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   2013| July-September  | Volume 9 | Issue 3  
    Online since July 22, 2013

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Outcomes of Xanthogranulomatous cholecystitis in laparoscopic era: A retrospective Cohort study
Abdul Rehman Alvi, Imran Jalbani, Ghulam Murtaza, Aamir Hameed
July-September 2013, 9(3):109-115
DOI:10.4103/0972-9941.115368  PMID:24019688
Introduction: Xanthogranulomatous cholecystitis (XGC) is a rare variant of cholecystitis and reported incidence of XGC varies from different geographic region from 0.7% -9%. Most of the clinicians are not aware of the pathology and less evidence is available regarding the optimal treatment of this less common form of cholecystitis in the present era of laparoscopic surgery. Materials and Methods: A retrospective cohort study was conducted in a tertiary care university hospital from 1989 to 2009. Histopathologically confirmed XGC study patients (N=27) were compared with non-Xanthogranulomatous cholecystitis (NXGC) control group (N=27). The outcomes variables were operative time, complication rate and laparoscopic to open cholecystectomy conversion rate. The study group (XGC) was further divided in to three sub groups; group I open cholecystectomy (OC), laparoscopic cholecystectomy (LC) and laparoscopic converted to open cholecystectomy (LCO) for comparative analysis to identify the significant variables. Results: During the study period 6878 underwent cholecystectomy including open cholecystectomy in 2309 and laparoscopic cholecystectomy in 4569 patients. Histopathology confirmed xanthogranulomatous cholecystitis in 30 patients (0.43% of all cholecystectomies) and 27 patients qualified for the inclusion criterion. Gallbladder carcinoma was reported in 100 patients (1.45%) during the study period and no association was found with XGC. The mean age of patients with XGC was 49.8 year (range: 29-79), with male to female ratio of 1:3. The most common clinical features were abdominal pain and tenderness in right hypochondrium. Biliary colic and acute cholecystitis were the most common preoperative diagnosis. Ultrasonogram was performed in all patients and CT scan abdomen in 5 patients. In study population (XGC), 10 were patients in group I, 8 in group II and 9 in group III. Conversion rate from laparoscopy to open was 53 % (n=9), surgical site infection rate of 14.8% (n=4) and common bile duct injury occurred one patient in open cholecystectomy group (3.7%). Statistically significant differences between group I and group II were raised total leukocyte count: 10.6±3.05 vs. 7.05±1.8 (P-Value 0.02) and duration of surgery in minutes: 248.75±165 vs. 109±39.7 (P-Value 0.04). The differences between group III and group II were duration of surgery in minutes: 208.75±58 vs. 109±39.7 (P-Value 0.03) and duration of symptoms in days: 3±1.8 vs. 9.8±8.8 (P-Value 0.04). The mean hospital stay in group I was 9.7 days, group II 5.6 days and in group III 10.5 days. Two patients underwent extended cholecystectomy based on clinical suspicion of carcinoma. No mortality was observed in this study population. Duration of surgery was higher in XGC group as compared to controls (NXGC) (203±129 vs.128±4, p-value=0.008) and no statistically significant difference in incidence proportion of operative complication rate were observed among the group (25.9% vs. 14.8%, p-value=0.25. Laparoscopic surgery was introduced in 1994 and 17 patients underwent laparoscopic cholecystectomy and higher conversion rate from laparoscopic to open cholecystectomy was observed in 17 study group (XGC) as compared to 27 Control group (NXGC) 53%vs.3.3% with P-value of < 0.023. Conclusion: XGC is a rare entity of cholecystitis and preoperative diagnosis is a challenging task. Difficult dissection was encountered in open as well in laparoscopic cholecystectomy with increased operation time. Laparoscopic cholecystectomy was carried out with high conversion rate to improve the safety of procedure. Per operative clinical suspicion of malignancy was high but no association of XGC was found with gallbladder carcinoma, therefore frozen section is recommended before embarking on radical surgery.
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Single incision laparoscopic distal pancreatectomy with splenectomy for neuroendocrine tumor of the tail of pancreas
Gadiyaram Srikanth, Neel Shetty, Deepak Dubey
July-September 2013, 9(3):132-135
DOI:10.4103/0972-9941.115377  PMID:24019693
Laparoscopic resection is becoming the standard of care for tumors located in the body and tail of pancreas. We herein report a patient with neuroendocrine tumor in the tail of pancreas who underwent single incision laparoscopic distal pancreatectomy with splenectomy without the use of a commercial port device.
  1 2,625 115
A simplified protocol of combined thoracoscopy and laparoscopic excision for large subdiaphragmatic hepatic hydatid cysts
Uday S Kumbhar, G Satyam, PRK Bhargav, Venkata Pavan Kumar Chigurupati
July-September 2013, 9(3):141-144
DOI:10.4103/0972-9941.115384  PMID:24019696
Human hydatid disease caused by echinococcus granulosus is one of the commonest zoonosis and it primarily affects the liver. Amongst, the various treatment options, surgical management with removal of its contents and pericystectomy under the cover of anti-helminthic is the treatment of choice. Large hydatid cysts located in the posterosuperior aspect of liver often require thoracic approach. In this context, we describe an innovative combined thoraco-laparoscopic technique for the surgical treatment of large subdiaphragmatic hepatic hydatid cyst.
  1 2,410 100
Laparoscopic vertical sleeve gastrectomy after open gastric banding in a patient with situs inversus totalis
K Sugunakara Rao
July-September 2013, 9(3):145-146
DOI:10.4103/0972-9941.115385  PMID:24019697
  - 1,555 80
Does case selection and outcome following laparoscopic colorectal resection change after initial learning curve? Analysis of 235 consecutive elective laparoscopic colorectal resections
Kurumboor Prakash, NP Kamalesh, K Pramil, IS Vipin, A Sylesh, Manoj Jacob
July-September 2013, 9(3):99-103
DOI:10.4103/0972-9941.115366  PMID:24019686
Introduction: Laparoscopic colorectal surgery is being widely practiced with an excellent short-term and equal long-term results for colorectal diseases including cancer. However, it is widely believed that as the experience of the surgeon/unit improves the results get better. This study aims to assess the pattern of case selection and short-term results of laparoscopic colorectal surgery in a high volume centre in two different time frames. Materials and Methods: This study was done from the prospective data of 265 elective laparoscopic colorectal resections performed in a single unit from December 2005 to April 2011. The group was subdivided into initial 132 patients (Group 1) from December 2005 to December 2008 and next 133 patients (Group 2) between December 2008 and April 2011 who underwent laparoscopic colorectal resections for cancer. The groups were compared for intraoperative and perioperative parameters, type of surgery, and the stage of the disease. Results: The age of patients was similar in Groups 1 and 2 (57.7 and 56.9, respectively). Patients with co-morbid illness were significantly more in Group 2 than in Group 1 (63.2% vs. 32.5%, respectively, P≤0.001). There were significantly more cases of right colonic cancers in Group 1 than in Group 2 (21.9% vs. 11.3%, respectively, P<0.02) and less number of low rectal lesions (20.4% vs. 33.8%, respectively, P≤0.02). The conversion rates were 3.7% and 2.2% in Groups 1 and 2, respectively. The operating time and blood loss were significantly more in Group 1 than in Group 2. The ICU stay was significantly different in Groups 1 and 2 (31.2± 19.1 vs. 24.7± 18.7 h, P≤0.005). The time for removal of the nasogastric tube was significantly earlier (P=0.005) in Group 2 compared to Group 1 (1.37± 1.1 vs. 2.63±1.01 days). The time to pass first flatus, resumption of oral liquids, semisolid diet, and complications were similar in both groups. The hospital stay was more in Group 1 than in Group 2 ( P≤0.01). The numbers of lymph nodes retrieved was similar in both groups. The T stage of the disease in Groups 1 and 2 were similar, however, the number of T4 lesions was significantly more in Group 2 (8.3% vs. 18.7%, respectively, P<0.01). Conclusion: This study shows that with increasing experience, laparoscopic colorectal surgery can be practiced safely with minimal conversion rates and morbidity. As the units experience improves, there is a trend towards selecting advanced cases and performing complex laparoscopic colorectal procedures. With increasing experience, there is a trend towards better short-term outcome after laparoscopic colorectal surgeries.
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Gasless single incision trans-axillary thyroidectomy: The feasibility and safety of a hypo-morbid endoscopic thyroidectomy technique
Panchangam R K Bhargav, Uday S Kumbhar, G Satyam, KB Gayathri
July-September 2013, 9(3):116-121
DOI:10.4103/0972-9941.115370  PMID:24019689
Introduction: A range of minimally invasive endoscopic techniques (gas dependent and gasless) have been attempted for thyroidectomy in the past two decades. In this context, we evaluated the feasibility and safety of our technique of a gasless trans-axillary thyroidectomy. Material and Methods: This retrospective study from the Department of Endocrine and metabolic surgery in Southern India included 15 cases. The details of operative technique, intra and postoperative data were documented in all the cases. Only cases with benign thyroid nodules were included. Exclusion criteria were diffuse toxic goiters (Graves' disease), thyroid cancer, > 6 cm nodules, recurrent goitres and patients with shoulder joint pathology. Statistical analysis was done with SPSS software 12.0 version. Results: F:M -14:2. Mean age of the patient group was 26.4 years (15-52). Mean operative time was 123.4 (82-206) minutes. The only specific complications were induration in the infraclavicular area between axillary incision and thyroid region, prolonged wound drainage and stiffness in lower 3 rd of sternocleidomastoid. Wound drainage lasted for 5.4 days (4 -8). There was no significant operative morbidity. Conclusion: This gasless trans-axillary technique for nodular goitres is safe and effective in the hands of an experienced thyroid surgeon.
  - 3,471 176
Two-port laparoscopic cholecystectomy with modified suture retraction of the fundus: A practical approach
Ming G Tian, Pei J Zhang, Y Yang, Fan J Shang, J Zhan
July-September 2013, 9(3):122-125
DOI:10.4103/0972-9941.115372  PMID:24019690
Context: Although transumbilical single incision laparoscopic cholecystectomy (SILC) has been demonstrated to be superior cosmetic, it is only limited to simple cases at present. In complex cases, the standard four- or three-port LC is still the treatment of choice. Aim: To summarize the clinical effect of a modified technique in two-port LC. Settings and Design: A consecutive series of patients with benign gallbladder diseases admitted to the provincial teaching hospital who underwent LC in the past 4 years were included. A modified two-port LC was the first choice except for those requiring laparoscopic common bile duct exploration (LCBDE). Materials and Methods: The operation was done with suture retraction of the fundus by a needle-like retractor. The patients' data, including the operative time, time consumed by gallbladder retraction, operative bleeding, conversion rate, rate of adding trocars, and postoperative complications were recorded. Statistical Analysis: Data were expressed as percentage and mean with standard deviation. Results: Total 107 patients with chronic calculous cholecystitis (N = 61), acute calculous cholecystitis (N = 43), and cholecystic polyps (N = 3) received two-port LC. The procedure was successful in 99 out of 107 cases (success rate, 92.5%), and a third trocar was added in the remaining 8 cases (7.5%) due to severe pathological changes. The operative time was 47.2 (±13.21) min. There was no conversion to open surgery. Conclusion: Two-port LC using a needle-like retractor for suture retraction of the gallbladder fundus is a practical approach when considering the safety, convenience, and indications as well as relatively minimal invasion.
  - 1,966 180
Transumbilical single-incision laparoscopic sleeve gastrectomy: Short-term results and technical considerations
Reinhard Mittermair
July-September 2013, 9(3):104-108
DOI:10.4103/0972-9941.115367  PMID:24019687
Background:Laparoscopic sleeve gastrectomy (SG) has gained popularity and acceptance among bariatric surgeons, mainly due its low morbidity and mortality. Single-incision laparoscopic surgery has emerged as another modality of carrying out the bariatric procedures. While the single-incision transumbilical (SITU) approach represents an advance, especially for cosmetic reasons, its application in morbid obesity at present is limited. We describe our short-term surgical results and technical considerations with SITU-SG. Materials and Methods:SITU-SG was performed in 10 patients between June 2010 and June 2011. SG was performed in a standard fashion and was started 6 cm from the pylorus using a 36 French bougie. Results: They were all females with a mean age of 45 years. Preoperative BMI was 40 kg/m 2 (range, 35-45). The mean operative time was 98 min. No peri- or postoperative complications or deaths occurred. All patients were very satisfied with the cosmetic outcomes and excess weight loss. Conclusion: True SITU laparoscopic SG is safe and feasible and can be performed without changing the existing principles of the procedure.
  - 3,030 166
Primary posterior perineal herniation of urinary bladder
Kurumboor Prakash, Palanisami N Kamalesh
July-September 2013, 9(3):126-127
DOI:10.4103/0972-9941.115374  PMID:24019691
Primary perineal hernia is a rare clinical condition wherein herniation of viscera occurs through pelvic diaphragm. They are usually mistaken for sciatic hernia, rectal prolapse or other diseases in the perineum. Correct identification of the type of hernia by imaging is crucial for planning treatment. We present a case of primary posterior herniation of urinary bladder and rectal wall through levator ani repaired laparoscopically using a mesh repair.
  - 2,699 93
Laproendoscopic single site oesophageal diverticulectomy
Chinnusamy Palanivelu, Anirudh Vij, Subbiya Rajapandian, Senthilnathan Palanisamy, Jasmeet S Ahluwalliah, Praveenraj Palanivelu
July-September 2013, 9(3):128-131
DOI:10.4103/0972-9941.115375  PMID:24019692
Epiphrenic divericula are uncommon disorders of the lower oesophagus, which are symptomatic in only 15-20% of cases. The optimum treatment modality for such cases remains an oesophageal diverticulectomy with long myotomy with or without an antireflux operation. Recently, this is increasingly being done through the laparoscopic approach. Here we describe the first reported case of oesophageal diverticulectomy through the laparoendoscopic single site approach. A 57-year-old man presented to us with 6 months history of dysphagia and regurgitation. Patient was investigated with upper gastrointestinal (UGI) endoscopy, barium swallow, CECT chest and abdomen, oesophageal manometry and 24 hour pH study. He was diagnosed to have lower oesophageal diverticulum with mildly elevated pressure readings in manometric studies with normal peristalsis. Based on his symptoms, he was taken up for surgery. A laparoscopic transhiatal oesophageal diverticulectomy with myotomy was done through laparoendoscopic single site technique. The procedure lasted 160 min. There was no intraoperative complication. Gastrograffin study was done on postoperative day 2 following which he was started on liquids. He made an uneventful recovery and was discharged on fourth day. He remained asymptomatic on follow up. Oesophageal diverticulectomy is possible through laparoendoscopic single site approach if necessary expertise is available.
  - 1,933 98
A case of complete transection of right main bronchus in a child: Role of thoracoscopy and bronchoscopy
Ramesh B Hatti, Vinod B Hosalli, Raghavendra N Vanaki, Devaraj H Patil
July-September 2013, 9(3):136-137
DOI:10.4103/0972-9941.115379  PMID:24019694
Isolated tracheobronchial injuries are extremely rare in children and challenging due to life threatening complications. Blunt trauma to chest, especially in pediatric age group, is usually associated with multi-organ involvement and high mortality rate. These patients rarely reach a hospital. We have described here a case of complete transection of right main bronchus in a child, without hilar vascular injury, and its successful management, emphasizing the role of bronchoscopy and thoracoscopy.
  - 1,978 93
Erosion of small intestine with necrotising fasciitis of over lying abdominal wall after expanded poly-tetrafluoroethylene mesh implantation: A rare complication after laparoscopic incisional hernia repair
Ashish Shrivastava, Akshara Gupta, Achal Gupta, Jyoti Shrivastava
July-September 2013, 9(3):138-140
DOI:10.4103/0972-9941.115381  PMID:24019695
Complications such as bowel erosions, enterocutaneous fistulae are rare with the use of expandedpoly-tetrafluoroethylene (ePTFE) mesh in laparoscopic incisional hernia repair (LIHR). This unusual case patient presented to us with necrotising fasciitis of overlying anterior abdominal wall with peritonitis withsepticaemia and underwent aLIHR6 weeks before, which has not been reported till yet. We report a case of LIHR, presented to us with necrotising fasciitis of overlying anterior abdominal wall, peritonitis and septicaemia which was managed by small bowel segmental resection and exteriorisation of the ends, debridement of overlying anterior abdominal wall and maximum resection of implanted mesh. This case is unusual secondary to long experience with ePTFE mesh and the lack of published cases similar to this one. A brief review of relevant literature has been included in the article. We recommend pre-peritoneal placement of dual mesh fixed preferably by trans-abdominal polypropylene suture in LIHR.
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04