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   Table of Contents - Current issue
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July-September 2019
Volume 15 | Issue 3
Page Nos. 185-280

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SYSTEMATIC REVIEW  

The unwanted third wheel in the Calot's triangle: Incidence and surgical significance of caterpillar hump of right hepatic artery with a systematic review of the literature p. 185
Luigi Marano, Alberto Bartoli, Karol Polom, Raffaele Bellochi, Alessandro Spaziani, Giampaolo Castagnoli
DOI:10.4103/jmas.JMAS_75_18  PMID:29737324
Background: Caterpillar hump of the right hepatic artery is a rare variation increasing the risk of vascular and biliary injuries during hepatobiliary surgery. The aim of this study is to record the cases of the right hepatic artery forming caterpillar hump in a cohort of patients underwent laparoscopic cholecystectomy and to report a review of the literature systematically conducted. Methods: We reviewed clinical and surgical video data of 230 patients with symptomatic cholelithiasis treated with laparoscopic cholecystectomy between January 2016 and August 2017. A systematic literature search in PubMed, Medline, Cochrane and Ovid databases until 30th June 2017 was also performed in accordance with the PRISMA statement. Results: Our institutional data indicated that 1.3% of 230 patients presented caterpillar hump right hepatic artery. The systematic review included 16 studies reporting data from a total of 498 human cadavers and 579 patients submitted to cholecystectomy. The overall proportion of surgical patients with the caterpillar hump right hepatic artery was 6.9%. Conclusions: Variations of the cystic artery are not just an anatomical dissertation, assuming a very crucial role in surgical strategies to avoid uncontrolled vascular lesions. A meticulous knowledge of the hepatobiliary triangle in association with all elements of 'Culture of Safety in Cholecystectomy' is mandatory for surgeons facing more than two structures within Calot's triangle.
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ORIGINAL ARTICLES Top

Clip-stone and T clip-sinus: A clinical analysis of six cases on migration of clips and literature review from 1997 to 2017 Highly accessed article p. 192
Liwei Pang, Jindong Yuan, Yan Zhang, Yuwen Wang, Jing Kong
DOI:10.4103/jmas.JMAS_53_18  PMID:29794362
Introduction: With the development of laparoscopic skills, the laparoscopic common bile duct exploration (LCBDE) and laparoscopic cholecystectomy (LC) has become the standard surgical procedure for choledocholithiasis. We usually use Hem-o-lok clips to control cystic duct and vessels, which is safe on most occasions and has few perioperative complications such as major bleeding, wound infection, bile leakage, and biliary and bowel injury. However, a rare complication of post-cholecystectomy clip migration (PCCM) increases year by year due to the advancement and development of LC, CBD exploration as well as the wide use of surgical ligation clips. Materials and Methods: Six patients whose clips are found dropping into CBD or forming T-tube sinus after laparoscopic surgery in our department. Results: Six patients whose clips are found dropping into CBD (clip-stone) (3/6) or forming T-tube sinus (T clip-sinus) (3/6) after LCBDE or LC. Conclusions: PCCM is a rare but severe complication of LCBDE. A pre-operative understanding of bile duct anatomy, the use of the minimum number of clips and the harmonic scalpel during the surgeries is necessary. Considering clip-stone or clip-sinus in the differential diagnosis of patients with biliary colics or cholangitis after LCBDE even years after surgery, the detailed medical history and pre-operative examination are inevitable, especially for these patients who had undergone LCBDE.
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Extended totally extraperitoneal repair (eTEP) for ventral hernias: Short-term results from a single centre Highly accessed article p. 198
Sarfaraz Jalil Baig, Pallawi Priya
DOI:10.4103/jmas.JMAS_29_18  PMID:29794361
Introduction: There has been a surge of innovative procedures in the field of abdominal wall hernias. Works of pioneers such as Dr. Yuri Novitsky, Dr. Jorge Daes and Dr. Igor Belyansky have started a new era in the field of hernia surgery. Conventional and popular surgeries for ventral hernias are open onlay mesh hernioplasty, open retromuscular mesh hernioplasty (Rives-Stoppa procedure) and laparoscopic intraperitoneal mesh hernioplasty. Evidence seems to suggest that retromuscular mesh hernioplasty has advantages over other procedures regarding recurrence and surgical site occurrences. An alternative strategy has been developed for this setting where a mesh is placed in retromuscular space by minimal access technique of the extended Totally Extraperitoneal approach (eTEP). Methods: We have retrospectively analysed the data of 21 patients who underwent an eTEP procedure with a minimum follow-up of 2 months. Their data were analysed for operative details, intra-operative and post-operative complications. Results: For a total of 21 patients, we have recorded a total of two surgical site occurrences (1 seroma and 1 linea alba dehiscence) and one recurrence. One patient had chronic pain. There was no surgical site infection. Conclusion: Judging from our short-term results, we suggest that the eTEP technique can be adapted in centres with advanced laparoscopic skills with the careful patient selection.
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Initial experience with minimally invasive extended pancreatectomies for locally advanced pancreatic malignancies: Report of six cases p. 204
Tze-Yi Low, Brian K. P Goh
DOI:10.4103/jmas.JMAS_69_18  PMID:30416147
Background: Recently, there have been several reports on minimally-invasive surgery for extended pancreatectomy (MIEP) in the literature. However, to date, only a limited number of studies reporting on the outcomes of MIEP have been published. In the present study, we report our initial experience with MIEP defined according to the latest the International Study Group for Pancreatic Surgery (ISPGS) guidelines. Methods: Over a 14-month period, a total of 6 consecutive MIEP performed by a single surgeon at a tertiary institution were identified from a prospectively maintained surgical database. EP was defined as per the 2014 ISPGS consensus. Hybrid pancreatoduodenectomy (PD) was defined as when the entire resection was completed through minimally-invasive surgery, and the reconstruction was performed open through a mini-laparotomy incision. Results: Six cases were performed including 2 robotic extended subtotal pancreatosplenectomies with gastric resection, 1 laparoscopic-assisted (hybrid) extended PD with superior mesenteric vein wedge resection, 2 robotic-assisted (hybrid) PD with portal vein resection (1 interposition Polytetrafluoroethylene graft reconstruction and 1 wedge resection) and 1 totally robotic PD with wedge resection of portal vein. Median estimated blood loss was 400 (250–1500) ml and median operative time was 713 (400-930) min. Median post-operative stay was 9 (6–36) days. There was 1 major morbidity (Grade 3b) in a patient who developed early post-operative intestinal obstruction secondary to port site herniation necessitating repeat laparoscopic surgery. There were no open conversions and no in-hospital mortalities. Conclusion: Based on our initial experience, MIEP although technically challenging and associated with long operative times, is feasible and safe in highly selected cases.
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Per-operative modified rigid cholangioscopy for removal of intrahepatic stones associated with choledochal cyst in children p. 210
Vikesh Agrawal, Himanshu Acharya, Arjun Saxena, Dhananjaya Sharma
DOI:10.4103/jmas.JMAS_83_18  PMID:29794365
Introduction: Choledochal cyst (CDC) is often associated with intrahepatic stones (IHSs) in children which necessitate their removal during excision. The endoscopic equipment needed for their clearance such as paediatric flexible cholangioscope and other advanced modalities are not freely available in resource-poor setups. We describe per-operative modified rigid cholangioscopy using rigid paediatric cystoscope for stone removal during open CDC excision. Methods: All children with CDC presenting with IHSs between January 2015 and December 2017 were included in the present study. IHSs were diagnosed by ultrasound/magnetic resonance cholangiopancreatography (MRCP). In these patients, after cyst excision by open technique, a 9 Fr paediatric cystoscope with 4 Fr working channel was inserted into the common hepatic duct for visualisation and clearance of stones from (intrahepatic bile ducts). Follow-up was done using liver function tests, ultrasound and MRCP (if needed). Patients underwent three monthly liver function test and ultrasound and if needed MRCP. Results: Six cases of CDC presenting with IHS were managed, and one case with post-R-en-Y IHS was treated with this technique. Rigid paediatric cystoscope with working channel and forceps was used. All cases were successfully managed, and one case was found to have intrahepatic duct stenosis was dilated. Conclusion: Per-operative rigid endoscopy using paediatric cystoscope is an easily available tool in most of the setups for the management of IHS associated with CDC in children.
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Surgery strategy of 13 cases to control bleeding from the liver on laparoscopic repeat liver resection for recurrent hepatocellular carcinoma p. 214
Shuiping Yu, Tang Bo, Binzong Hou, Jiangfa Li, Xueling Zhou
DOI:10.4103/jmas.JMAS_214_17  PMID:29794359
Introduction: Laparoscopic repeat liver resection (LRLR) is a safe and effective treatment in recurrent hepatocellular carcinoma (rHCC) in particular patients. However, there are less reports about surgery strategy of LRLR for rHCC. The aim of this study was to perform a systematic strategy for bleeding of liver to increase the safety and feasibility of LRLR for rHCC. Methods: In this study, a total of 13 cases of LRLR for rHCC, including 8 males and 5 females; aged 28–72 years, mean age 54 years, who were received at least one laparotomy due to HCC. We employ to block the local blood flow, ligation of the left or right hepatic artery and/or approach of Pringle according to the assessment of the degree of adhesions in the abdominal and the first hepatic portal, the location of the tumour (edge/central). Results: Three cases were less adhesions, nine cases were dense adhesions but 1 case was serious adhesions. Two cases were employed to block the local blood flow, 3 cases were employed to ligation of the left or right hepatic artery and 7 cases were employed to approach of Pringle. Twelve cases were successfully completed by LRLR whereas 1 case was completed by transfer to the open resection, including massive resection in 3 cases (the diameter of resection ≥3 cm), small hepatectomy in 10 cases (the diameter of resection <3 cm), no severe perioperative complication. The average operative time was (142 ± 34) min, the average intraoperative blood loss was (251 ± 92) ml and the average post-operative hospital time was (9 ± 3) d. The mean follow-up time was 25 months. Until the last follow-up, 11 cases survived while 2 cases died because of tumour recurrence. Conclusions: It can improve the safety and feasibility of LRLR for rHCC, according to the degree of adhesion of the peritoneal adhesions and the first hepatic portal, then selecting the appropriate technique to control the bleeding of the hepatectomy.
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Laparoscopic 'steering wheel' derotation technique for midgut volvulus in children with intestinal malrotation p. 219
Vikesh Agrawal, Abhishek Tiwari, Himanshu Acharya, Rajesh Mishra, Dhananjaya Sharma
DOI:10.4103/jmas.JMAS_24_18  PMID:29737312
Introduction: Since the first description by William Ladd, the Ladd's procedure has been the surgery of choice for the correction of malrotation. The laparoscopic Ladd's procedure is becoming popular with the advent of minimal access surgery and is described in the literature. Various techniques of the Ladd's procedure have been described but none of them describes the stepwise technique for derotation of volvulus which is the most difficult and confusing part of the surgery. We describe 'steering wheel' technique for easy derotation of volvulus associated with malrotation. Method: A total of 62 patients were diagnosed to have an intestinal malrotation between 2010 and 2017. All cases which had complete non-rotation with a midgut volvulus were reviewed. Out of these, 48 patients were operated with open technique and 14 patients were subjected to the laparoscopic correction. Technique: Using three-port technique, stepwise derotation of volvulus is done which simulates the rotation of steering of car at an acute turn and has been described in four simple steps. This technique also stresses the importance of the release of Ladd's band before derotation. Results: Of 62 patients diagnosed with malrotation, 14 (22.6%) patients underwent the laparoscopic Ladd's procedure. The mean age was 26 + 8 months, mean weight was 10 + 2 kg and included eight males (57%) and six females (43%). There was only one (7.14%) conversion to open technique, due to a huge dilatation of duodenum causing difficulty in dissection in a patient with malrotation without volvulus. The laparoscopic Ladd's procedure took an average time of 70 ± 15 min. Conclusion: The laparoscopic 'steering wheel' derotation technique is easy and provides a stepwise description of the laparoscopic derotation of volvulus associated with malrotation in children.
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Laparoscopic parastomal hernia repair: A modified technique of mesh placement in Sugarbaker procedure Highly accessed article p. 224
Sameer Rege, Amiteshwar Singh, Ajinkya Rewatkar, Janesh Murugan, Richard Menezes, Shrinivas Surpam, Roshan Chiranjeev
DOI:10.4103/jmas.JMAS_17_18  PMID:29794357
Introduction: Conventional surgery for parastomal hernia entails primary suture repair or stoma relocation. Laparoscopic surgery has advantages of less pain, faster post-operative recovery and better cosmesis. While the Sugarbaker technique has been valued for least recurrences, however, it exposes the stomal loop to the parietal surface of the mesh exposing it to complications. We report a modification of mesh placement after primary defect repair to improvise the safety of meshplasty and to minimise mesh erosions into the stomal loop of bowel. Patients and Methods: Patients with permanent stoma presenting with a parastomal bulge leading to difficulty with stoma care or abdominal distention or pain were included in the study. A pre-operative computed tomography scan was performed in all patients to rule out any recurrence of primary pathology for which stoma was created and to study the abdominal musculature and defects. Results: Of 14 patients, 12 patients had end-sigmoid stoma, one had end ileostomy following surgery for ulcerative colitis and one had urinary conduit. The size of the defect varied from 4.5 cm to 6 cm in diameter, and the average duration of surgery was 125 min. Pain assessed on VAS score was higher in the first 12 h, and all were started on orals on the next day, and average hospital stay was 4.2 days. The longest follow-up of 7 years and shortest of 15 months did not reveal any complications as recurrence, seroma, mesh infections or erosions into the stoma. Conclusion: Modified placement of composite mesh is safe and helps in minimising mesh-related complications of the Sugarbaker technique for parastomal hernias.
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A prospective study of gastro-oesophageal reflux disease symptoms and quality of life 1-year post-laparoscopic sleeve gastrectomy p. 229
Andrew G.N. Robertson, Andrew J Cameron, Brian Joyce, Phil Le Page, Bruce Tulloh, Andrew C de Beaux, Peter J Lamb
DOI:10.4103/jmas.JMAS_43_18  PMID:29974879
Introduction: There are concerns that laparoscopic sleeve gastrectomy (LSG) can cause severe gastro-oesophageal reflux disease (GORD). The aim of this study was to assess GORD symptoms and quality of life following LSG. Methods: A prospective study of patients undergoing LSG (2014–2016) was performed with follow-up by DeMeester Reflux/Regurgitation Score, Bariatric Quality of Life Index (BQLI) and Bariatric Analysis and Reporting Outcome System (BAROS) Score pre-operatively, 6 months and 1-year post-operatively. Results: Twenty-two patients were studied. Mean modified DeMeester Reflux/Regurgitation Score improved from 2.25 (±0.67) pre-operatively to 0.81 (±0.25) at 12 months (P = 0.04). At 12 months, two patients had symptomatic reflux, but overall satisfaction score was unaffected. Mean BQLI Score underwent a non-significant improvement at 12 months. BAROS Score showed all patients to have excellent (n = 19) or very good (n = 3) results (12 months). Conclusion: GORD symptoms improve for most patients' 1-year post-operatively. A small proportion of patients will develop troublesome GORD, but overall satisfaction remains high.
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Robotic-assisted minimally invasive oesophagectomy for cancer: An initial experience p. 234
Chinnusamy Palanivelu, Sumanta Dey, Sandeep Sabnis, Raghavendra Gupta, Bharath Cumar, Saravana Kumar, Ramesh Natarajan, Parthasarathi Ramakrishnan
DOI:10.4103/jmas.JMAS_7_18  PMID:29737322
Background: The morbidity related to radical oesophagectomy can be reduced by adopting minimally invasive techniques. Over 250 thoraco-laparoscopic oesophagectomy (TLE) was done in our centre over the last 15 years, before adopting robotic surgery as the latest innovation in the field of minimally invasive surgery. Here, we share our initial experience of robotic-assisted minimally invasive oesophagectomy (RAMIE) for carcinoma oesophagus. Methods: A prospective observational study conducted from February to December 2017. A total of 15 patients underwent RAMIE in this period. Data regarding demography, clinical characteristics, investigations, operating techniques, and post-operative outcome were collected in detail. Results: There were 10 (66.7%) male patients and the median age of all patients was 62.9 (range 36–78) years. The median body mass index was 24.4 (range 15–32.8) kg/m2. Twelve (80.0%) patients had squamous cell carcinoma (SCC) of the oesophagus and 3 (20%) patients had adenocarcinoma (AC). Five (33.3%) patients received neoadjuvant therapy. All 15 patients underwent RAMIE. Patients with SCC underwent McKeown's procedure, and those with AC underwent Ivor Lewis procedure. Extended two-field lymphadenectomy (including total mediastinal lymphadenectomy) was done for all the patients. The median operating time was 558 (range 390–690) min and median blood loss was 145 (range 90–230) ml. There were no intra-operative adverse events, and none of them required conversion to open or total thoracolaparoscopic procedure. The most common post-operative complications were recurrent laryngeal nerve paresis (3 patients, 20.0%) and pneumonia (2 patients, 13.3%). The median hospital stay was 9 (range 7–33) days. In total, 9 (60%) patients required adjuvant treatment. Conclusion: Adequate experience in TLE can help minimally invasive surgeons in easy adoption of RAMIE with satisfactory outcome.
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CME ARTICLE Top

How to write an article: An introduction to basic scientific medical writing p. 242
Anil Sharma
DOI:10.4103/jmas.JMAS_91_18  PMID:29974882
An original scientific article published in a peer-reviewed professional journal of repute provides great personal satisfaction, adds stature and endows professional respectability to contributing authors. Various types of surgical publications that exist nowadays are case report, cohort study, case–control study, randomised controlled trial narrative review, systematic review, Cochrane review, meta-analysis, editorials and leading articles. A study/research protocol is a standardised document, common to all research projects that typically comprise study objectives, study design, selection of participants, study intervention, study evaluations, safety assessments, statistics and participant rights committees. Once the study protocol is completed and reviewed, it is submitted to the local Institutional Review Board/Institutional Ethics Committee for approval. An outline of the levels of evidence and grades of recommendation is available from the Centre for evidence-based medicine at the University of Oxford. A standardised, structured template exists for scientific presentations in the field of medicine which is also followed in medical writing and publications Introduction Methods Results And Discussion (IMRAD). Instructions to authors would normally include reference to International Committee of Medical Journal Editors and Committee on Publication Ethics guidelines for good and ethical publication practice. It is strongly advised to follow the recommended guidelines appropriate for the published study.
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UNUSUAL CASES Top

Laparoscopic splenic vessels and spleen-preserving extended distal pancreatectomy for single metastatic renal cell carcinoma p. 249
Christophe Roger Berney
DOI:10.4103/jmas.JMAS_150_18  PMID:30618418
Laparoscopic splenic vessels and spleen-preserving (SVSP) distal pancreatectomy has been recommended to reduce long-term risk of developing infectious complications. Due to its technical challenge, most cases relate to <50% of the pancreatic gland being excised. We present our first case of a patient incidentally found to have a solitary pancreatic metastatic renal cell carcinoma (RCC), following left nephrectomy for kidney cancer 15 years ago. He underwent laparoscopic SVSP-extended distal pancreatectomy (EDP). Final histopathology confirmed the diagnosis and margins were clear. He made a good recovery and despite loosing >70% of his pancreas, hasn't developed new-onset diabetes. No adjuvant chemotherapy was necessary, but he will require long-term follow-up. This case suggests that even when the pancreatic lesion is located more proximally, near or at the pancreatic neck, laparoscopic SVSP-EDP may still be considered a safe and preferable option despite its greater complexity, increased intraoperative bleeding risk and longer operative time.
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A new hybrid mini-laparoscopic technique for Spigelian hernia p. 253
Gustavo Lopes Carvalho, Gustavo Henrique Belarmino Góes, Raquel Nogueira Cordeiro, Diego Laurentino Lima, Lucyeli Luna Lopes Amorim, Raimundo Hugo Matias Furtado
DOI:10.4103/jmas.JMAS_179_18  PMID:30178771
We describe the original technique used for the treatment of a patient who presented with pain and bulging in the abdomen, who was diagnosed with Spigelian hernia (SH) using ultrasound. In this case, the hernia occurred in the anterolateral abdominal wall with herniation of the distal ileum and mesentery, in addition to a large right inguinal hernia. A mini-laparoscopic approach was proposed; due to Child-A hepatic cirrhosis, it was done by a hybrid technique, using a harmonic scalpel. The primary closure of the hernia defects was performed, followed by the placement of a polypropylene mesh in the preperitoneal space. The mesh was fixed. In this case, the inguinal hernia was homolateral to the SH. Following the surgery, the patient had no further complications, being discharged the day after the procedure.
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High insertion of cystic duct at the gallbladder fundus: An undescribed anomaly! p. 256
Gabriel Rodrigues, Shruti Rahul Pandit, Afroz Khan, Bharath Veerabharappa, Balaji Jayasankar, Rasagna Anaparti
DOI:10.4103/jmas.JMAS_199_18  PMID:30416140
The anatomy of the biliary tree is complex, and its variations of both intra- and extra-hepatic bile ducts can be found in approximately 30% of the general population. These variations are not picked up on routine pre-operative investigations of patients planned for a laparoscopic cholecystectomy (LC) and often present as an unusual 'surprise' and a challenge that can make dissection in the Calot's triangle difficult leading to iatrogenic injury. We present a case of a 53-year-old female with an undescribed anomaly encountered during an LC. There was a high insertion of the cystic duct into the fundus of the gallbladder. No such anomaly has been described in literature till date.
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Laparoscopic adrenalectomy for ganglioneuroma presenting as an adrenal incidentaloma p. 259
Ankush Sarwal, Rajesh Khullar, Anil Sharma, Vandana Soni, Manish Baijal, Pradeep Chowbey
DOI:10.4103/jmas.JMAS_228_18  PMID:30618428
Adrenal incidentaloma (AI) has now become a common finding in clinical practice with advances in abdominal imaging. The prevalence of AI as reported in the literature is 0.2%–3%. Ganglioneuroma (GN) is often a benign non-functioning adrenal tumour, which has been rarely reported as AI in literature. Confirmed diagnosis of GN can only be done by histopathological examination. GNs are often asymptomatic even if they are large, and adrenalectomy is treatment for GN, with good prognosis after surgical removal. Here, we report a patient with an incidental adrenal mass that was managed laparoscopically and diagnosed as an adrenal GN on histopathology.
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Laparoscopic approach to tailgut cyst (retrorectal cystic hamartoma) p. 262
Martín Gascón Hove, Jorge Martín Gil, Teresa Sánchez Rodríguez, Ángel Ferrero Lomas, Jesús Peraza Casajús, Antonio López-Farré, José de Jaime Guijarro
DOI:10.4103/jmas.JMAS_71_18  PMID:30416148
Retrorectal cystic hamartomas, or tailgut cysts, are complex congenital cystic lesions which arise from embryologic tissues. Fewer than 200 cases have been reported worldwide, with women outnumbering men by 3:1. They are asymptomatic in 50% of the cases; the remainder present with back pain or mass effect as the most common symptoms. Malignant transformation rarely occurs. Guided biopsy is controversial, while surgery is the therapy of choice. We report the case of a 31-year-old woman complaining about perineal and vague lower abdominal pain, who was submitted to magnetic resonance imaging, which revealed a multilocular cystic, well-circumscribed retrorectal mass. Subsequently, laparoscopic excision was successfully accomplished. Operative time was 175 min. Intra- and post-operative course was uneventful. Hospital stay was 75 h. While any malignancy suspicion should lead to open surgery, given the risk of rupture, we support the benefits of laparoscopy may also be applied.
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Total laparoscopic repair of Spigelian hernia with undescended testis p. 265
Shahaji Satish Deshmukh, Paras R Kothari, Abhaya R Gupta, Vishesh Balbhadra Dikshit, Prashant Patil, Geeta Anil Kekre, Aditi Deshpande, Apoorva Achyut Kulkarni, Aboli Hukeri
DOI:10.4103/jmas.JMAS_196_18  PMID:30618422
Spigelian hernia is very rare in the paediatric age group. We present the case of an 11-month-old male child who presented with left Spigelian hernia with the left undescended testis in its sac. Hernia repair with orchidopexy was done using total laparoscopic approach. It is the first reported case of total laparoscopic repair of Spigelian hernia with undescended testis in the paediatric age group.
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HOW I DO IT Top

A standardised and simplified technique for laparoscopic resection of the splenic flexure p. 268
Marco Lotti, Elia Poiasina, Gabor Panyor, Michele Marini, Michela Giulii Capponi, Nadiane Paderno, Pietro Calcagno, Eugenio Poletti, Luca Campanati
DOI:10.4103/jmas.JMAS_118_18  PMID:29974872
The splenic flexure is an uncommon location of colorectal cancer, being involved in 2%–3% of cases. The low chance of being engaged in resecting cancer of the splenic flexure can make it difficult for surgeons to build their learning curve and to achieve a reliable experience. As the majority of colectomies are still performed by low-volume surgeons, there is growing agreement that providing local services with adequate surgical education and training could be an effective strategy to improve outcomes and global health. Arming surgeons with simplified and easy-to-learn surgical techniques could be an important step of this strategy. A novel simplified technique for laparoscopic resection of the splenic flexure is presented, which combines laparoscopic mobilisation of the right colon with extracorporeal vascular ligation and bowel anastomosis.
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PERSONAL VIEWPOINTS Top

'Colleaguography' in place of cholangiography, to prevent bile duct injury during laparoscopic cholecystectomy p. 273
Vinay K Kapoor
DOI:10.4103/jmas.JMAS_165_18  PMID:30106027
Bile duct injury (BDI) is not uncommon during laparoscopic cholecystectomy (LC). Intra-operative cholangiography (IOC) has been recommended to reduce the risk of BDI during LC. Facilities for IOC are, however, scarcely available in India. The author suggests 'in vicinity colleaguography' (IVC) – opinion of a surgical colleague in vicinity – as an easy alternative to IOC.
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The influence of social media in minimally invasive surgery education: How surgeons exchange experience and knowledge in these platforms p. 275
Diego Laurentino Lima, Raquel Nogueira Cordeiro, Gustavo Lopes Carvalho, Flavio Malcher
DOI:10.4103/jmas.JMAS_270_18  PMID:30618437
Engagement with social media is increasing within medical professionals. There are many different platforms, such as Facebook, Instagram, Whatsapp, Twitter, Telegram, and so on. Social media is a new and important tool for surgical education. More and more surgeons are joining restricted groups to discuss surgical techniques, manuscripts, etc in a daily basis. It is important that residents and surgeons have a very critical opinion about what they look online. Not everything is good or feasible.
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LETTERS TO THE EDITOR Top

Surgical intervention for varicose veins during pregnancy: Is it sensible? p. 277
Bhupendra Kumar Jain, Deepti Choudhary
DOI:10.4103/jmas.JMAS_197_18  PMID:30777989
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The importance of long-term postoperative follow-up, including low threshold for endoscopic examination of the remnant stomach after Roux-en-Y gastric bypass p. 279
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DOI:10.4103/jmas.JMAS_166_18  PMID:30106028
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The value of neural monitoring in endoscopic-robotic thyroidectomy approaches p. 280
Hui Sun, Angkoon Anuwong, Gianlorenzo Dionigi
DOI:10.4103/jmas.JMAS_273_17  PMID:29737318
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04