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   Table of Contents - Current issue
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July-September 2018
Volume 14 | Issue 3
Page Nos. 177-264

Online since Wednesday, June 6, 2018

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REVIEW ARTICLE  

What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review p. 177
Sonia Fernandez-Ananin, Arnulfo F Fernández, Carmen Balagué, David Sacoto, Eduardo Maria Targarona
DOI:10.4103/jmas.JMAS_94_17  PMID:29319024
Background: Surgical treatment of achalasia fails in 10%–20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. In this study, we review and evaluate the possible treatments to be carried out when surgical myotomy fails. We define its benefits and results, with the purpose of defining a therapeutic algorithm. Materials and Methods: The systematic review was performed following the guidelines established by the Meta-analysis of Observational Studies in Epidemiology statement. We searched several electronic databases (MEDLINE, PubMED, EMBASE and Cochrane) from January 1991 to March 2017, with the keywords 'recurrent achalasia' 'POEM remyotomy', 'esophagomyotomy failure', 'Heller myotomy failure', 'myotomy failure', 'pneumatic balloon dilatation achalasia' and combinations between them, 'redo Heller', 'redo myotomy', 'reoperative Heller'. Results: A total of 61 observational studies related to the treatment of patients with failure of Heller's myotomy were initially found. Finally, 37 articles were included in our study that provided data on 289 patients. Of these 289 patients, diagnosed of failed Heller's myotomy, 87 were treated with pneumatic dilatation (PD), 166 underwent surgical revision and finally 36 were treated with POEM. No randomised controlled trial was identified. Conclusions: The three therapeutic options analysed in this review are effective and safe in the treatment of patients with achalasia with failure of surgical myotomy. The best results can be achieved following an algorithm similar to the one proposed here, where each procedure must be performed by well-experienced team in the selected modality.
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ORIGINAL ARTICLES Top

Laparoscopic versus open treatment of gallbladder cancer: A systematic review and meta-analysis p. 185
Xin Zhao, Xiang Yang Li, Wu Ji
DOI:10.4103/jmas.JMAS_223_16  PMID:28782743
Background: The aim of this review was to evaluate the effect of laparoscopic surgery on the treatment of patients with gallbladder cancer (GBC). Methods: A comprehensive search of Medline and Cochrane Library was conducted to identify relevant articles. A meta-analysis was subsequently performed. Results: A total of 20 studies including 1217 patients met the inclusion criteria. The meta-analysis showed that the 5-year survival rate was significant higher in laparoscopic group than open group (48.4% vs. 38.5%; odds ratio [OR], 1.63; 95% confidence interval [CI], 1.22–2.19; P = 0.001). Although the scar recurrence rate was significant higher in laparoscopic group than open group (7.1% vs. 4.0%; OR, 2.10; 95% CI, 1.11–3.96; P = 0.02), the overall recurrence rates between two groups were not significant different (44.8% vs. 42.2%; OR, 0.86; 95% CI, 0.64–1.14; P = 0.29). In addition, compared with open extended cholecystectomy (EC), laparoscopic EC (LEC) was associated with less intraoperative blood loss, shorter post-operative hospital stays and insignificant less complication rate (10.0% vs. 18.3%; OR, 0.51; 95% CI, 0.15–1.73; P = 0.28). Conclusion: Laparoscopic simple cholecystectomy does not lead to a worse prognosis when applied on patients with GBC. LEC can be performed in specialised expert centres on elective patients.
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Can post-operative antibiotic prophylaxis following elective laparoscopic cholecystectomy be completely done away with in the Indian setting? A prospective randomised study p. 192
Vikram Singh Chauhan, PL Kariholu, Sabyasachi Saha, Himanshu Singh, Jasmine Ray
DOI:10.4103/jmas.JMAS_95_17  PMID:29067946
Premise and Objective: Elective laparoscopic cholecystectomy (LC) has low risk for post-operative infectious complications; still most clinicians use persistent post-operative prophylactic antibiotics out of habit, tradition, or simply as defensive practice due to evolving medicolegal implications of a large number of surgeries being showcased as daycare or next day discharge procedures. This randomised prospective trial was done to test the need for such prophylaxis in cases of elective LC in a rural/semi-urban setting. Materials and Methods: Two hundred and ten successive patients undergoing elective LC were randomised into groups receiving single dose of injection ceftriaxone at the time of induction of anaesthesia, (Group A = 112 cases) and those who in addition to above received injection ceftriaxone twice daily for 2 days postoperatively (Group B = 98 cases). Post-operative infectious complications between two groups were compared for variables such as age, sex, body mass index and bile/stone spillage. Results: There was no significant difference in surgical site infection rates between the groups for variables such as age, sex, body mass index, duration of symptoms, American Society of Anesthesiologists grade, duration of surgery and hospital stay. Intraoperative spillage of stones (9.8% [A]: 5.1% [B]) did not increase infectious complications even in the presence of positive bile culture (Group A, N = 7 vs. Group B, N = 3). An operative time of greater than 60 min was found to be associated with increased surgical site infection (P = 0. 0006). Conclusion: Single dose of ceftriaxone at the time of induction is adequate prophylaxis following elective LC even in the rural/semi-urban Indian setting and routine continued administration of antibiotic should be abandoned as it contributes to adverse reactions, drug resistance and unnecessary financial burden.
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Transversus abdominis plane block for pain relief in patients undergoing in endoscopic repair of abdominal wall hernia: A comparative, randomised double-blind prospective study p. 197
Aparna Sinha, Lakshmi Jayaraman, Dinesh Punhani, Pradeep Chowbey
DOI:10.4103/jmas.JMAS_138_17  PMID:28928325
Introduction: Transversus abdominis plane (TAP) block is now a well-established technique in post-operative analgesia for lower abdominal surgeries. We evaluated the effect of ultrasound-guided TAP block on recovery parameters in patients undergoing endoscopic repair of abdominal wall hernia. Methods: Thirty adults were randomised to receive either ropivacaine with dexmedetomidine (TR) or saline (TP) in TAP block, before emergence from anaesthesia. The patients were assessed for pain relief, sedation, time to ambulate (TA), discharge readiness (DR), postoperative opioid requirement and any adverse events. Results: The median visual analogue scale pain score of the study group (TR) and the control group (TP) showed a significant difference at all time points. TA was 5.3 ± 0.5 (TR) versus 7.4 ± 0.8 (TP), P<0.001 and DR was 7.5 ± 0.9 (TR) versus 8.9 ± 0.6 (TP), P<0.001 in hours. No adverse events were observed in any group. Conclusion: This study demonstrates that TAP block is a feasible option for pain relief following endoscopic repair of abdominal wall hernias. It produces markedly improved pain scores and promotes early ambulation leading to greater patient satisfaction and earlier discharge.
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Post-cholecystectomy syndrome: A new look at an old problem p. 202
Divya Arora, Robin Kaushik, Ravinder Kaur, Atul Sachdev
DOI:10.4103/jmas.JMAS_92_17  PMID:29067945
Background: Despite being the most commonly performed operations, sometimes cholecystectomy fails to relieve symptoms; this is now a well-recognised clinical entity termed 'post-cholecystectomy syndrome' (PCS). Very few studies from India deal with PCS, and the present study was carried out to find the incidence and risk factors for PCS in patients undergoing elective laparoscopic cholecystectomy (LC). Materials and Methods: The records of 207 patients undergoing elective LC were prospectively maintained for 6 months after surgery. Persistence or appearance of new symptoms after surgery was documented and investigated only when they persisted beyond 30 days of surgery. Results: There were 185 (89.4%) female patients and 22 (10.6%) male patients with a mean age of 44.4 years (age range: 12–79 years). Conversion to open cholecystectomy was done in 18 patients (8.69%), mainly due to adhesions and unclear anatomy. The incidence of symptoms was found to be 13% at 6 months follow-up, showing a reducing trend from 58% in the 1st week after LC; the most common symptom in symptomatic patients was dyspepsia (55.56%). On investigation, a cause for symptoms could be detected in only 0.97%. Conclusion: Symptoms are common after LC, but they settle over time. Very few patients have a detectable cause for symptoms after LC, and it is difficult to predict which patients will become symptomatic after LC; in the present series, previous attacks of cholecystitis and presence of co-morbid conditions were the only consistent risk factors for symptoms after LC.
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Subfascial Endoscopic Perforator Surgery: A safe and novel minimal invasive procedure in treating varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence p. 208
Manash Ranjan Sahoo, Leesa Misra, Sumeet Deshpande, Sambit Kumar Mohanty, Santosh Kumar Mohanty
DOI:10.4103/jmas.JMAS_107_17  PMID:29067937
Aim: Aim of this study is to evaluate the results of Subfascial Endoscopic Perforator Surgery(SEPS) in treating varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence. Materials and Methods: A case series was undertaken at our institute from the period January 2010 to January 2014 on 45 pregnant women. Pregnant women with failed conservative management for varicose veins were subjected to SEPS in 2nd trimester Perioperative parameters like operative time, intraoperative complications, post-operative complications, hospital stay, pain relief, ulcer healing duration and recurrence rate were studied. All the patients were reviewed and followed up for a minimum period of 3 years. Results: During the study period.total of 45 pregnant women were enrolled in the study. The median age of the patients was 26 years (range 22 years - 30 years). The mean operative time was 90±10 minutes. The post-operative hospital stay was 1-2days. There were no intraoperative complications like bleeding or gas embolism. There were no post-operative complications like seroma or abscess, port site infection, deep vein thrombosis and gas embolism. Mean healing duration of ulcers following surgery was 7-8 weeks.No patient complained of temporary or permanent paraesthesia. Every patient was subjected to follow up for a minimum period of 3 years. 5(11.1%) patients with recurrence were documented in the study. Conclusion: SEPS is a safe, cost effective and novel minimal invasive procedure in treatment of varicose veins in 2nd trimester of pregnancy for below knee perforator incompetence.
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Quality of life after Nissen fundoplication in patients with gastroesophageal reflux disease: Comparison between long- and short-term follow-up p. 213
P S. S Castelijns, J E. H Ponten, M C. G vd Poll, ND Bouvy, JF Smulders
DOI:10.4103/jmas.JMAS_75_17  PMID:28928332
Introduction: Nissen fundoplication is the golden standard for surgical treatment of gastroesophageal reflux disease (GERD). Numerous studies report excellent short-term results. However, data regarding long-term quality of life are lacking. The aim of this study is to investigate the long-term quality of life after Nissen fundoplication in patients with GERD and to compare this with the short-term results. Patients and Methods: We retrospectively analysed all patients who underwent laparoscopic Nissen fundoplication for GERD between January 2004 and January 2016. All patients received a validated GERD-Health-Related Quality of Life questionnaire by mail to assess post-operative quality of life. Maximum quality of life is represented by a score of 75. Secondary outcome measures were complications and recurrence rate. Results: One hundred and seventy-five (77.1%) of the 227 operated patients returned the questionnaire. The median follow-up was 3.7 (0.1–10.3) years. Mean age was 51.6 (range 15–85) and 72 patients were male. We report an excellent quality of life with a median total score of 70 (range 2–75). Re-operation rate was 13.6% (23/169); the re-operation was due to recurrent reflux in 12 patients and due to persistent dysphagia in 11 patients. 91.3% of the re-operations were performed within the first 5 years after surgery. Mortality rate was zero. Conclusion: We report a large series of single-centre, single-surgeon laparoscopic Nissen fundoplication. Despite the re-operation rate of 13.6%, we found excellent long-term symptomatic outcome. There was no difference between short- and long-term results.
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Laparoscopic Nissen fundoplication: The effects of high-concentration supplemental perioperative oxygen on the inflammatory and immune response: A randomised controlled trial Highly accessed article p. 221
Mario Schietroma, Sara Colozzi, Beatrice Pessia, Francesco Carlei, Marino Di Furia, Gianfranco Amicucci
DOI:10.4103/jmas.JMAS_120_16  PMID:29582795
Background: A number of studies have been reported on the effects of high-concentration oxygen (HCO) on cytokine synthesis, with controversial results. We assessed the effect of administration of perioperative HCO on systemic inflammatory and immune response in patients undergoing laparoscopic Nissen fundoplication (LNF). Materials and Methods: Patients (n = 117) were assigned randomly to an oxygen/air mixture with a fraction of inspired oxygen (FiO2) of 30% (n = 58) or 80% (n = 59). Administration was commenced after induction of anaesthesia and maintained for 6 h after surgery. White blood cells, peripheral lymphocytes subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-1 and IL-6 and C-reactive protein (CRP) were investigated. Results: A significantly higher concentration of neutrophil elastase, IL-1, IL-6 and CRP was detected post-operatively in the 30% FiO2group patients in comparison with the 80% FiO2group (P < 0.05). A statistically significant change in HLA-DR expression was recorded post-operatively at 24 h, as a reduction of this antigen expressed on monocyte surface in patients from 30% FiO2group; no changes were noted in 80% FiO2group (P < 0.05). Conclusions: This study demonstrated that perioperative HCO (80%), during LNF, can lead to a reduction in post-operative inflammatory response, and possibly, avoid post-operative immunosuppression.
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Liver hydatid cyst with cystobiliary communication: Laparoscopic surgery remains an effective option p. 230
Nikhil Chopra, Vivek Gupta, Rahul , Saket Kumar, Pradeep Joshi, Vishal Gupta, Abhijit Chandra
DOI:10.4103/jmas.JMAS_81_17  PMID:28928333
Introduction: Most centres offer laparoscopic treatment for liver hydatid cyst (LHC). There have been concerns about the management of intra-peritoneal spillage, bleeding, and cystobiliary communication (CBC) during laparoscopic surgery for LHC. CBC can exist in 13%–37% of cases of LHC. No randomised studies have compared open versus laparoscopic approach for the treatment of LHC. We specifically analysed the outcomes of laparoscopic treatment of LHC with special reference to associated biliary complications. Patients and Methods: We analysed our prospectively collected data of patients undergoing laparoscopic treatment of LHC from 2009 to 2016. Patients undergoing open surgery or interventional radiology procedures were not included. Data analysed included demographic profile, investigational parameters, intra-operative findings and postoperative results with special reference to biliary complications and presence/management of CBC. Results: A total of 41 patients underwent laparoscopic treatment of LHC. History of jaundice was present in 5 (12.2%) patients. CBC was documented in 16 (39.02%) patients. In 11 patients, CBC was detected intra-operatively as visible communication, which was suture ligated or clipped. Five patients had occult CBC, detected as bile leak in the post-operative period. The leak resolved spontaneously in 7 patients and with biliary stenting in 2 patients. Only one patient had a persistent biliary leak. Postoperative bile leak was more common in patients with raised alkaline phosphatase. No statistically significant association was seen with size or location of the cyst, number of cysts and World Health Organisation classification. Conclusion: Laparoscopic treatment of LHC with associated CBC provides acceptable results.
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Stomach resection with intraoperative fluoroscopy in laparoscopic distal gastrectomy for early gastric cancer p. 236
Jun Kawachi, Hiroyuki Kashiwagi, Hidemitsu Ogino, Naoko Isogai, Rai Shimoyama, Ryuta Fukai, Katsunori Miyake, Akiko Sasaki, Takahiro Terashima, Shinichi Teshima, Kazunao Watanabe
DOI:10.4103/jmas.JMAS_61_17  PMID:29067944
Background: In Japan, laparoscopic distal gastrectomy (LDG) is common for early gastric cancer. Formerly, we used to verify the location of the marking clip to decide the proximal incisional line with our hand, through a small epigastric incision. In 2015, we introduced intracorporeal reconstruction and started to decide the incisional line using intraoperative fluoroscopy. Herein, we aimed to evaluate the efficacy and safety of intraoperative fluoroscopy in LDG. Patients and Methods: A total of 19 patients were included in this retrospective observational study. On the day before operation, we endoscopically clipped several points located 2 cm proximal to the tumour edge to cover about half of the tumour. After lymph node dissection, we incised the stomach with an endoscopic linear stapling device, including the previously placed clips, guided by intraoperative fluoroscopy. Reconstruction was performed in all patients who underwent Billroth I and Roux-en-Y procedures. Results: No complications were observed during pre-operative endoscopic clipping or intraoperatively. On pathological examination, all resected specimens had negative margins, and the mean distance from the tumour edge was 28.5 ± 16.5 (13–60) mm. Conclusion: Stomach resection with intraoperative fluoroscopic guidance was safe and effective.
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UNUSUAL CASES Top

Laparoscopic cholecystectomy with choledochoduodenostomy in a patient with situs inversus totalis p. 241
Yogesh P Takalkar, Mandar S Koranne, Kumar S Vashist, Pranalee G Khedekar, Mahadeo N Garale, Sameer A Rege, Abhay N Dalvi
DOI:10.4103/jmas.JMAS_122_17  PMID:29882522
A 50-year-old female presented to us with features of obstructive jaundice. Investigations revealed cholelithiasis with single large impacted calculus in the common bile duct (CBD) and significant dilatation of extrahepatic biliary tree. Incidentally, the patient was also detected to have situs inversus totalis (SIT). Attempt at extraction of the calculus in the CBD by endoscopic retrograde cholangiography failed, and a 7F stent was placed. The patient was subjected to laparoscopic cholecystectomy, CBD exploration with the extraction of the offending calculus and laparoscopic choledochoduodenostomy (LCDD). The patient had an uneventful recovery and is since discharged. PubMed search did not reveal LCDD in SIT as a procedure reported in literature to the best of our knowledge.
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Application of fluorescent cholangiography during single-incision laparoscopic cholecystectomy for cholecystitis with a right-sided round ligament: Preliminary experience p. 244
Motoi Nojiri, Tsuyoshi Igami, Yoshitaka Toyoda, Tomoki Ebata, Yukihiro Yokoyama, Gen Sugawara, Takashi Mizuno, Junpei Yamaguchi, Masato Nagino
DOI:10.4103/jmas.JMAS_159_17  PMID:29226884
An 82-year-old woman was diagnosed with cholecystitis with a right-sided round ligament. We planned a single-incision laparoscopic cholecystectomy. Based on the findings of fluorescent cholangiography, the running course of the common bile duct was confirmed before dissection of Calot's triangle, and the confluence between the cystic duct and the common bile duct was exposed after the dissection of Calot's triangle. The planned surgery was successful. The operative time and intraoperative blood loss were 157 min and 2 mL, respectively. The patient was discharged from our hospital 3 days after surgery. Application of fluorescent cholangiography during a laparoscopic cholecystectomy for the patients with a right-sided round ligament should be widely accepted.
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Port site desmoid tumour following laparoscopic cholecystectomy: A case report p. 247
Gautham Krishnamurthy, Vijay Chetan Jha, Ganga Ram Verma
DOI:10.4103/jmas.JMAS_209_17  PMID:29319019
Desmoid tumours are locally aggressive tumours occurring either spontaneously or in familial conditions. History of trauma is invariably present with surgical trauma being a common cause. Port site desmoid tumours are extremely rare conditions. Inadequate treatment results in high recurrence rate and substantial morbidity. Reconstruction, if required, by the appropriate technique is vital to avoid an incisional hernia. Adjuvant therapy may be useful in large locally advanced or recurrent tumours. We describe a young female with large port site desmoid tumour following laparoscopic cholecystectomy managed with wide local excision and mesh placement.
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Rib desmoplastic fibroblastoma: Video-assisted resection p. 250
Agustín Buero, Walter Sebastian Nardi, Gustavo Alejandro Lyons, Pablo Dezanzo
DOI:10.4103/jmas.JMAS_210_17  PMID:29319020
A 46-year-old man was referred to our department due to chronic chest pain. A computed tomography showed an exophytic image arising from 5th rib that was projected on the middle lobule. The patient underwent an exploratory videothoracoscopic because we couldn't discard lung compromise. A corneal-like lesion emerging from the inner side of the 5th rib was revealed. Complete video-assited resection was done. Histopathology examination revealed a desmoplastic fibroblastoma. To our knowledge this is the first case of desmoplastic fibroblastoma arising from a rib and the second case published in all literature of chest wall involvement.
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Thoracoscopic oesophagectomy for end-stage achalasia p. 253
Vaibhav Kumar Varshney, Subhash Chandra Soni, Manju Kumari, Pawan Kumar Garg, Ashok Puranik
DOI:10.4103/jmas.JMAS_222_17  PMID:29319022
Achalasia cardia is an oesophageal motility disorder characterised by aperistalsis and failure of relaxation of the lower oesophageal sphincter. The management is predominantly palliative with focus on addressing the sphincter that involves either pneumatic dilatation or Heller myotomy which relieves dysphagia in the majority of the cases. End-stage achalasia (ESA) is characterised by failed myotomy, massively dilated and tortuous oesophagus with nutritional deterioration due to progressive dysphagia and vomiting. In these subgroups of patients, oesophagectomy may be the last resort. While oesophagectomy has been described for ESA before, thoracoscopic oesophagectomy has not been reported previously. Hereby, we report our experience of performing minimally invasive oesophagectomy (thoracoscopic) with the gastric pull-up.
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Concomitant intraperitoneal onlay mesh repair with endoscopic component separation and sleeve gastrectomy p. 256
P Praveen Raj, Siddhartha Bhattacharya, S Saravana Kumar, R Parthasarathi, C Palanivelu
DOI:10.4103/jmas.JMAS_147_17  PMID:29226882
Bariatric surgery can be safely combined with laparoscopic intraperitoneal onlay mesh (IPOM) repair. In case of large ventral hernias, laparoendoscopic component separation can also be combined to achieve tension-free closure of the defect. Concomitant bariatric surgery and hernia repair also offer the additional benefit of reduction in recurrence of hernias as obesity, one of the risk factors, is treated in the process. We present a case of 60-year-old man with a body mass index of 45.3 kg/m2 with a large recurrent ventral hernia. We performed a lap sleeve gastrectomy with laparoendoscopic anterior component separation with IPOM. The operative steps included hernia contents reduction, conventional sleeve gastrectomy, anterior component separation on either side, intra-corporeal closure of hernia defect and placement of a composite mesh. Patient recovery was uneventful. Concomitant bariatric surgery with laparoendoscopic component separation with IPOM may be safe, but more studies are required.
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INVITED COMMENTARY Top

Concomitant bariatric surgery and component separation: Historical advance or a blunder? p. 259
Ramana Balsubramanian
DOI:10.4103/jmas.JMAS_223_17  PMID:29483380
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HOW I DO IT DIFFERENTLY? Top

Ileostomy site approach for adhesiolysis and laparoscopic cholecystectomy in a hostile abdomen: A novel technique p. 261
Deeplaxmi Purushottam Borle, Nikhil Agrawal, Asit Arora, Senthil Kumar, Tushar Kanti Chattopadhyay
DOI:10.4103/jmas.JMAS_73_17  PMID:28782748
Introduction: Gallstones are an etiological factor in 23%–54% of patients with acute pancreatitis. A small proportion of these patients will also have intestinal complications requiring necrosectomy with diverting loop ileostomy. Later, these patients require cholecystectomy and ileostomy reversal. Laparoscopic cholecystectomy is fraught with difficulty in these patients due to dense intra-abdominal adhesions, and many surgeons resort to an open approach. We describe a technique which takes advantage of the ileostomy site for initial access. Materials and Surgical Technique: Ileostomy reversal is done and a SILS (Covidien, Mansfield, Massachusetts, USA) port is inserted under direct vision, through the ileostomy site. Adhesiolysis is done through the SILS port. Additional ports are inserted and standard steps are followed for cholecystectomy. Conclusion: The use of ileostomy incision as the first port facilitates adhesiolysis and subsequent port placement in the hostile abdomen encountered in these patients. We describe a novel technique of ileostomy reversal and laparoscopic cholecystectomy using SILS port.
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LETTER TO THE EDITOR Top

Primary leiomyosarcoma of the inferior vena cava p. 264
Vipul D Yagnik
DOI:10.4103/jmas.JMAS_187_17  PMID:29067942
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04