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July-September 2010 Volume 6 | Issue 3
Page Nos. 59-90
Online since Friday, August 20, 2010
Accessed 59,739 times.
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REVIEW ARTICLE |
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Bleeding complications in laparoscopic cholecystectomy: Incidence, mechanisms, prevention and management  |
p. 59 |
Robin Kaushik DOI:10.4103/0972-9941.68579 PMID:20877476Background: Laparoscopic cholecystectomy (LC) has established itself firmly as the 'gold standard' for the treatment of gallstone disease, but it can, at times, be associated with significant morbidity and mortality. Existing literature has focused almost exclusively on the biliary complications of this procedure, but other complications such as significant haemorrhage can also be encountered, with an immediate mortality if not recognized and treated in a timely manner. Materials and Methods: Publications in English language literature that have reported the complication of bleeding during or after the performance of LC were identified and accessed. The results thus obtained were tabulated and analyzed to get a true picture of this complication, its mechanism and preventive measures. Results: Bleeding has been reported to occur with an incidence of up to nearly 10% in various series, and can occur at any time during LC (during trocar insertion, dissection technique or slippage of clips/ ligatures) or in the postoperative period. It can range from minor haematomas to life-threatening injuries to major intra-abdominal vessels (such as aorta, vena cava and iliacs). Conclusion: Good surgical technique, awareness and early recognition and management of such cases are keys to success when dealing with this problem. |
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ORIGINAL ARTICLES |
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Is oesophageal manometry a must before laparoscopic fundoplication? Analysis of 46 consecutive patients treated without preoperative manometry |
p. 66 |
Anish P Nagpal, Harshad Soni, Sanjiv Haribhakti DOI:10.4103/0972-9941.68581 PMID:20877477Aims: To evaluate retrospectively the outcome of laparoscopic fundoplication in a cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD). Materials and Methods: Forty-six patients with typical symptoms of GERD, from March 2001 to November 2009, were studied. The study was limited to patients with positive findings on upper GI endoscopy done by ourselves and "typical" symptoms (heartburn, regurgitation, and dysphagia) of GERD. Laparoscopic Nissen's fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only 1 patient, who had negative endoscopic findings, underwent a 24-hour pH-monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient's evaluation of outcome and quality of life after surgery. Results: Relief of the primary symptom responsible for surgery was achieved in 85% of patients at a mean follow-up of 28 months. Thirty-nine patients were asymptomatic, 2 had minor gastrointestinal symptoms not requiring medical therapy, 3 patients had gastrointestinal symptoms requiring medical therapy/ Proton Pump Inhibitors and in 2 patients the symptoms worsened after surgery. There were no deaths. Clinically significant complications occurred in 6 patients. Median hospital stay was 3 days, decreasing from 6 in the first 10 patients to 3 in the last 10 patients. Conclusions: Preoperative oesophageal manometry is not mandatory for laparoscopic fundoplication done in selected patients with typical symptoms of GERD and upper GI endoscopy suggestive of large hiatus hernia. |
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Laparoscopic splenectomy in patients of β thalassemia: Our experience |
p. 70 |
Nirmal M Patle, Om Tantia, Prakash Kumar Sasmal, Shashi Khanna, Bimalendu Sen DOI:10.4103/0972-9941.68583 PMID:20877478Background : Laparoscopic splenectomy has become a standard treatment of various haematological disorders, but its feasibility in the setting of β thalassemia has not been established. Materials and Methods: Fifty patients of β thalassemia underwent laparoscopic splenectomy between January 2006 and December 2008. "Anterior approach" method was practiced in all cases, with early ligation of splenic artery and delayed ligation of splenic vein. Specimen was extracted piecemeal via the umbilical port in initial 12 cases, while in 37 cases the specimen was extracted through a 7-8-cm pfannenstiel incision. Twelve patients of β thalassemia having grade IV splenomegaly with hepatomegaly were electively operated by conventional open method. Results: The procedure was completed in 49 patients. One (2%) patient required conversion to open surgery. Mean operating time in the first 12 cases was 151 minutes (110-210 minutes), while in 37 cases of splenectomy completed laparoscopically it was 124 minutes (80-190 minutes) [P < 0.05]. Mean intra-operative blood loss was 73.8 ml (30-520 ml). No major intra-operative complications occurred. No patient required per-operative blood transfusion. Mean postoperative hospital stay was 4.7 days (2-11 days). Mean preoperative blood transfusion requirement was 11.98 units per patient per year, while mean postoperative blood transfusion requirement was 4.04 units [P< 0.05]. Conclusion: Laparoscopic splenectomy is feasible and safe even in patients of β thalassemia with massive splenomegaly. Removal of specimen via a pfannenstiel incision significantly saves time, carries low morbidity and is a cosmetically acceptable alternative. |
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UNUSUAL CASES |
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Boerhaave's syndrome: Thoracolaparoscopic approach |
p. 76 |
Shulmit Vaidya, Suraj Prabhudessai, Nitish Jhawar, Roy V Patankar DOI:10.4103/0972-9941.68585 PMID:20877479We present a case of Boerhaave's syndrome managed thoracolaparoscopically. A 45-year- old man presented with hydropneumothorax following severe retching. He was treated with Intercostal drainage insertion as the primary management and referred to a tertiary care centre. There endoscopic stapling was attempted, following which he developed a leak. He presented to us with severe sepsis and mediastinal collection on the ninth day following the perforation. We treated him with thoracoscopic mediastinal toilet, laparoscopic-assisted feeding jejunostomy and cervical oesophagostomy. The patient was managed conservatively. A computed tomography (CT) scan was repeated at intervals of 15 days. He was continued on full jejunostomy feeds. Regular assessment of the oesophagus injury was conducted via the CT scan. The patient had complete healing of the perforation at end of two months. His oesophagostomy was closed and he remained symptom-free at follow-up. We conclude that thoracoscopy has an important role to play in the management of patients with mediastinal sepsis and late presentation of Boerhaave's perforation. |
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Laparoscopic ureteric reimplantation of a single-system ectopic ureter in a girl: A rarity |
p. 80 |
Suresh Kumar, Malay Kumar Bera, Keya Pal Bera, Mukesh Kumar Vijay, Anup Kr Kundu DOI:10.4103/0972-9941.68584 PMID:20877480A 14-year-old girl presented with continuous dribbling of urine along with normal voiding pattern since childhood. Cystourethroscopy showed absence of right ureteric opening, and vaginoscopy showed right ureter opening into vaginal vault. Radiological images showed small right kidney with normal excretory function with single-system ectopic ureter. Patient underwent laparoscopic transperitoneal extravesical ureteric reimplantation. At 3 months' follow-up, intravenous urography (IVU) and micturating cystourethrogram (MCU) showed no obstruction and reflux. |
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Laparoscopic splenectomy for tuberculous abscess of the spleen |
p. 83 |
Deepraj Bhandarkar, Avinash Katara, Manu Shankar, Gaurav Mittal, Tehemton E Udwadia DOI:10.4103/0972-9941.68582 PMID:20877481Abscess of the spleen is an uncommon clinical entity and a tuberculous abscess is particularly rare. Although image-guided aspiration has been reported, splenectomy is the preferred modality of treatment. We report a 32-year-old female diagnosed to have a large, multilocular splenic abscess during investigation of a pyrexial illness. Her haemoglobin was 9.8 gm%, ESR 100 mm/1 st hour and she was HIV negative. She had been on anti-tubercular chemotherapy (started elsewhere) for 2 months but had shown poor response. A laparoscopic splenectomy undertaken using four-ports was challenging due to the presence of perisplenitis and adhesions in the splenic hilum. Also, fundus of stomach densely adherent to the upper pole of the spleen required stapled resection. Postoperatively, she developed a low-output pancreatic fistula that resolved with conservative treatment within a week. Histopathology of the spleen confirmed tuberculosis. She responded well to anti-tubercular chemotherapy and remains well 3 years later. |
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HOW I DO IT DIFFERENTLY |
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Novel technique for closure of defect in laparoscopic ventral hernia repair |
p. 86 |
Deborshi Sharma, Vikas Jindal, Om Prakash Pathania, Shaji Thomas DOI:10.4103/0972-9941.68580 PMID:20877482Laparoscopic repair of ventral hernia is the standard of care in today`s era. With increasing experience, different theories and techniques have been described by different authors to overcome the intraoperative and postoperative problems. We describe a novel technique for closure of defect in laparoscopic hernia repair which has the added advantage. |
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LETTERS TO EDITOR |
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Simultaneous laparoscopic nephrectomy in ADPKD |
p. 89 |
Ramen Kumar Baishya, Prabhat Ranjan, Ravindra B Sabnis, Mahesh R Desai DOI:10.4103/0972-9941.68577 PMID:20877484 |
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Laparoscopic right paraduodenal hernia repair |
p. 89 |
James G Bittner IV DOI:10.4103/0972-9941.68578 PMID:20877483 |
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