anastomosis leak and formation of pseudoaneurysm occurred in one patient (5%); this patient later died due to uncontrolled intra-abdominal haemorrhage. There were no remote complications during a mean follow-up of 17.2 months. Conclusion: LCCE in adult patients is safe and feasible, but bilioenteric anastomosis leak may have fatal consequences.
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Institutional experience with laparoscopic-assisted anorectal pull-through in a series of 17 cases: A retrospective analysis p. 265
Madhu Ramasundaram, Jegadeesh Sundaram, Prakash Agarwal, Raj Kishore Bagdi, Selvapriya Bharathi, Apurva Arora
DOI:10.4103/jmas.JMAS_254_16  PMID:28695882
Aims: To retrospectively analyse the results of laparoscopically-assisted anorectal pull-through (LAARP) for high anorectal malformation (ARM) in male children in our institution. Materials and Methods: We analysed the hospital records of patients who had undergone LAARP from October 2010 to December 2015 in terms of age, operative time, length of hospital stay and post-operative complications. Results: Of 17 cases, 13 (76%) were in 6–12 months age group, whereas rest of them were in 12–18 months age group. The recto-prostatic urethral fistula was encountered in 82% (n = 14) of patients and rectovesical type in two cases (12%). The mean operative time was 132 min with mean length of hospital stay being 4 days. Rectal mucosal prolapse was the most common complication noted. Conclusions: LAARP is a feasible approach to male children with high ARMs with less post-operative morbidity.
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Endoscopic gastric polypectomy assisted by laparoscopy for giant gastric and duodenal lesion treatment: Case series from two centres p. 269
Luis Alberto Topete-Gonzalez, Morris E Franklin, Jorge Ernesto Balli-Martinez, Jan Lammel-Lindemann, Sofia Perez-Banuet-Farell, Orestes Valles-Guerra, Eduardo Flores-Villalba
DOI:10.4103/jmas.JMAS_15_17  PMID:28695877
Background: Endoscopy has developed rapidly, generating new challenges. Today, there are several procedures done endoscopically with very good results. In the past, the assisted laparoscopic colon polypectomy has been described, reducing the morbidity of a bigger procedure. Nonetheless, little has been said about the use of hybrid surgery in the management of gastric or duodenal polyps. Objectives: Evaluating the safety and efficacy of the assisted laparoscopic gastric endoscopic polypectomy. Patients and Methods: A retrospective review of the database at our two centres was performed from 1996 to 2014. Thirteen patients were found in whom an assisted laparoscopic gastric or duodenal endoscopic tumour resection was performed. Results: Thirteen patients, eight males and five females, with a median age of 61 years and average body mass index of 29.3. The procedure was done effectively and no need for further procedures was required for any patient. No complications were reported in the early post-operative period. Conclusions: The study shows that assisted laparoscopic gastric endoscopic polypectomy is a feasible and safe procedure that can be used for the management of giant polyps, which cannot be resected with the classical endoscopic polypectomy reducing the morbidity and complications associated with larger procedures.
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Clinical reappraisal of vasculobiliary anatomy relevant to laparoscopic cholecystectomy p. 273
Kuldip Singh, Ranbir Singh, Manjot Kaur
DOI:10.4103/jmas.JMAS_268_16  PMID:28872096
Background: Laparoscopic cholecystectomy (LC) has many advantages as compared to open cholecystectomy. However, vasculobiliary injuries still continue to be a matter of concern despite advances in laparoscopic techniques. Misidentification and misperception of vasculobiliary structures is considered to be a pivotal factor leading to injuries. Although many studies since time immemorial have stressed on the importance of anatomy, an insight into laparoscopic anatomy is what essentially constitutes the need of the hour. Objective: To assess the frequency and the relevance of anatomical variations of extrahepatic biliary system in patients undergoing LC. Materials and Methods: The present study is an observational study performed for a period of 2 years from August 2014 to August 2016. It included all diagnosed patients of cholelithiasis undergoing routine LC performed by a single surgeon by achieving a critical view of safety. During dissection, vascular and ductal anomalies were noted and assessed for their relevance in LC. Results: Seven hundred forty cases of cholelithiasis, irrespective of pathology, comprising 280 (37.83%) men and 460 (62.16%) females with a mean age of 39.85 ± 18.82 years were included in the study. Photodocumentation and operative recordings were available in 93% of cases. Operative findings revealed 197 (26.62%) vascular anomalies and 90 (12.16%) ductal anomalies. A single cystic artery was seen in 340 cases, and a normal cystic duct was seen in 650 cases. Variations in ductal anatomy were fewer than variations in vascular anatomy. Conclusion: Extra-biliary anatomy relevant to LC is unpredictable and varies from patient to patient. Vascular anomalies are more frequent than the ductal anomalies, and surgeon should be alert regarding their presence.
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Robot-assisted thyroidectomy using a gasless, transaxillary approach for the management of thyroid lesions: Indian experience p. 280
SP Somashekhar, KR Ashwin
DOI:10.4103/jmas.JMAS_42_16  PMID:28872097
Aim: Since last decades, more and more thyroidectomies have been performed by the minimally invasive method. Compared to conventional thyroidectomy, minimally invasive thyroidectomy has a superior cosmetic result. However, the outcome depends, in a large extent, on the skill of the operator and the learning curve is relatively long. Robotic thyroidectomy (RT) is a relatively new approach in treating thyroid lesions with improved ergonomics and surgical outcomes. Purpose: We performed a prospective study of robotic-assisted transaxillary approach for thyroidectomy in Indian patients to examine the feasibility of the procedure. Materials and Methods: A total of 35 patients underwent RT. Demographics, surgical indications, operative findings, postoperative functional outcome, local complications and pathological outcomes were recorded and analyzed. Results: The median age of the cohort was 28.6 years and 31 of the patients were women. The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). Eighteen patients underwent less than total thyroidectomy and 17 patients underwent total thyroidectomy, with no conversion. The mean console time standard deviation was 115 min initially, and with experience, it reduced to 106 min for subsequent cases. The mean blood loss was 13 ml. Post-operative outcome was good with no serious complication noted in our series. Conclusion: Robotic-assisted thyroidectomy using a gasless transaxillary approach is a feasible, safe and noninferior surgical alternative for selected patients. We believe with time RT will be widened and it will be performed more often.
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Is a diagnostic video-assisted thoracoscopic thymectomy an acceptable first-line approach to the suspicious anterior mediastinal mass? p. 286
Ricky Vaja, Vijay Joshi, Alan G Dawson, David A Waller
DOI:10.4103/jmas.JMAS_113_15  PMID:28872098
Introduction: The incidental early-stage thymic mass presents a diagnostic challenge. Video-assisted thoracoscopic (VAT) thymectomy is an attractive but potentially morbid solution. The aim was to show it can be safely applied as a first-line modality in those with undiagnosed thymic enlargement with acceptable long-term results. Methods: A total of 45 patients were identified (24 male, median age 52 interquartile range [IQR]: 41–66 years) in a 14-year experience who had CT evidence of an enlarged, possibly malignant thymic mass, but no tissue diagnosis before undertaking VAT thymectomy. The clinical outcomes of both benign and malignant diagnoses were compared. Results: Myasthenic symptoms were present in 20 patients (44%), whereas 15 (33%) were asymptomatic. Benign lesions were resected in 27 patients (60%): thymic hyperplasia (56%), thymic cyst (33%), lipoma (7%) and xanthogranulomatous inflammation (4%). Of the 18 malignant patients, 82% had thymoma (three had Masaoka Stage I, 11 Stage II and one Stage III), 6% thymic carcinoma, 6% teratoma and 6% seminoma. Seven patients required radiotherapy for R1 resection. There was no difference in median hospital stay in either group: Benign group: 4 versus 5 days (P = 0.07). One patient in both groups required conversion to open. Two patients in the malignant group had significant morbidity (one myocardial infarction and one pulmonary embolism). There were no cases of tumour recurrence or mortality at a median follow-up of 6.6 years (IQR: 4.4–9.5 years). Conclusion: Right-sided diagnostic VAT thymectomy is a safe and effective first-line approach to suspected malignant thymic enlargement. At 5-year follow-up, there were no cases of recurrence in the malignant group.
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Impact of bariatric surgery on obstructive sleep apnoea–hypopnea syndrome in morbidly obese patients p. 291
Pratyusha Priyadarshini, Vijay Pal Singh, Sandeep Aggarwal, Harshit Garg, Sanjeev Sinha, Randeep Guleria
DOI:10.4103/jmas.JMAS_5_17  PMID:28872099
Background: Obstructive sleep apnea (OSA) is commonly associated with morbid obesity. Weight loss following bariatric surgery results in resolution or improvement of OSA. However, few studies have done objective assessment of the impact of bariatric surgery on OSA. Objective: The aim of this study was to assess the outcome of bariatric surgery on OSA. Setting: The study was conducted in the teaching institution of a tertiary care centre. Methods: Twenty-seven morbidly obese patients seeking bariatric surgery were administered Epworth Sleepiness Scale (ESS) health questionnaire and subjected to overnight polysomnography. Repeat assessment using ESS and polysomnography was done at 3–6 months after surgery. Results: Mean age was 42.4 ± 10.5 years, and majority (77.8%) were female. The mean pre-operative weight and body mass index (BMI) were 126.4 ± 24.9 kg and 48.4 ± 8.2 kg/m2, respectively. Nearly 29.6% patients had symptoms of excessive daytime somnolence based on ESS score and overnight polysomnography detected the presence of OSA in 96.3% patients, of which 51.9% had severe OSA. At mean follow-up of 5.2 ± 2.5 months after surgery, mean weight and BMI decreased to 107.4 ± 24.5 kg and 41.2 ± 8.2 kg/m2, respectively. Mean ESS score and mean apnoea–hypopnea index declined from 8.9 ± 3.2 to 4.03 ± 2.15 (P < 0.001) and from 31.8 ± 20.4 to 20.2 ± 23.1 (P = 0.007), respectively. Number of patients requiring continuous positive airway pressure (CPAP) therapy declined from 15 to 3 and average CPAP requirement came down from 11.3 cm of H2O to 6 cm of H2O. Conclusion: OSA was present in a significant proportion of patients undergoing bariatric surgery. Bariatric surgery resulted in significant improvement in both subjective and objective parameters of OSA.
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Comparison of mid-term clinical outcomes of laparoscopic partial cystectomy versus conventional partial cystectomy for the treatment of hepatic hydatid cyst p. 296
Ilhan Ece, Huseyin Yilmaz, Serdar Yormaz, Bayram Çolak, Fahrettin Acar, Husnu Alptekin, Mustafa Sahin
DOI:10.4103/jmas.JMAS_238_16  PMID:28872100
Background: The aim of this study was to compare the mid-term outcomes of open and laparoscopic partial cystectomy (LPC). Methods: The medical records of patients who underwent conventional partial cystectomy (CPC) and LPC for liver hydatid cyst from May 2010 to February 2015 were retrospectively reviewed. Operative time, blood loss, length of hospital stay, post-operative morbidity, mortality and mid-term follow-up outcomes were evaluated. Results: Amongst 130 patients, 38 patients were underwent LPC and 92 underwent CPC. Blood loss and post-operative complications were similar in both groups. The mean operative time in the LPC and the CPC groups was, respectively, 95.4 ± 13.1 and 63.5 ± 15.6 min, which showed a significant difference between the both groups. The mean length of hospital stay in CPC group was significantly longer when compared the LPC group. The mean diameter of cyst in LPC group was 6.1 ± 1.1 cm and 7.8 ± 2.1 cm in CPC group with a significant difference. The overall complication rates were 13.1% in LPC group and 17.3% in CPC group without significant difference. The most common complication was biliary leakage and surgical site infection. Conclusion: LPC for the surgical treatment of liver hydatid cyst appears to be safe and effective method with low morbidity rates in selected patients.
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UNUSUAL CASES Top

Laparoscopic excision of leiomyosarcoma of inferior vena cava p. 303
Pravin Rajendra Suryawanshi, Mohit Munesh Agrawal
DOI:10.4103/jmas.JMAS_152_16  PMID:28782739
Leiomyosarcoma of inferior vena cava (IVC) is a rare soft tissue tumour. Only 0.5% of all soft tissue sarcomas of adults and only 300 cases are reported till date. We describe our encounter with such a case where we were successful in radical excision of tumour with the use of vascular staplers on the IVC without compromising IVC lumen. Leiomyosarcoma of IVC is a rare entity, and laparoscopic excision of the tumour is possible in exophytic tumour.
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Thoracoscopic management of oesophageal mucocele: Old complication, new approach p. 306
Vijayaraj Pavankumar, Raja Kalayarasan, Chandrasekar Sandip, Pottakkat Biju
DOI:10.4103/jmas.JMAS_118_16  PMID:28695874
Oesophageal mucocele is an uncommon complication of bipolar exclusion of oesophagus. Traditionally, this condition is managed through thoracotomy which is associated with significant morbidity. The present report outlines the thoracoscopic management of oesophageal mucocele following surgical exclusion for oesophageal perforation. Left thoracoscopic oesophagectomy for oesophageal mucocele described in this report has not been published earlier.
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Laparoscopic splenectomy for sclerosing angiomatoid nodular transformation of the spleen p. 309
Matilda Bushati, Antonio Sommariva, Maria Cristina Montesco, Carlo Riccardo Rossi
DOI:10.4103/jmas.JMAS_95_16  PMID:28695885
Sclerosing angiomatoid nodular transformation (SANT) is a rare, benign, proliferative vascular lesion that arises from the splenic red pulp. Most patients with SANT have no clinical symptoms and are discovered incidentally on imaging. There are no definitive radiological signs and a distinction from other splenic diseases, and malignant processes remain difficult. Confirmation of the diagnosis of SANT requires a histological and immunohistochemical evaluation of the resected spleen. Here, we report an unusual case of SANT of the spleen successfully treated with an elective laparoscopic splenectomy (LS). LS is a safe and effective method for diagnosis of SANT.
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A case report of modified laparoscopic keyhole plus repair for parastomal hernia following ileal conduit p. 312
S Rajapandian, Samrat V Jankar, Sumanta Dey, Vikram Annamaneni, Sandeep C Sabnis, S Sathiymurthy, R Parthsarathi, P Praveen Raj, P Senthilnathan, C Palanivelu
DOI:10.4103/jmas.JMAS_249_16  PMID:28695881
Parastomal hernia is one of the most common but challenging complication after stoma formation. Modified Sugarbaker technique is the recommended procedure for repair parastomal hernia, however, keyhole repair technique had also been used in certain instances. In cases of parastomal hernia following ileal conduit procedure, the Sugarbaker technique is been described, although with associated theoretical risk of conduit failure. We are reporting a case of post-radical cystectomy with ileal conduit presented with symptomatic large parastomal hernia. Laparoscopic modified keyhole plus repair has been done successfully in this patient with no recurrence in 2 years of follow-up. The purpose of our case report is to describe our novel modification of the laparoscopic keyhole technique which can be a feasible and acceptable alternative surgical method in these types of patients.
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Laparoscopic excision of rare case of recurrent presacral teratoma p. 315
S Rajapandian, Samrat V Jankar, Bhushan Chittawadgi, Siddhartha Bhattacharya, Sandeep C Sabnis, R Sathyamoorthy, R Parthasarathi, P Senthilnathan, P Praveen Raj, C Palanivelu
DOI:10.4103/0972-9941.199213  PMID:28872101
Tumours of the presacral space are rare to present. Most of them are benign masses, very rarely malignant. Surgery is the mainstay of treatment as it establishes the diagnosis and prevents the adverse consequences associated with malignant degeneration and secondary bacterial infection. Their surgical excision is often difficult because of their anatomic location. Very few cases have been reported so far concerning a laparoscopic management of presacral tumour. We hereby present a young girl with recurrent presacral teratoma. She underwent laparoscopic successful excision of tumour with uneventful post-operative recovery. Here, we are highlighting the importance of laparoscopic approach for this scenario in terms additional advantages of minimally invasive approach such as better visualisation of the deep structures in the narrow presacral space, precise dissection in a limited space between the tumour and neighbouring structures with avoiding injury to neurovascular structure.
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HOW I DO IT DIFFERENTLY? Top

Gall bladder flip technique in laparoscopic cholecystectomy p. 318
Munish Sharma, Anubhav Vindal, Pawanindra Lal
DOI:10.4103/jmas.JMAS_84_17  PMID:28782749
Background: The precise steps for the removal of gall bladder from the gall bladder bed are not well standardised. The dissection becomes more difficult near the fundus where the assistant's grasper holding the fundus creates a 'tug of war' like situation. Materials and Methods: This is a description of a simple technique that aids in accurate dissection of the gallbladder from liver bed. As the gallbladder dissection approaches fundus and more than two-third of gallbladder is dissected from liver bed, the medial and lateral peritoneal folds of gall bladder are further incised. The assistant is asked to leave the traction from the gallbladder fundus, while the surgeon holds the dissected surface of gall bladder around 2–3 cm away from its attachment with liver and flip it above the liver. Further dissection is carried out using a hook or a dissector till it is disconnected completely from the liver bed. Results: We have employed 'Flip technique' in around 645 consecutive cases of laparoscopic cholecystectomy operated in the past 3 years. Only one case of liver bed bleeding and two cases of injury to gall bladder wall were noted during this part of dissection in this study. Ease of dissection by surgeons was rated as 9.6 on a scale of 1–10. Conclusion: Gallbladder 'Flip technique' is a simple and easily reproducible technique employed for dissection of gall bladder from liver bed that reduces complications and makes dissection easier.
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IMAGES IN LAPAROSCOPY Top

Single-incision laparoscopic excision of symptomatic accessory spleen in the pelvis: An initial report p. 321
Toru Obuchi, Akinori Takagane, Kei Sato, Hitoshi Yonezawa, Osamu Funato, Makoto Kobayashi
DOI:10.4103/0972-9941.199212  PMID:28872102
An accessory spleen (AS) is commonly located near the spleen's hilum and/or in the pancreas tail. However, a symptomatic AS is rarely found in the pelvis. We present a resected case with lower abdominal pain whose final diagnosis was symptomatic AS caused by torsion in the pelvis. An 18-year-old man was presented to our hospital with lower abdominal pain. Enhanced abdominal computed tomography showed an inflammatory mass with a cord-like band in the pelvic space. We finally diagnosed pelvic neoplasm and performed single-incision laparoscopic surgery (SILS) using an access platform. SILS of these tumours located on a pelvic lesion has never been reported; this is the first report of torsion of a pelvic AS. SILS for AS is a safe, feasible procedure, even when the AS lays in the pelvic space.
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LETTERS TO THE EDITOR Top

Mini gastric bypass: Un-answered questions p. 323
Ramen Goel
DOI:10.4103/jmas.JMAS_10_17  PMID:28872103
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Are objections to one anastomosis/mini gastric bypass scientific? p. 325
Kamal K Mahawar
DOI:10.4103/jmas.JMAS_28_17  PMID:28872104
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04