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   Table of Contents - Current issue
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April-June 2021
Volume 17 | Issue 2
Page Nos. 141-278

Online since Monday, March 15, 2021

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REVIEW ARTICLES  

Laparoscopic splenectomy after trauma: Who, when and how. A systematic review Highly accessed article p. 141
Pietro Fransvea, Gianluca Costa, Angelo Serao, Francesco Cortese, Genoveffa Balducci, Gabriele Sganga, Pierluigi Marini
DOI:10.4103/jmas.JMAS_149_19  PMID:31670290
Importance: A deep knowledge of the indication for laparoscopic splenectomy (LS) in trauma case can lead trauma surgeon to offer in a wider number of situations a minimally invasive approach to a common injuries. Objective: To present and review the advantages and disadvantages of laparoscopic approach for spleen trauma and to identify patient whose can benefit from a minimally invasive approach versus patient that need open surgery to assess the whole severity of trauma. Evidence Review: A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. Studies conducted on animals were not considered. All other laparoscopic procedures for spleen trauma were excluded. Results: Nineteen articles were included in this study, reporting 212 LS after trauma. The most study includes blunt trauma patient. All LS were performed in haemodynamically stable patient. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%), including 16 (7.5%) post-operative deaths. Conclusions and Relevance: This article reports the feasibility and safety of a minimally invasive approach for common trauma injuries which can help non-advanced laparoscopic skill trauma surgeon to develop the best indication to when to adopt this kind of approach.
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The efficacy and safety of laparoscopy combined with gastroscopy positioning in treating gastric stromal tumours: A systematic review and meta-analysis p. 147
Hu Zhang, Jie Chen, Chen Chen
DOI:10.4103/jmas.JMAS_294_19  PMID:33723177
Background and Objectives: The objective was to assess the efficacy and safety in treating gastric stromal tumours by laparoscopy combined with gastroscopy positioning surgery. Methods: The randomised controlled trials (RCTs), which are about the efficacy and safety of laparoscopy combined with gastroscopy positioning surgery in treating gastric stromal tumours were searched from the PubMed (1998–1990–2018.6), Wanfang Data (1990–2018.6), China National Knowledge Infrastructure (1979–2018.6) and International Statistical Institute (1998–2018.6). The data were extracted from these trials, and the meta-analysis was made through from RevMan 5.3 software. Results: Six RCTs involving 451 patients were included in the study (227 patients in the laparoscopy combined with gastroscopy positioning group and 224 patients in laparoscopic surgery group). Compared with laparoscopic surgery group, this meta-analysis showed that laparoscopy combined with gastroscopy positioning group could shorten the post-operation hospital stay (P < 0.05) and reduce the intraoperative blood loss (P < 0.05). However, there was no significant difference in others between the two groups, such as operation time (P > 0.05), post-operative time of recovery of intestinal peristalsis (P > 0.05) and the total hospital stay (P > 0.05). Conclusion: Compared with laparoscopic surgery group, the better total effect occurs in laparoscopy combined with gastroscopy positioning group for the treatment of gastric stromal tumours is better. Laparoscopy combined with gastroscopy positioning group for the gastric stromal tumours is acceptable.
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ORIGINAL ARTICLES Top

Early laparoscopic cholecystectomy in acute gallbladder perforation: Single-centre experience p. 153
Gautham Krishnamurthy, Senthil Ganesan, Jayapriya Ramas, Karthikeyan Damodaran, Aswin Khanna, Radhakrishna Patta
DOI:10.4103/jmas.JMAS_176_19  PMID:33723178
Background: Acute gallbladder perforation (GBP) is associated with significant mortality and morbidity. Percutaneous drainage followed by interval cholecystectomy has been the preferred management. The outcomes of early surgery, especially by laparoscopy, have not been well studied in GBP. We present our experience in early laparoscopic cholecystectomy in GBP. Methodology: A retrospective analysis of patients admitted with GBP between April 2014 and December 2018 was done. Clinical presentation, preoperative imaging, surgical procedure, operative findings and the outcomes in these patients were analysed. Video of the surgeries was reviewed in case of the absence of data from the case records. Results: Fifteen patients were treated for GBP during the study period. Eleven patients were male, and the mean age was 61 years. Fourteen patients (93.3%) had associated co-morbidities. Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock were present in 3, 3, 6 and 3 patients, respectively. The location of the collection was gallbladder fossa, pericholecystic, subhepatic and diffuse in 3, 5, 4 and 3 patients, respectively. Intraoperatively, 13 patients were detected to have perforation at the fundus of the gallbladder. Cystic duct stump was managed with clip, endoloop, suturing and external drainage in 7, 2, 5 and 1 patient, respectively. Laparoscopic cholecystectomy was completed in 12 (80%) patients. Retroinfundibular technique was used in 12 (80%) patients. There was one conversion. Two patients required endoscopic retrograde cholangiogram + bile duct stenting, and one was reexplored for cystic artery bleed. There were no mortalities. The median duration of post-operative hospital stay and drain removal was 3 (1–19) and 3 (1–6), respectively. Conclusion: Early laparoscopic cholecystectomy in acute GBP is feasible and can be safely performed in centres having sufficient expertise. Retroinfundibular technique of laparoscopic cholecystectomy is useful in tackling frozen Calot's triangle in GBP.
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Is weight regaining significant post laparoscopic Roux-en-Y gastric bypass surgery? – A 5-year follow-up study on Indian patients p. 159
Mohamed Ismail, Dileep Nagaraj, Mahesh Rajagopal, Hafiz Ansari, Kingsly Iyyankutty, Megha Nair, Aparna Hegde, PD Rekha
DOI:10.4103/jmas.JMAS_108_19  PMID:33723179
Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) has been proven to induce significant weight loss and remission of related co-morbidities in patients with morbid obesity. The long-term follow-up data show weight regain or failure to achieve complete remission of type 2 diabetes mellitus (T2DM) in some patients. In this study, we report weight loss patterns and remission of T2DM in patients with morbid obesity during a 5-year follow-up after RYGB. Objective: The objective was to evaluate outcomes during the follow-up on excess weight loss (EWL) and remission of T2DM after laparoscopic RYGB among Indian patients. Setting: The study was conducted in a tertiary care hospital, Kerala, India. Materials and Methods: This is a retrospective study in patients who underwent surgery between 2007 and 2010. The patient demographics, pre- and post-operative body mass index (BMI), co-morbidities and EWL were recorded from the medical records. These data were compared between pre-operative and follow-up intervals till 5 years using statistical approaches. Results: The study included 157 patients (91 males and 66 females) having a mean pre-operative BMI of 47.91 ± 7.01 kg/m2. A significant reduction in the BMI was observed at each follow-up point (P < 0.01) till 5 years after the surgery. The mean percentage of EWL increased from 34.57% ± 12.62% to 71.50% ± 15.41% from 3 months to 5 years after the surgery. Twelve per cent (n = 19) of patients achieved normal BMI (<25 mg/kg2) by 3rd year after the surgery. However, the remission of T2DM was achieved in >50% of patients within a year of surgery. During the 5th year, weight regain (1–22 kg) was observed in 36.70% (n = 58) patients, and recurrence of T2DM was observed in two patients. Conclusions: The long-term durability of RYGB in the study population was satisfactory with significant weight loss and remission of T2DM.
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Feasibility of robot-assisted surgery in elderly patients with rectal cancer p. 165
Wei-Chih Su, Ching-Wen Huang, Cheng-Jen Ma, Po-Jung Chen, Hsiang-Lin Tsai, Tsung-Kun Chang, Yen-Cheng Chen, Ching-Chun Li, Yung-Sung Yeh, Jaw-Yuan Wang
DOI:10.4103/jmas.JMAS_154_19  PMID:33723180
Background: Although surgical resection is the main treatment for rectal cancer, the optimal surgical protocol for elderly patients with rectal cancer remains controversial. This study evaluated the feasibility of robot-assisted surgery in elderly patients with rectal cancer. Patients and Methods: This retrospective study enrolled 156 patients aged 28–93 years diagnosed with Stage I–III rectal cancer, who underwent robot-assisted surgery between May 2013 and December 2018 at a single institution. Results: In total, 156 patients with rectal cancer, including 126 non-elderly (aged < 70 years) and 30 elderly (aged ≥70 years) patients, who underwent robot-assisted surgery were recruited. Between the patient groups, the post-operative length of hospital stay did not differ statistically significantly (P = 0.084). The incidence of overall post-operative complications was statistically significantly lower in the elderly group (P = 0.002). The disease-free and overall survival did not differ statistically significantly between the two groups (P = 0.719 and 0.390, respectively). Conclusions: Robot-assisted surgery for rectal cancer was well tolerated by elderly patients, with similar results to the non-elderly patients. Oncological outcomes and survival did not depend on patient age, suggesting that robot-assisted surgery is a feasible surgical modality for treating operable rectal cancer and leads to age-independent post-operative outcomes in elderly patients.
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Experience in identifying the variant adrenal venous anatomy during modified retroperitoneoscopic adrenalectomy p. 175
Dongliang Hu, Dan Zhu, Yingao Zhang, Xinghuan Wang
DOI:10.4103/jmas.JMAS_31_20  PMID:33723181
Background: Adrenal vein plays an important role in performing laparoscopic adrenalectomy successfully. However, it often presents with a multitude of venous anatomical variants. Hence, having a thorough knowledge on the variant types is crucial to reduce operative complications. This study aims to present our experience in identifying adrenal vein variation in adrenalectomy through modified retroperitoneal approach. Patients and Methods: A total of 187 patients underwent modified retroperitoneoscopic adrenalectomy between July 2017 and February 2019. Perioperative data and adrenal vein variants were recorded and analysed. Results: Variant adrenal veins were encountered in seven patients. On the right side, two cases were drained by two adrenal veins; one case had a common trunk of adrenal vein and an accessory hepatic vein and one case had an adrenal vein joined with the opening of the right renal vein. On the left side, two cases of anatomic variations were described as follows: one vein converged with the left inferior phrenic vein and joined with the left renal vein, whereas the other vein directly joined with the left renal vein. One case had two adrenal veins that joined with the left renal vein. Conclusions: Accurate identification and proper handling of the anatomical variation in the drainage of adrenal vein are crucial to safe LA. It is helpful to anticipate and avoid bleeding, especially in large adrenal tumours.
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Training for laparoscopic colorectal surgery creating an appropriate porcine model and curriculum for training p. 180
Tehemton Erach Udwadia
DOI:10.4103/jmas.JMAS_86_20  PMID:33723182
Background: Laparoscopic colorectal surgery (LCRS) was first described in 1991, and its safety, efficacy and patient benefit were adequately documented in literature. However, its penetration and acceptability is poor in most countries, due to its long learning curve and lack of surgeons training and confidence. A Minimal Access Surgery (MAS) Training Center in Mumbai has over the last 7 years trained more than 8000 surgeons in various MAS specialities. The centre has initiated courses for LCRS training. Materials and Methods: The anatomy of the pig colon is very different from human anatomy. The pig colon anatomy is altered to mimic human colon anatomy in the porcine abdomen, permitting hands-on practice on most laparoscopic colorectal surgical procedures, as part of the LCRS training course, under mentorship of expert faculty, who simultaneously assess participants performance. Results: Each participant performs and assists for at least three procedures and is evaluated at each step of the procedure by a structured format. The overall evaluation by Faculty which though subjective, is detailed and favourable. Feedback of each participant is good and acceptable as a very helpful course. Conclusion: This porcine model is ideal for hands-on training for LCRS. Participants achieve a good degree of skill level and confidence in performing LCRS procedures on fresh bleeding porcine cadaver models. The centre is factual and pragmatic and stresses that it needs more than a course to make a safe surgeon; operation room mentorship is the finishing school.
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C-shaped pleura cautery in primary spontaneous pneumothorax patients for pleurodesis p. 188
Tao Zhu, Zhao-Jia Gao, Ming Zhang, Yong Wang
DOI:10.4103/jmas.JMAS_141_19  PMID:32098935
Background: Although pleurodesis is usually used to reduce the recurrence rate for primary spontaneous pneumothorax (PSP) in surgery, existing techniques cannot meet the higher requirements of little surgical injury and less relapse. Hence, we developed a new pleurodesis technique and named multipoint pleura cautery. Aim: In this study, we aimed to investigate the effectiveness and outcomes of the uniportal video-assisted thoracoscopic surgery C-shaped pleura cautery in the surgical treatment of PSP. To the best of our knowledge, this is a new surgical technique for pleurodesis and must be of concern. Patients and Methods: The medical records of 20 patients undergoing surgery for C-shaped pleura cautery between 2015 and 2017 were reviewed. The patients were evaluated with regard to age, gender, body mass index, smoking habit, operation time, duration of hospitalization, post-operative pain and follow-up. Results: We have performed a bullectomy combined C-shaped pleura cautery for 20 patients with PSP from January 2016 to December 2017. None of the patients suffered post-operative bleeding and haematothorax complications, and one was ipsilateral relapsed 5 months after surgery. The lung computed tomography showed that recurrence of pneumothorax was due to air leakage in the right lower lung, and there was no air leakage at the site where pleurodesis had been performed. Conclusions: Although this technique requires further investigation, it may be a useful method of pleurodesis.
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A comparison of renal vascular control techniques during laparoscopic nephrectomy p. 192
Gokhan Koc, Gokhan Rahmi Ekin, Batuhan Ergani, Yusuf Ozlem Ilbey
DOI:10.4103/jmas.JMAS_287_19  PMID:33723183
Background: We compared outcomes of en bloc stapler ligation of the renal hilum with separate Hem-o-lok polymer clip ligation of the renal vessels during laparoscopic nephrectomy (LN). Materials and Methods: Clinical data of patients who underwent LN for renal surgery from January 2009 to December 2015 were collected. Operation time, estimated blood loss, device malfunction rate, open conversion rate, complications and arteriovenous fistula (AVF) formation were evaluated. Results: En bloc stapler ligation and separate clip ligation were performed in 64 and 66 patients, respectively. The mean operative time was 106.8 ± 20.8 min (range: 70–165) in the en bloc stapler ligation group compared with 112.5 ± 24.1 min (range: 70–180) in the separate clip ligation group (P = 0.147). The mean estimated blood loss was 141.4 ± 124.1 ml (range: 25–600) in the en bloc stapler ligation group compared with 147.6 ± 112.4 ml (range: 25–450) in the separate clip ligation group (P = 0.767). The open conversion was required in 7/64 (10.9%) and 2/66 (3.0%) patients in the en bloc stapler ligation and separate clip ligation groups, respectively (P = 0.093). Stapler device malfunction occurred in 6 patients (9.3%). There were no statistically significant differences in overall complications (P = 0.726), minor (Grade 1–2) complications (P = 0.698) and major (Grade 3–5) complications (P = 0.716). No patient was diagnosed with AVF formation during overall median 33-month (interquartile range: 30, range: 24–96) follow-up. Conclusions: En bloc stapler ligation of the renal hilum during nephrectomy is an effective and safe technique. Although there is no reported AVF formation with en bloc stapler ligation of the renal hilum, longer follow-up is necessary.
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Prophylactic active irrigation drainage reduces the risk of post-operative pancreatic fistula-related complications in patients undergoing limited pancreatic resection p. 197
Jiadeng Chao, Chunfu Zhu, Zhongzhi Jia, Xudong Zhang, Xihu Qin
DOI:10.4103/jmas.JMAS_290_19  PMID:33047685
Objective: The objective of this study is to evaluate the efficacy of prophylactic active irrigation drainage in preventing post-operative pancreatic fistula (POPF) and POPF-related complications in patients undergoing limited pancreatic resection (LPR). Materials and Methods: Patients who underwent LPR for benign or borderline pancreatic lesions between February 2014 and March 2019 were enroled in this retrospective study. Patients were divided into two groups according to the type of intraperitoneal drainage used: closed-suction drainage (CSD) or continuous active irrigation drainage (CAID). Data regarding the outcomes and complications of surgery were collected and analysed. Results: A total of 50 patients (33 women; age, 50.1 ± 10.8 years) were included in this study. Twenty-nine patients were treated with CSD, and 21 patients were treated with CAID. Clinically relevant POPF and POPF-related complications occurred in 11 patients in the CSD group and in two patients in the CAID group ( P = 0.024). Patients in the CSD group demonstrated a longer tube indwelling time than those in the CAID group (17.1 ± 10.2 days vs. 13.7 ± 7.5 days; P = 0.044). Mean post-operative hospital stay was also longer in the CSD group than in the CAID group (20.6 ± 7.9 days vs. 16.1 ± 6.3 days; P = 0.039). Conclusions: Prophylactic CAID appears to be an effective alternative for the management of POPF and POPF-related complications in patients undergoing LPR.
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Robot-assisted laparoscopic pyeloplasty: A retrospective case series review p. 202
Sunil Kumar, Deepak Prakash Bhirud, Ankur Mittal, Shiv Charan Navriya, Satish Kumar Ranjan, Kim Jacob Mammen
DOI:10.4103/jmas.JMAS_10_20  PMID:32964889
Introduction: Anderson-Hynes pyeloplasty has been gold standard in the management of pelviureteric junction obstruction (PUJO). It has evolved from open to laparoscopic and now robotic surgery. Open surgery has its drawback of long incision and scar mark, significant post-operative pain and long hospital stay. The main limitation of laparoscopic surgery had been the difficulty in endosuturing. Robotic surgery has incorporated the minimal access method of laparoscopy and endowrist movement of open surgery to overcome the challenge of intracorporeal suturing. Here, we present our initial experience of robotic pyeloplasty. Patients and Methods: A total of 30 patients underwent robot-assisted laparoscopic pyeloplasty (RALP) over 19 months. Diagnosis of PUJO was made by computed tomography urography, diuretic renogram and retrograde pyelogram in selected patients. All patients underwent RALP by colon reflecting approach. Post-operative evaluation was done by DTPA scan at 3- and 6-month follow-up. Data were analysed after a mean follow-up of 11 months. Results: The mean operative time was 148 min and the mean hospital stay was 3.5 days. While 93% of the patients showed objective improvement in their drainage pattern on DTPA renogram, 90% of the patients were symptom-free at the end of 6 months. Conclusions: Robotic pyeloplasty is a safe and easily conquerable technique with comparable outcomes in the hands of surgeons who are beginners in this technique.
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Preservation of the left colic artery and superior rectal artery in laparoscopic surgery can reduce anastomotic leakage in sigmoid colon cancer p. 208
Xiaolong Tang, Mengjun Zhang, Chao Wang, Qingsi He, Guorui Sun, Hui Qu
DOI:10.4103/jmas.JMAS_15_20  PMID:32964883
Background: The aim was to study the clinical significance in the preservation of the left colic artery (LCA) and superior rectal artery (SRA) for the laparoscopic resection of sigmoid colon cancer (SCC). Patients and Methods: A total of 316 patients with SCC were divided into two groups. Group A received D3 resection with preservation of LCA and SRA, whereas Group B ligatured artery at the root of the inferior mesenteric artery. The operation time, number of resected lymph nodes, blood loss and anastomotic leakage rate were compared. Results: In Group A, the average operation time was 283.02 ± 51.48 min, the average blood loss was 111.81 ± 77.08 ml and the average lymph node dissection was 14.8 ± 7.7. There was no statistical significance in blood loss and number of resected lymph nodes between Group A and B (P > 0.05). Longer operating time were observed in Group A as compared to Group B (P < 0.05). The anastomotic leakage rate had statistical significance between these two groups (P < 0.05). Conclusions: Preservation of LCA and SRA was safe and feasible for the laparoscopic surgery of SCC, which could reduce anastomotic leakage rate.
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Complications after bariatric surgery: A multicentric study of 11,568 patients from Indian bariatric surgery outcomes reporting group p. 213
Ramen Goel, Amrit Manik Nasta, Madhu Goel, Arun Prasad, Gurvinder Jammu, Mathias Fobi, Mohamed Ismail, Praveen Raj, Raj Palaniappan, Sandeep Aggarwal, Vivek Bindal, Abhishek Katakwar, Amar Vennapusa, Aparna Govil Bhasker, Atul Peters, Deep Goel, Digvijay Bedi, Jaydeep Palep, Lakshmi Kona, Magan Mehrotra, Manish Baijal, Mohit Bhandari, Nandakishore Dukkipati, Randeep Wadhawan, Sarfaraz Baig, Satish Pattanshetti, Surendra Ugale
DOI:10.4103/jmas.JMAS_12_20  PMID:32964881
Background: Complications after bariatric surgery are not uncommon occurrences that influence the choice of operations both by patients and by surgeons. Complications may be classified as intra-operative, early (<30 days post-operatively) or late (beyond 30 days). The prevalence of complications is influenced by the sample size, surgeon's experience and length and percentage of follow-up. There are no multicentric reports of post-bariatric complications from India. Objectives: To examine the various complications after different bariatric operations that currently performed in India. Materials and Methods: A scientific committee designed a questionnaire to examine the post-bariatric surgery complications during a fixed time period in India. Data requested included demographic data, co-morbidities, type of procedure, complications, investigations and management of complications. This questionnaire was sent to all centres where bariatric surgery is performed in India. Data collected were reviewed, were analysed and are presented. Results: Twenty-four centres responded with a report on 11,568 bariatric procedures. These included 4776 (41.3%) sleeve gastrectomy (SG), 3187 (27.5%) one anastomosis gastric bypass (OAGB), 2993 (25.9%) Roux-en-Y gastric bypass (RYGB) and 612 (5.3%) other procedures. Total reported complications were 363 (3.13%). Post-operative bleeding (0.75%) and nutritional deficiency (0.75%) were the two most common complications. Leaks (P = 0.009) and gastro-oesophageal reflux disease (P = 0.019) were significantly higher in SG, marginal ulcers in OAGB (P = 0.000), intestinal obstruction in RYGB (P = 0.001) and nutritional complications in other procedures (P = 0.000). Overall, the percentage of complications was higher in 'other' procedures (6.05%, P = 0.000). There were 18 (0.16%) reported mortalities. Conclusions: The post-bariatric composite complication rate from the 24 participating centres in this study from India is at par with the published data. Aggressive post-bariatric follow-up is required to improve nutritional outcomes.
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HOW I DO IT Top

Laparoscopic loop cystojejunostomy: An alternative to Roux-en-Y cystojejunostomy for pancreatic pseudocyst p. 221
Mohit K Badgurjar, Pranav Mandovra, Surendra K Mathur, Roy Patankar
DOI:10.4103/jmas.JMAS_73_20  PMID:32964880
Surgical internal drainage of pancreatic pseudocyst can be done into the stomach, duodenum or jejunum depending on the anatomic relation of pseudocyst with hollow viscera. For cystojejunostomy, a Roux-en-Y loop is preferred over loop cystojejunostomy as former is thought to avoid the reflux of jejunal contents into the cyst cavity. This study presents our experience with laparoscopic loop cystojejunostomy showing loop cystojejunostomy for the pseudocyst of the pancreas can be safely performed laparoscopically with simpler technique with no complications including reflux.
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Laparoscopic real-time vessel navigation using indocyanine green fluorescence during the laparoscopic-Warshaw technique: First clinical experience p. 226
Yuma Ebihara, Takehiro Noji, Kimitaka Tanaka, Yoshitsugu Nakanishi, Toshimichi Asano, Yo Kurashima, Soichi Murakami, Toru Nakamura, Takahiro Tsuchikawa, Keisuke Okamura, Toshiaki Shichinohe, Satoshi Hirano
DOI:10.4103/jmas.JMAS_161_20  PMID:33723184
Background: Laparoscopic-Warshaw technique (lap-WT) may be selected as a function-preserving operation for malignant border lesions in the tail region of the pancreas. However, previous reports showed that there are complications such as infection and abscess formation due to lack of blood flow to the spleen after surgery. To overcome the problems, we have performed real-time vessel navigation by using indocyanine green (ICG) fluorescence during lap-WT. Materials and Methods: We report our experience of three patients with pancreatic tumour who underwent real-time vessel navigation during lap-WT at Hokkaido University from May 2017 to September 2018. Results: The median operating time was 339 min (174–420). The median intraoperative bleeding was 150 ml (0–480). There were no incidences of complications. There were no cases with post-operative spleen ischaemia or abscess formation and varices formation. Conclusion: We believe that laparoscopic real-time vessel navigation using indocyanine green fluorescence during lap-WT could contribute in reducing the post-operative spleen-related complications.
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Robotic thyroid surgery using bilateral axillo-breast approach: From a trainees' point of view p. 230
Gyan Chand, Jin Wook Yi, Goonj Johri
DOI:10.4103/jmas.JMAS_110_20  PMID:32964870
Background: Across surgical disciplines, the demand for cosmetically superior procedures is stronger than ever and patient-centered health care has become the standard of care. Endoscopic thyroidectomy has revolutionized the field of minimal access endocrine surgery and akin to other surgical disciplines, there has been a natural progression towards robot-assisted thyroidectomy. Amongst the many described approaches, bilateral axillo-breast approach (BABA) and transaxillary are most widely practiced. Aims and Objectives: Our aim was to describe the technique of robot-assisted thyroid surgery (RATS) using BABA. Methods: This is based on the corresponding authors' training and experience of over 50 cases of RATS using BABA, at the Seoul National University, Republic of Korea. Results: Post-operative outcomes were excellent with lesser pain, better cosmesis and similar oncological outcomes in carefully selected thyroid cancers in comparison to conventional thyroidectomy. Conclusion: RATS using BABA is easy to master for endoscopic thyroid surgeons and offers excellent postoperative outcomes, ergonomics, vision and dexterity.
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The technique of fourth jejunal artery-based jejunal conduit for oesophagojejunostomy after thoracolaparoscopic oesophagogastrectomy for locally advanced Siewert type II tumour p. 236
Gunasekaran Gopalakrishnan, Raja Kalayarasan, Senthil Gnanasekaran, Biju Pottakkat
DOI:10.4103/jmas.JMAS_99_20  PMID:32964877
Background: Locally advanced long Siewert type II tumor requires total gastrectomy and D2 lymphadenectomy with distal esophagectomy and mediastinal lymphadenectomy for curative resection. In this scenario, a laparoscopic transhiatal approach is not feasible, and the conventional left thoracoabdominal approach is associated with increased morbidity. Aims and Objectives: To describe a novel technique of fourth jejunal artery based jejunal conduit for thoracoscopic esophagojejunostomy after laparoscopic esophagogastrectomy. Materials and Methods: The laparoscopic total gastrectomy with distal esophagectomy specimen is extracted through the periumbilical incision. A pedicled jejunal conduit based on the fourth jejunal artery is prepared, and the jejunal conduit is placed in the mediastinum under laparoscopic guidance. Using the thoracoscopic approach in a prone position, additional esophageal clearance and subcarinal lymphadenectomy are performed. Handsewn end to side esophagojejunostomy is performed at the level of the carina. Results: Three patients with long Siewert type II underwent this procedure after neoadjuvant chemotherapy. None of the patients had conduit related complications. All three patients had abdominal lymph node involvement and two patients had mediastinal lymph node involvement. Conclusion: Pedicled jejunal conduit based on the fourth jejunal artery is safe for intrathoracic anastomosis after minimally invasive esophagogastrectomy for locally advanced Siewert type II tumor.
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UNUSUAL CASES Top

Chronic encysted giant seroma post-ventral hernia repair masquerading as peritoneal cyst and its laparo-seroscopic management: A case report and literature review p. 241
Bhushan Chittawadagi, Palanisamy Senthilnathan, Chinnusamy Palanivelu
DOI:10.4103/jmas.JMAS_117_20  PMID:32964891
Seroma formation is one the most common occurrence post-ventral hernia repair, with varied presentation from asymptomatic collection to infected collection to chronic collection, which may sometimes present as a diagnostic dilemma and therapeutic challenge. We report a case of giant abdominal swelling presenting as an encysted peritoneal cyst, which was ultimately found to be a chronic seroma and was managed successfully with combined laparo-seroscopic approach.
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Laparoscopic approach in cholecystogastric fistula with cholecystectomy and omental patching: A case report and review p. 245
Sunil Kumar Nayak, R Parthasarathi, G H. V. Raghavendra Gupta, Chinnusamy Palanivelu
DOI:10.4103/jmas.JMAS_87_20  PMID:32964876
Cholecystoenteric fistulas are rare complications of cholelithiasis, with cholecystogastric fistulas (CGFs) being the rarest. Recommended treatment is surgery; however, select asymptomatic patients can be managed conservatively. The population frequently involved is old age with multiple comorbidities. Open surgery comes with its added morbidities, especially in this subgroup and hence laparoscopic surgery might be beneficial. Sometimes, these fistulas can be incomplete. Here, we describe a case of incomplete CGF managed by laparoscopic cholecystectomy and omental patching along with a brief review of the literature.
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Duodenal neuroendocrine tumours in morbidly obese: Amalgamated strategy to optimise outcome p. 249
Nikhil Jain, Banshidhar Soni, Ashish Khetan, Siddharth Mishra, Bhuwanesh Sharma, Rajesh Bhojwani
DOI:10.4103/jmas.JMAS_77_20  PMID:32964873
The association of gastroenteropancreatic neuroendocrine tumours (GEP-NETs) with obesity has been reported and researched on. Rendering of a laparoscopic treatment treating these concurring pathologies in unison has not been described. Two morbidly obese patients with duodenal NETs underwent a resectional procedure, with curative intent, in the form of laparoscopic subtotal gastrectomy with roux-en-y gastrojejunostomy with partial duodenectomy and a laparoscopic one-anastomosis gastric bypass-mini gastric bypass with remnant gastrectomy and partial duodenectomy. Both patients had an uneventful convalescence with acceptable weight loss and no evidence of tumour recurrence on follow-up. The indolent nature of NETs, as compared to the morbidity of obesity provides the rationale for treating this particular cohort of patients with a surgical procedure that would serve to remove the tumour and also provide therapeutic benefit for obesity. With experience in advanced laparoscopic procedures, this can be accomplished safely with acceptable results.
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Laparoscopic-assisted transjejunal endoscopic management of intrahepatic calculi and anastomotic stricture in a patient with Roux-en-Y hepaticojejunostomy p. 253
Elbert Khiangte, Kamal Chetri, Iheule Newme Khiangte, Karabi Patowary Deka, Partha Phukan, Mukesh Agarwala
DOI:10.4103/jmas.JMAS_79_20  PMID:32964874
Management of complications in patients with Roux-en-Y reconstruction is still today an important surgical and endoscopic challenge. Various techniques have been employed to manage biliary strictures and intrahepatic calculi in patients with Roux-en-Y hepaticojejunostomy (RYHJ). We report the case of a 24-year-old female who had undergone RYHJ reconstruction 3 years back for choledochal cyst, admitted with the diagnosis of obstructive jaundice due to anastomotic stricture and multiple hepatic duct calculi. She was successfully treated with laparoscopic-assisted transjejunal endoscopic management of intrahepatic calculi and anastomotic stricture, which appears to be safe and useful procedure for anastomotic stricture and hepatic duct calculi in patients with surgically altered anatomy.
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Laparoscopic excision for small intestinal mesenteric tumour diagnosed Schloffer tumour p. 256
Toru Obuchi, Kohei Kemuriyama, Hiroshi Tamura, Hiroshi Imano, Reijiro Saito, Kazuhiko Endo, Masato Takahashi
DOI:10.4103/jmas.JMAS_107_20  PMID:32964869
This report presents a case of Schloffer tumour at the small intestinal mesentery, mimicking a malignant tumour, treated laparoscopically. Six years prior, a 57-year-old woman underwent laparoscopic salpingo-oophorectomy for a benign, cystic, ovarian tumour, but she had no history of malignancy. She was treated at an outpatient clinic for gastrointestinal complaints and was relieved of these symptoms. Abdominal computed tomography showed an incidental mesenteric tumour of the small intestine, tending toward growth. Due to the tumour's malignant potential, laparoscopic examination was performed. A spherical tumour with a base in the jejunum mesentery was observed. It was removed without damage. The post-operative course was uneventful, and the patient was discharged 3 days after the operation without complications. Histological diagnosis showed this to be a Schloffer tumour, but no malignancy was observed. Unidentified intraperitoneal tumours in patients with surgical histories may be Schloffer tumours, and this should be kept in mind.
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Laparoscopic excision of a Type II choledochal cyst with cystolithiasis p. 259
Arihanth Ravichandran, Anbalagan Pichaimuthu, Rekha Arcot
DOI:10.4103/jmas.JMAS_181_20  PMID:33723185
Choledochal cysts can present with abdominal pain, jaundice and stones.MRI is the standard imaging tool and the type of biliary enteric anastomosis depends on the cyst type.
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Laparoscopic resection for low rectal cancer in a patient with horseshoe kidney – Technical considerations to prevent iatrogenic injuries p. 262
B Vigneshwaran, Dillip Muduly, Mahesh Sultania, Tim Houghton, Madhabananda Kar
DOI:10.4103/jmas.JMAS_142_20  PMID:33723186
Horseshoe kidney (HSK) is a rare congenital malformation of the kidneys and is commonly associated with other anomalies of the renovascular and ureteropelvic systems. These anomalies present a surgical challenge, especially for surgeries involving the retroperitoneum. We present the case of a 56-year-old male patient with biopsy-proven rectal cancer who had completed neoadjuvant chemoradiation and was planned for curative resection. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis revealed the presence of an HSK. Reconstructed three-dimensional (3D) images of the renal vasculature revealed the presence of an accessory renal artery originating directly from the aorta and supplying the isthmus of the HSK without any other venous or ureteral anomalies. Laparoscopic abdominoperineal resection with total mesorectal excision was done without any untoward complications. The presence of HSK per se is not a contraindication for laparoscopic operations involving the retroperitoneum. Pre-operative 3D CECT helps to identify the presence of anatomical variations and guides surgical resection.
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Laparoscopic treatment of postpartum pre-sacral haematoma p. 265
Rahul Gupta, Pradip Pokharia, Ujjwal Daspal, Houssem Ammar
DOI:10.4103/jmas.JMAS_153_20  PMID:33723187
Postpartum retroperitoneal or pelvic haematomas are rare after vaginal delivery. The clinical presentation can vary from being an incidental finding to the development of life-threatening bleeding. Due to their rarity, there are no established guidelines for the management of these postpartum haematomas. The reported treatments vary from watchful observation to emergent laparotomy. We report a case of postpartum pre-sacral haematoma after uneventful vaginal delivery managed successfully by laparoscopic drainage after the failure of conservative treatment.
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Laparoscopic right colectomy for colon cancer after liver transplantation p. 268
Riccardo Bertelli, Enrico Prosperi, Enrico Faccani, Luca Ansaloni
DOI:10.4103/jmas.JMAS_134_20  PMID:33723188
The incidence of colorectal cancer (CRC) after liver transplantation is 0.5%–4%. Laparoscopic surgery is the standard-of-care treatment, however it is rarely performed in patients who had previously undergone liver transplantation. Few reports exist regarding minimally invasive surgery in such context and none about laparoscopic right colectomy. We present the case of a 64-year-old female with a history of liver transplantation in 2001 and who developed a right-sided CRC. A laparoscopic right colectomy was successfully performed, and the post-operative course was uneventful. Given the known benefits, we believe that laparoscopic approach should be considered in such patients.
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PERSONAL VIEWPOINT Top

Twenty years of mini-laparoscopy in Brazil: What we have learned so far p. 271
Diego Laurentino Lima, Gustavo Lopes Carvalho, Raquel Nogueira Cordeiro
DOI:10.4103/jmas.JMAS_179_19  PMID:31997783
The mini-laparoscopic cholecystectomy (MLC) was first performed in 1996, as the logical advancement of the conventional laparoscopic cholecystectomy. In Brazil, mini-laparoscopy was first performed in 1998, by Professors Peter Goh and Go Wakabaiashi, who performed a cholecystectomy using 3-mm instruments. The first study, with a considerable number of patients, was performed in Recife by Dr. Carvalho, and he reported that 719 patients were submitted to a MLC with a small rate of conversion for conventional laparoscopy. We discuss the development of mini-laparoscopy in Brazil for the past 20 years.
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INVITED COMMENTARY Top

Robot-assisted pyeloplasty: The way forward p. 274
Pankaj N Maheshwari, Amandeep M Arora
DOI:10.4103/jmas.JMAS_59_20  PMID:32964878
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LETTERS TO THE EDITOR Top

Considerations for robotic-assisted laparoscopic surgery in children p. 276
Peter Anto Johnson, John Christy Johnson
DOI:10.4103/jmas.JMAS_327_20  PMID:33723189
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Rate of conversion to an open procedure: Is it really reduced in robotic colorectal surgery? p. 278
Rogério Serafim Parra, Marley Ribeiro Feitosa, Omar Féres
DOI:10.4103/jmas.JMAS_136_20  PMID:33723190
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04