Akshay Anand Agarwal

Current trends in laparoscopic groin hernia repair: A review

Hernia is a common problem of the modern world with its incidence more in developing countries. Inguinal hernia is the most common groin hernia repaired worldwide. With advancement in technology operative techniques of repair have also evolved. A PubMed and COCHRANE database search was accomplished in this regard to establish the current status of laparoscopic inguinal hernia repair in view of recent published literature. Published literature support that laparoscopic hernia repair is best suited for recurrent and bilateral inguinal hernia although it may be offered for primary inguinal hernia if expertise is available.

Gestational hypertrophy of the breast

A 22-year-old woman, parity 1, 24 weeks pregnant, presented with massive diffuse enlargement of both breasts, since, second trimester. Her earlier pregnancy was uneventful. Multiple ulcerations as a result of pressure necrosis were also present for the last 3–4 months (figure 1). Her breasts were normal on ultrasonography with no evidence of cancer. Fine-needle aspiration revealed hyperplasia of the mammary glands with foci of increased fat and connective tissue. The patient was managed conservatively with antibiotics and dressings and she improved. The ulcerations and the huge size were …

Solid pseudopapillary tumour of pancreas

Solid pseudopapillary tumour of the pancreas is a rare neoplasm (1%). This tumour primarily affects young women and is usually treated with surgical resection with a relatively favourable prognosis. We report an 18-year-old female patient presenting with moderate grade abdominal pain for 5 weeks. Abdominal examination revealed a lump palpable in the right upper abdomen. Contrast-enhanced CT abdomen reported soft tissue lesion arising from uncinate process of pancreas causing adjacent compression. Endoscopic ultrasound-guided fine-needle aspiration biopsy yielded a cellular sample comprising pseudopapillary arrangement with bland appearing tumour cells consistent with benign neoplasm. And because of unusual location, Whipple procedure was performed. The patient was discharged under satisfactory conditions. Final histology confirmed the diagnosis. Solid pseudopapillary tumours of the pancreas are a rare but treatable pancreatic tumour. Complete surgical excision is the treatment of choice and can be achieved through an open or minimal access technique.

Day Case Thyroid and Parathyroid Surgery: Time to Replicate Same in Developing Countries.

We would like to congratulate the authors for making the concept of same day-discharge in thyroid and parathyroid surgery a seemingly attainable goal [1]. This is more appealing in a developing country like India considering the high incidence of disease and limited patient to bed ratio. In this attempt; however, the patient’s safety should not be in advertently compromised, a few issues need to be clarified before we can replicate a similar practice here. The large number of patients (n = 2,102) analyzed over a decade happens to be a major strength of this study. However, the retrospective nature of the database and the fact that the surgeries were performed by two consultant surgeons and a surgical trainee/ fellow is likely to impact the robustness of inferences from this study. The likelihood of post-operative complications has been related to volume of both the hospital and the surgeon [2]. We concur with the authors that a safe day case surgery begins with proper patient selection; however, the author have not made it clear as to which were the patients personaland home-related circumstances that rendered one suitable for day case surgery. With respect to procedures which can be offered as a day case procedure, it is not clear if the authors offered day case surgery to all patients listed in the less suitable or contra indicated group. More over there remains a continuing controversy between definitions of goiter in terms of size, more so as to what is the threshold for large goiters [3]. The authors have not mentioned the break up of procedure performed for the nodular goiters and follicular adenoma in terms of hemi/total thyroidectomy and the differences between the characteristics of patients between the three groups (day case, ambulatory, and in patients) in patients of various pathologies of thyroid and parathyroid. Also the authors have not made clear, the breakup of complications in terms of the underlying thyroid pathology or procedure that was performed. Both these information would be needed to come to any definite conclusion regarding safety and widespread replication of day case surgery. The practice of administering prophylactic calcium adopted by the unit has proven to be safe and cost-effective in preventing post-operative hypocalcemia after total or completion thyroidectomy [4]. However, the advent of rapid PTH measurement has made prediction of hypocalcemia post-thyroidectomy possible with acceptable accuracy. It has also proven to be cost-effective [5]. Nomo grams predicting post-operative hypocalcemia can avoid unnecessary calcium supplementation which occasionally poses as a risk to patients.

Hiroki Takahashi et al. "Usefulness of endoscopic breast-conserving surgery for breast cancer" Surgery Today in November (2014) 44: 2037-2044.

reactant, and the use of TLC, neutrophils and IL-6 is appropriate, and there were no significant differences between the two groups in their study. However, the percentage rise in these parameters was higher in the endoscopic group compared to the direct vision group due to the greater tissue mobilization. However, it is unclear whether the randomly selected 20 patients in each group are truly representative of the entire group. The follow-up of patients ranged from 9 to 40 months, with a mean of 23 months. The follow-up is therefore relatively short to comment on the recurrence, as the rate of recurrence is 1–2 % per year for up to 10 years [3]. Taking into account the patients’ perception of cosmesis is commendable. However, the conclusion about cosmesis at 3 months postoperatively is too short, as wound healing and remodeling takes longer than this, and complications like hypertrophic scars and keloid formation can develop up to a year after surgery, and radiotherapy is known to adversely affect wound healing. Most scars take approximately 7 months to fade away, so an evaluation of the cosmesis 6 months or later would have been ideal [4]. In addition, there is a potential bias of the assessment of cosmesis, as the patient themselves chose the procedure, and no mention has been made if the medical personnel assessing the cosmesis were part of the treating team.

Left-sided transmesocolic herniation of small bowel in an otherwise unaffected abdomen

Transmesocolic hernia is an uncommon type of internal hernia with incidence ranging from approximately 5–10%. To the best of our knowledge, this is the first reported case of a transmesocolic hernia through a gap within the descending mesocolon presenting clinically as an intestinal obstruction. A 75-year-old man was admitted with clinical features of intestinal obstruction. An abdominal X-ray showed multiple small bowel loops with air fluid levels. Contrast-enhanced CT of the abdomen revealed small bowel obstruction not only on the right, but also on the left side of the collapsed descending colon. Emergency surgery was performed. Strangulated bowel loops with gangrenous changes were resected and double-barrel ileostomy was carried out. The postoperative period was uneventful. Restoration of bowel was performed after 6 weeks. Preoperative diagnosis of bowel obstruction caused by a transmesocolic hernia remains difficult despite the currently available imaging techniques. Prompt surgery can prevent serious complications such as peritonitis and sepsis.

Penile strangulation due to plastic bottle neck: a surgical emergency

Use of various metallic and non-metallic constricting objects on the external male genitalia for increasing sexual performance or because of autoerotic intentions is an unusual practice that can potentially lead to penile strangulation with severe consequences. Depending on the type of constricting material, emergency removal of such an object is a challenge. We report a case of a 45-year-old man who presented to our hospital with a hard plastic bottle neck at the base of his penis that led to penile strangulation. The constricting agent was successfully removed. The patient had an uneventful recovery.

Spontaneous splenic rupture presenting as haemoperitoneum: coinfection of Plasmodium vivax and Plasmodium falciparum

Non-traumatic splenic rupture has been described in the medical literature as a clinical entity with grave consequences, if diagnosis and subsequent treatment are delayed. Various pathological reasons implicated in non-traumatic spontaneous splenic rupture have been described in literature ranging from infection, malignancy, metabolic disorders as well as haematological malignancies. This case reports a 30-year-old man who presented in the emergency department with complaints of fever and a sudden-onset abdominal pain with no history of trauma. At hospital admission, abdominal tenderness with splenomegaly was present with free fluid in abdomen. Haematological investigations established the coinfection of Plasmodium falciparum and Plasmodium vivax. Radiological investigations revealed splenic laceration with moderate haemoperitoneum. The patient was managed conservatively with strict vital monitoring. Later on, elective splenectomy was performed. The authors report only the second case in literature with coinfection of plasmodium species presenting with haemoperitoneum.