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CME ARTICLE
Anatomy relevant to cholecystectomy
Sanjay Nagral
April-June 2005, 1(2):53-58
DOI:10.4103/0972-9941.16527  PMID:21206646
This review discusses anatomical facts that are of relevance to the performance of a safe cholecystectomy. Misinterpretation of normal anatomy and anatomical variations contribute to the occurrence of major postoperative complications like biliary injuries following a cholecystectomy, the incidence being higher with laparoscopic cholecystectomy. A look at the basic anatomy is therefore important for biliary and minimally invasive surgeons. This includes normal anatomy and variations of the biliary apparatus as well as the arterial supply to the gallbladder. Specific anatomical distortions due to the laparoscopic technique, their contribution in producing injury and a preventive strategy based on this understanding are discussed. Investigative modalities that may help in assessing anatomy are considered. Newer insights into the role of anatomic illusions as well as the role of a system-based approach to preventing injuries is also discussed.
  50,951 1,847 12
REVIEW ARTICLE
Diagnosis and management of Spigelian hernia: A review of literature and our experience
T Mittal, V Kumar, R Khullar, A Sharma, V Soni, M Baijal, PK Chowbey
October-December 2008, 4(4):95-98
DOI:10.4103/0972-9941.45204  PMID:19547696
Spigelian hernia occurs through slit like defect in the anterior abdominal wall adjacent to the semilunar line. Most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient. The hernia ring is a well-defined defect in the transverses aponeurosis. The hernial sac, surrounded by extraperitoneal fatty tissue, is often interparietal passing through the transversus and the internal oblique aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique. Spigelian hernia is in itself very rare and more over it is difficult to diagnose clinically. It has been estimated that it constitutes 0.12% of abdominal wall hernias. The spigelian hernia has been repaired by both conventional and laparoscopic approach. Laparoscopic management of spigelian hernia is well established. Most of the authors have managed it by transperitoneal approach either by placing the mesh in intraperitoneal position or by raising the peritoneal flap and placing the mesh in extraperitoneal space. There have also been case reports of management of spigelian hernia by total extraperitoneal approach. We retrospectively reviewed our experience of ten patients between 1997 and 2007. Eight patients (8/10) presented with abdominal pain and two patients (2/10) were asymptomatic. In six patients (6/10) we performed an intraperitoneal onlay IPOM repair, in two patients (2/10) transabdominal preperitoneal repair (TAPP), and in two (2/10) total extraperitoneal repair (TEP). There were no recurrences, or other morbidity at mean follow up period of 3.2 years (range 6 months to 10 years).
  29,465 545 28
SYMPOSIUM
The Shouldice technique for the treatment of inguinal hernia
Chin Keung Chan, Gabriel Chan
July-September 2006, 2(3):124-128
DOI:10.4103/0972-9941.27723  PMID:21187981
The Shouldice repair has been refined over several decades and is the gold standard for the prosthesis-free treatment of inguinal hernias. A recurrence rate around 1% has been consistently demonstrated over the years. The objective of this paper is to outline and highlight the key principles, including the dedicated pre-operative preparation, the use of local anesthesia, a complete inguinal dissection and the eponymous four-layered reconstruction. A knowledge and understanding of inguinal hernia anatomy and the patho-physiology of recurrence are vital to achieving a long-term success and patient satisfaction for a pure tissue repair.
  24,633 594 3
EDITORIAL
Laparoscopic colostomy takedown offers advantages over traditional surgery
Thomas M Schmelzer, William W Hope, David A Iannitti, Kent W Kercher, B Todd Heniford
October-December 2006, 2(4):201-202
PMID:21234145
  24,316 426 2
REVIEW ARTICLE
Laparoscopy in the management of stone disease of urinary tract
Rajiv Yadav, Rajeev Kumar, Ashok K Hemal
October-December 2005, 1(4):173-180
DOI:10.4103/0972-9941.19264  PMID:21206660
As in other fields of urology, the use of minimally invasive techniques has helped decrease the morbidity and convalescence associated with the management of urolithiasis. Laparoscopy has also been used as one of the minimally invasive techniques. This has developed particularly with the increasing experience and use of intracorporeal suturing techniques. However, in comparison with other surgeries, laparoscopy for stone removal is relatively uncommon and we review the current indications, technical limitation and results.
  22,747 444 2
UNUSUAL CASES
Management of post cholecystectomy Mirizzi's syndrome
Simon Janes, L Berry, B Dijkstra
January-March 2005, 1(1):34-36
DOI:10.4103/0972-9941.15244  PMID:21234142
Various strategies have been proposed for the management of retained calculi within the biliary tree following cholecystectomy. We present a unique case of a cystic duct remnant calculus causing Mirizzi syndrome, only the fourth such case of its kind. An open procedure was planned, however the calculus was eventually extracted endoscopically. The pathophysiology and management of Mirizzi syndrome and retained calculi within the cystic duct remnant are discussed along with the merits of a minimally invasive approach.
  20,408 472 5
REVIEW ARTICLE
Endoscopic neck surgery
PK Chowbey, Vandana Soni, R Khullar, Anil Sharma, M Baijal
January-March 2007, 3(1):3-7
DOI:10.4103/0972-9941.30679  PMID:20668611
Endoscopic surgery in the neck was attempted in 1996 for performing parathyroidectomy. A similar surgical technique was used for performing thyroidectomy the following year. Most commonly reported endoscopic neck surgery studies in literature have been on thyroid and parathyroid glands. The approaches are divided into two types i.e., the total endoscopic approach using CO2 insufflation and the video-assisted approach without CO2 insufflation. The latter approach has been reported more often. The surgical access (port placements) may vary-the common sites are the neck, anterior chest wall, axilla, and periareolar region. The limiting factors are the size of the gland and malignancy. Few reports are available on endoscopic resection for early thyroid malignancy and cervical lymph node dissection. Endoscopic neck surgery has primarily evolved due to its cosmetic benefits and it has proved to be safe and feasible in suitable patients with thyroid and parathyroid pathologies. Application of this technique for approaching other cervical organs such as the submandibular gland and carotid artery are still in the early experimental phase.
  19,087 599 2
ORIGINAL ARTICLE
Laparoscopic versus open appendicectomy: An Indian perspective
Utpal De
January-March 2005, 1(1):15-20
DOI:10.4103/0972-9941.15241  PMID:21234139
BACKGROUND: Laparoscopic appendicectomy though widely practiced has not gained universal approval. Laparoscopic appendicectomy in India is relatively new and the literature is scant. This study was aimed to compare laparoscopic with open appendicectomy and ascertain the therapeutic benefit, if any, in the overall management of acute appendicitis. MATERIALS AND METHODS: The study group consisted of two hundred and seventy nine patients suffering from acute appendicitis. One hundred patients underwent laparoscopic appendicectomy (LA) and one hundred seventy nine patients underwent open appendecectomy (OA). Comparison was based on length of hospital stay, operating time, postoperative morbidity, duration of convalescence and operative cost in terms of their medians. The Mann-Whitney statistics (T) were calculated and because of large samples, the normal deviate test (Z) was used. RESULTS: Of the hundred patients, six patients (6%) had the procedure converted to open surgery. The rate of infections and overall complications (LA: 15%, OA: 31.8%, P < 0.001) were significantly lower in patients undergoing LA. The median length of stay was significantly shorter after LA (3 days after LA, 5 days after OA, P < 0.0001) than after OA. The operating time was shorter {OA: 25 min (median), LA: 28 min (median), 0.01< P < 0.05} in patients undergoing open appendicectomy compared to laparoscopic appendicectomy. CONCLUSION: Hospital stay for LA is significantly shorter and the one-time operative charges appear to be almost the same. LA is also associated with increased clinical comfort in terms of fewer wound infections, faster recovery, earlier return to work and improved cosmesis.
  17,396 506 7
SYMPOSIUM
Causes of recurrence in laparoscopic inguinal hernia repair
Jan F Kukleta
July-September 2006, 2(3):187-191
DOI:10.4103/0972-9941.27736  PMID:21187994
Aim: The analysis of possible mechanisms of repair failure is a necessary instrument and the best way to decrease the recurrence rate and improve the overall results. Avoiding historical errors and learning from the reported pitfalls and mistakes helps to standardize the relatively new laparoscopic techniques of trans-abdominal preperitoneal and total extraperitoneal. Materials and Methods: The video tapes of all primary laparoscopic repairs done by the author that led to recurrence were retrospectively analyzed and compared with findings at the second laparoscopic repair. A review of the available cases of recurrences occurring between 1994 and 2003 is the basis of this report. Summary: Adequate mesh size, porosity of mesh material, slitting of the mesh, correct and generous dissection of preperitoneal space and wrinkle-free placement of the mesh seem to be the more important factors in avoiding recurrence rather than strength of the material or strong penetrating fixation. Special attention should be paid to preperitoneal lipoma as a possible overlooked herniation or potential future pseudorecurrence despite nondislocated correctly positioned mesh. Conclusion: Laparoscopic hernia repair is a complex but very efficient method in experienced hands. To achieve the best possible results, it requires an acceptance of a longer learning curve, structured well-mentored training and high level of standardization of the operative procedure.
  16,763 423 5
ORIGINAL ARTICLE
Laparoscopic reversal of Hartmann procedure
Vishwanath Golash
October-December 2006, 2(4):211-215
PMID:21234148
Background: The Hartmann procedure is a standard life-saving operation for acute left colonic complications. It is usually performed as a temporary procedure with the intent to reverse it later on. This reversal is associated with considerable morbidity and mortality by open method. The laparoscopic reestablishment of intestinal continuity after Hartmann procedure has shown better results in terms of decrease in morbidity and mortality. Materials and Methods: The laparoscopic technique was used consecutively in 12 patients for the reversal of Hartmann procedure in the last 3 years. The adhesiolysis and mobilization of the colon was done under laparoscopic guidance. The colostomy was mobilized and returned to abdominal cavity after tying the anvil in the proximal end. An end-to-end intracorporeal anastomosis was performed between the proximal colon and the rectum using the circular stapler. Results: Mean age of the patients was 40 years and the mean time of restoration of intestinal continuity was 130 days. Two patients were converted to open. The mean time of operation was 90 min. There were no postoperative complications and mortality. The mean hospital stay was 5 days. Conclusion: Laparoscopic reversal of Hartmann is technically safe and feasible.
  15,333 366 3
Does laparoscopic Nissen fundoplication prevent the progression of Barrett's oesophagus? Is the length of Barrett's a factor?
Fahad Bamehriz, Sanjeev Dutta, Catherine Gill Pottruff, Christopher A Allen, Mehran Anvari
January-March 2005, 1(1):21-28
DOI:10.4103/0972-9941.15242  PMID:21234140
INTRODUCTION: Recent studies have suggested that both laparoscopic and open anti-reflux surgery may produce regression of Barrett's mucosa. MATERIAL AND METHODS; We reviewed 21 patients (13M: 8F, mean age 46.73.18 years) with documented Gastroesophageal Reflux Disease (GERD) and Non-dysplastic Barrett's esophagus (15 patients ?3 cm segment, 6 patients < 3 cm segment) on long term proton pump inhibitor therapy who underwent laparoscopic Nissen fundoplication (LNF) between 1993 and 2000. All patients had undergone pre and yearly postoperative upper GI endoscopy with 4 quadrant biopsies every 2 cm. All patients also underwent pre- and 6 months postoperative 24-hr pH study, esophageal manometry, SF36, and GERD symptom score. The mean duration of GERD symptoms was 8.41.54 years pre-operative. The mean follow-up after surgery was 396.32 months. RESULTS: Postoperatively, there was significant improvement in reflux symptom score (37.5 3.98 points versus 8.7 2.46 points, P = 0.0001), % acid reflux in 24 hr (26.5 3.91% versus 2.1 0.84%, P< 0.0001) and an increase in lower esophageal sphincter pressure (3.71 1.08 mmHg versus 12.29 1.34 mmHg, P = 0.0053). Complete or partial regression of Barrett's mucosa occurred in 9 patients. All patients with complete regression had <4 cm segment of Barrett's. Progression or cancer transformation was not observed in any of the patients. CONCLUSION: LNF in patients with Barrett's oesophagus results in significant control of GERD symptoms. LNF can prevent progression of Barrett's oesophagus and in patients with Barrett's <4 cm may lead to complete regression.
  15,214 384 1
EDITORIAL
Natural orifice transluminal endoscopic surgery: Past, present and future
Jonathan P Pearl, Jeffrey L Ponsky
April-June 2007, 3(2):43-46
DOI:10.4103/0972-9941.33271  PMID:21124650
  13,013 1,034 12
REVIEW ARTICLE
Laparoscopy in pancreatic tumors
SV Shrikhande, SG Barreto, PJ Shukla
April-June 2007, 3(2):47-51
DOI:10.4103/0972-9941.33272  PMID:21124651
Recently, increasing number of manuscripts - original articles and case reports have attempted to provide evidence of the forays of minimal access surgery into pancreatic diseases. Many, based on the lack of Level I evidence, still believe that laparoscopy in pancreatic surgery is experimental. This article attempts to look into data exploring the existing use of minimally invasive surgery in pancreatic disease to answer a vital question - what does the evidence say on the current status of laparoscopic surgery in pancreatic tumors.
  13,431 586 7
ORIGINAL ARTICLE
Laparoscopic biopsy in patients with abdominal lymphadenopathy
DS Bhandarkar, RS Shah, AN Katara, M Shankar, VA Chandiramani, TE Udwadia
January-March 2007, 3(1):14-18
DOI:10.4103/0972-9941.30681  PMID:20668613
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.
  13,529 445 8
ORIGINAL ARTICLES
Endoscopic thyroidectomy: Our technique
Shailesh P Puntambekar, Reshma J Palep, Anjali M Patil, Neeraj V Rayate, Saurabh N Joshi, Geetanjali A Agarwal, Milind Joshi
July-September 2007, 3(3):91-97
DOI:10.4103/0972-9941.37191  PMID:19789664
Minimally invasive surgery is widely employed for the treatment of thyroid diseases. Several minimal access approaches to the thyroid gland have been described. The commonly performed surgeries have been endoscopic lobectomies. We have performed endoscopic total thyroidectomy by the anterior chest wall approach. In this study, we have described our technique and evaluated the feasibility and efficacy of this procedure. Materials and Methods: From June 2005 to August 2006, 15 cases of endoscopic thyroidectomy were done at our institute. Five patients were male and 10 were female. Mean age was 45 years. (Range 23 to 71 years). Four patients had multinodular goiter and underwent near-total thyroidectomy; four patients had follicular adenoma and underwent hemithyroidectomy. Out of the seven patients of papillary carcinoma, four were low-risk and so a hemithyroidectomy was performed while three patients in the high risk group underwent total thyroidectomy. A detailed description of the surgical technique is provided. Results : The mean nodule size was 48 mm (range 20-80 mm) and the mean operating time was 85 min (range 60-120 min). In all cases, the recurrent laryngeal nerve was identified and preserved intact, the superior and inferior parathyroids were also identified in all patients. No patients required conversion to an open cervicotomy. All patients were discharged the day after surgery. All thyroidectomies were completed successfully. No recurrent laryngeal nerve palsies or postoperative tetany occurred. The postoperative course was significantly less painful and all patients were satisfied with the cosmetic results. Conclusions : It is possible to remove large nodules and perform as well as total thyroidectomies using our endoscopic approach. It is a safe and effective technique in the hands of an appropriately trained surgeon. The patients get a cosmetic benefit without any morbidity.
  13,208 526 3
Anastomotic leak rate and outcome for laparoscopic intra-corporeal stapled anastomosis
Vitali Goriainov, Andrew J Miles
April-June 2008, 4(2):39-43
DOI:10.4103/0972-9941.41942  PMID:19547680
Objectives: A prospective audit of all patients undergoing laparoscopic surgery with the intention of primary colonic left-sided intracorporeal stapled anastomosis to identify the clinical anastomotic leak rate on an intention to treat basis. Methods: All patients undergoing laparoscopic colorectal surgery resulting in left-sided stapled anastomosis were included. All operations were conducted by the same surgical team with the same pre-operative preparation and surgical technique. The factors analysed for this audit were patient demographics (age and sex), indication for operation, procedure performed, height of anastomosis, leak rate and the outcome, inpatient stay, mortality, rate of defunctioning stomas, and rate of conversion to open procedure. Results: Eighty-four patients (49 females, 35 males; median age 70 years, range 19-89 years) underwent colonic procedures with left-sided intracorporeal stapled anastomosis. An intra-operative air leak was evident in one patient, whose anastomosis was oversewn intracorporeally and defunctioned by ileostomy. There were only two clinically evident anastomotic leaks post-operatively (2.9%). One patient died of overwhelming sepsis within 48h of re-operation: Seven patients (8.3%) had a primary defunctioning stoma, with two further stomas formed due to anastomotic leakage. Five cases (6%) were converted to open surgery. The median post-operative stay was six days, range 2-23. Thirty-day mortality was 50% in the leak group and 0% in the non-leak group. Conclusion: We believe that this study demonstrates that the anastomotic leak rate from intra-corporeal laparoscopic anastomosis is no greater than for open surgery or laparoscopic surgery with extra-corporeal anastomosis.
  12,994 402 2
REVIEW ARTICLE
Controversies in laparoscopic repair of incisional hernia
Abeezar I Sarela
January-March 2006, 2(1):7-11
DOI:10.4103/0972-9941.25670  PMID:21170220
Background: Incisional hernias can be a significant problem after open abdominal surgery. Laparoscopic incisional hernia repair (LIHR) is conceptually appealing: a large, abdominal wall re-incision with potential wound-related ill effects is avoided and an intra-peritoneal onlay mesh is expected to provide security that is equivalent to open, retro-muscular mesh repair. As such, LIHR has gained substantial popularity despite sparse, randomised clinical data to compare with conventional, open repair. Aim: To enumerate and discuss important, controversial issues in patient-selection, technique and early post-operative care for LIHR. Materials and Methods: Pragmatic summary of comprehensive review of English language literature, discussion with experts and personal experience. Outcomes: Six important areas of some dispute were identified: 1. Size of abdominal-wall defect that is suitable for LIHR: Generally, defect-diameter > 10 cm is better served by open retromuscular repair with tension-free re-approximation of the edges of the defect. 2. Extent of adhesiolysis: Complete division of adhesions to the anterior abdominal wall may identify sub-clinical "Swiss-cheese" defects but incurs some risk of additional complications. 3. Intra-operative recognition of enterotomy: Possible options are either laparoscopic suture of bowel injury and simultaneous completion of LIHR, or staged LIHR or conversion to open suture-repair. 4. Choice of mesh: "Composite" meshes are regarded as the current standard of care but there is paucity of data regarding potential dangers of intra-peritoneal polypropylene mesh. 5. Technique of mesh-fixation: Trans-parietal sutures are more secure than tacks, with limited data to correlate with post-operative pain. 6. Alarm over post-operative pain: Unlike other advanced laparoscopic operations, the specificity of pain as a marker of intra-abdominal sepsis after LIHR remains unclear. Conclusion : Recognition of and attention to controversial issues will promote increased success of LIHR.
  12,451 473 2
SYMPOSIUM
Complications in groin hernia surgery and the way out
Pradeep K Chowbey, Murtaza Pithawala, Rajesh Khullar, Anil Sharma, Vandana Soni, Manish Baijal
July-September 2006, 2(3):174-177
DOI:10.4103/0972-9941.27734  PMID:21187992
Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than those of open surgery, especially in inexperienced hands and hence are best avoided. It is possible to avoid most of these complications if one follows a set of well-defined steps and principles of endoscopic inguinal hernia surgery. Complications are known to occur at each and every step of hernia surgery. Applying caution while performing each step can save the patient from a lot of morbidity. One starts by applying strict patient selection criteria for endoscopic hernia repair, especially in the initial part of ones learning curve. A thorough knowledge of anatomy goes a long way in avoiding most of the complications seen in hernia repair. This anatomy needs to be relearned from what one is used to, as the approach is totally different from an open hernia repair. And finally, learning and mastering the right technique is an essential prerequisite before one ventures into inguinal hernia repair. Although there has been an increased incidence of complications reported in endoscopic repair in the earlier series, this can be explained partly by the fact that it was in the early part of the learning curve of most endoscopic surgeons. As the experience grew and the techniques were standardized, the incidences of complications have also reduced and have come to be on par with open hernia surgery. The various complications and precautions to be taken to avoid them will be discussed.
  12,316 380 3
HOW I DO IT DIFFERENTLY?
Laparoscopic transabdominal extraperitoneal repair of lumbar hernia
A Sharma, R Panse, R Khullar, V Soni, M Baijal, PK Chowbey
April-June 2005, 1(2):70-73
DOI:10.4103/0972-9941.16530  PMID:21206649
Lumbar hernias need to be repaired due to the risk of incarceration and strangulation. A laparoscopic intraperitoneal approach in the modified flank position causes the intraperitoneal viscera to be displaced medially away from the hernia. The creation of a wide peritoneal flap around the hernial defect helps in mobilization of the colon, increased length of margin is available for coverage of mesh and more importantly for secure fixation of the mesh under vision to the underlying fascia. Laparoscopic lumbar hernia repair by this technique is a tensionless repair that diffuses total intra-abdominal pressure on each square inch of implanted mesh. The technique follows current principles of hernia repair and appears to confer all benefits of a minimal access approach.
  12,273 339 7
REVIEW ARTICLE
Twenty years after Erich Muhe: Persisting controversies with the gold standard of laparoscopic cholecystectomy
Kalpesh Jani, PS Rajan, K Sendhilkumar, C Palanivelu
April-June 2006, 2(2):49-58
DOI:10.4103/0972-9941.26646  PMID:21170235
This review article is a tribute to the genius of Professor Erich Muhe, a man ahead of his times. We trace the development of laparoscopic cholecystectomy and detail the tribulations faced by Muhe. On the occasion of the twentieth anniversary of the first laparoscopic cholecystectomy, we take another look at some of the controversies surrounding this gold standard in the management of gallbladder disease
  11,919 486 10
ORIGINAL ARTICLE
Role of laparoscopy in evaluation of chronic pelvic pain
Shripad Hebbar, Chander Chawla
July-September 2005, 1(3):116-120
DOI:10.4103/0972-9941.18995  PMID:21188008
Introduction: Chronic pelvic pain (CPP) is a common medical problem affecting women. Too often the physical signs are not specific. This study aims at determining the accuracy of diagnostic laparoscopy over clinical pelvic examination. Settings and Design: A retrospective study of patients who underwent diagnostic laparoscopy for CPP. Materials and Methods: The medical records of 86 women who underwent laparoscopic evaluation for CPP of at least 6-month duration were reviewed for presentation of symptoms, pelvic examination findings at the admission, operative findings and follow up when available. Statistical analysis used: McNemar Chi-square test for frequencies in a 2 x 2 table. Results: The most common presentation was acyclic lower abdominal pain (79.1%), followed by congestive dysmenorrhoea (26.7%). 61.6% of women did not reveal any significant signs on pelvic examination. Pelvic tenderness was elicited in 27.9%. Diagnostic laparoscopy revealed significant pelvic pathology in 58% of those who essentially had normal pervaginal findings. The most common pelvic pathology by laparoscopy was pelvic adhesions (20.9%), followed by pelvic congestion (18.6%). Laparoscopic adhesiolyis achieved pain relief only in one-third of the women. Conclusion: The study revealed very low incidence of endometriosis (4.7%). Overall clinical examination could detect abnormality in only 38% of women, where as laparoscopy could detect significant pathology in 66% of women with CPP. This shows superiority of diagnostic laparoscopy over clinical examination in detection of aetiology in women with CPP (P < 0.001). Adhesiolysis helps only small proportion of women in achieving pain control.
  11,928 360 3
UNUSUAL CASE
Torsion of the epiploic appendix: An unusual cause of acute abdomen
Samik Kumar Bandyopadhyay, Mayank Jain, Shashi Khanna, Bimalendu Sen, Om Tantia
April-June 2007, 3(2):70-72
DOI:10.4103/0972-9941.33277  PMID:21124656
Summary: Torsion of an epiploic appendix is a rare surgical entity. We present our experience in a thirty five year old female patient and a forty year old male patient. Materials and Methods: A 35 year old lady had presented with right iliac fossa pain of 2 days duration. Guarding and rebound tenderness was present over the area. Investigations showed mild leucocytosis and neutrophilia. Diagnostic laparoscopy revealed an inflamed epiploic appendix which was excised. Other intrabdominal organs were normal. A 40 year old male patient had presented with a history of recurrent, colicky, and paroxysmal right lower quadrant pain for 2 months. At laparoscopy, an inflamed torted epiploic appendix of the ascending colon was detected and excised. Other intrabdominal organs were normal. Results: Both the patients had an uneventful recovery and are asymptomatic at follow up of 10 and 7 months respectively. They have been followed up at 7 days, 4 wks and then 3 monthly. Discussion: The clinical presentation of an inflamed appendices epiploicae may be confusing. CT is helpful in disgnosis. Laparoscopy may be used to diagnose and treat the condition as well. Conclusion: Diagnostic laparoscopy is an useful tool for surgeons in assessing abdominal pain where the cause is elusive. It may be used to diagnose and treat torsion of an epiploic appendix effectively.
  11,481 321 6
REVIEW ARTICLE
Laparoscopic adrenalectomy
Nobuo Tsuru, Kazuo Suzuki
October-December 2005, 1(4):165-172
DOI:10.4103/0972-9941.19263  PMID:21206659
Laparoscopic adrenalectomy is currently recognized as the gold standard for the treatment of adrenal tumors. In order to assess the current status of laparoscopic adrenalectomy, we reviewed the literature focusing on the indications and contraindications, surgical techniques, complications and new methods. We also reviewed the results separately for aldosteronoma, pheochromocytoma, Cushing's syndrome, and primary or metastatic adrenal cancer. Laparoscopic adrenalectomy is a safe and effective treatment for adrenal disorders, excluding primary adrenal cancer. There are no differences of the various operative parameters between the transperitoneal and retroperitoneal approaches, so the choice of approach should depend on the surgeon's preference or the patient's circumstances. It is important for the surgeon to remove the tumor and the surrounding fat en bloc, especially in the case of large or irregular tumors because of the potential for malignancy. The surgeon must also immediately switch to an open procedure if the laparoscopic operation becomes difficult. We conclude that use of laparoscopic adrenalectomy allows the performance of minimally invasive surgery with the advantages of more rapid recovery and a shorter hospital stay than open adrenalectomy.
  11,170 376 2
SYMPOSIUM
Light weight meshes in incisional hernia repair
Volker Schumpelick, Uwe Klinge, Raphael Rosch, Karsten Junge
July-September 2006, 2(3):117-123
DOI:10.4103/0972-9941.27722  PMID:21187980
Incisional hernias remain one of the most common surgical complications with a long-term incidence of 10-20%. Increasing evidence of impaired wound healing in these patients supports routine use of an open prefascial, retromuscular mesh repair. Basic pathophysiologic principles dictate that for a successful long-term outcome and prevention of recurrence, a wide overlap underneath healthy tissue is required. Particularly in the neighborhood of osseous structures, only retromuscular placement allows sufficient subduction of the mesh by healthy tissue of at least 5 cm in all directions. Preparation must take into account the special anatomic features of the abdominal wall, especially in the area of the Linea alba and Linea semilunaris. Polypropylene is the material widely used for open mesh repair. New developments have led to low-weight, large-pore polypropylene prostheses, which are adjusted to the physiological requirements of the abdominal wall and permit proper tissue integration. These meshes provide the possibility of forming a scar net instead of a stiff scar plate and therefore help to avoid former known mesh complications.
  10,956 502 13
IMAGES IN LAPAROSCOPY
Umbilical port hernia following laparoscopic cholecystectomy
P Singh, Robin Kaushik, R Sharma
January-March 2006, 2(1):29-30
DOI:10.4103/0972-9941.25675  PMID:21170225
  11,109 251 4
2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04