Anubhav Vindal

Controlled tube duodenostomy in the management of giant duodenal ulcer perforation—a new technique for a surgically challenging condition

BACKGROUND Giant duodenal ulcer (GDU) perforation remains an extremely uncommon but a rather challenging condition to manage wherein routine surgical procedures are fraught with an extremely high incidence of failure and mortality. It therefore follows that this condition must be identified and managed differently at laparotomy than are most duodenal perforations. We describe a method by which to deal with this condition using triple-tube-ostomy. METHODS In a prospective setting, 20 patients underwent surgery using the technique described in the article. During the same period, 20 patients with GDU perforation, who were managed in the conventional manner, were evaluated. The outcomes of the 2 groups were compared. RESULTS The success rate was 100% in the study group compared with 30% in the control patients. CONCLUSIONS Based on the ease of the technique and the high success of the procedure in our experience in this select group, we recommend this procedure for the management of GDU perforation as a safe, reliable, and easy technique to learn.

Laparoscopic choledochoduodenostomy for biliary stone disease: a single-center 10-year experience.

BACKGROUND AND AIMS Patients with a dilated common bile duct (CBD) and multiple, primary, or recurrent stones are candidates for choledochoduodenostomy. This article reviews our technique and results of laparoscopic choledochoduodenostomy (LCDD) in patients with CBD stones. SUBJECTS AND METHODS Prospectively maintained data of patients with a dilated CBD and multiple, primary, or recurrent CBD stones who underwent LCDD after laparoscopic CBD exploration (LCBDE) at a tertiary-care teaching hospital in New Delhi, India, during a 10-year period from April 2001 to March 2011 were analyzed. RESULTS During this period, of 195 patients who underwent LCBDE for CBD stones, 27 patients underwent LCDD. The mean age of patients was 45.7±13.5 years. There were 6 male and 21 female patients. Sixteen (59.2%) patients had jaundice at presentation. Average CBD diameter was 19.6±4.4 mm. On average, 11.5±15.7 stones were removed from the CBD. Mean operative time was 156.3±25.4 minutes. Mean operative blood loss was 143.3±85.5 mL. Average postoperative hospital stay was 6.4±3.8 days. CBD clearance was obtained in all cases. One patient had a bile leak that resolved with conservative treatment. There was no mortality. No patient has had recurrence of symptoms or cholangitis after a follow-up of up to 9 years. CONCLUSION LCDD can be safely performed in patients with a large stone burden and recurrent or primary CBD stones. Although it requires advanced laparoscopic skills, the benefits of a single-stage laparoscopic procedure can be extended to these patients safely with good results.

Vesical dermoid: An unusual presentation

Dermoid cysts are considered developmental anomalies and consist of tissue from more than one germ cell layer. They occur most commonly in the ovaries, but might also be found at other sites, especially in the midline. Dermoid cysts are particularly rare in the urinary bladder. We herewith present one such case. A 26-year-old woman presented with complaints of the passage of hair in her urine for the past 2 years associated with two episodes of gross hematuria. She had no other genito-urinary or bowel complaints. The clinical, routine blood and urine examinations were normal. An ultrasound of the abdomen showed an irregular, echogenic lesion measuring 5.6 ¥ 6 ¥ 5.3 cm within the lumen of the urinary bladder. On trans-vaginal sonography, both ovaries and the uterus were found to be normal. Cystoscopy showed a 5 ¥ 5 cm mass arising from the dome of the urinary bladder with multiple hairs projecting from it. Computed tomography showed a well-defined lesion in the urinary bladder measuring 5.2 ¥ 3.1 ¥ 4.5 cm showing variegated attenuation of fat, soft tissue and bone. The patient underwent open surgery through lower midline incision. A 6 ¥ 5.5 cm mass was found to be arising from the right posterolateral wall of the bladder. It was covered with skin and hair on its surface. A tooth was also seen arising from the mass. The right ovary, which appeared normal on inspection, was densely adherent to the bladder wall at one of its poles. The intravesical mass was excised with a 1-cm rim of normal bladder mucosa, and right salpingo-oopherectomy was carried out because the ovary could not be separated from the bladder wall (Fig. 1). The bladder was repaired in two layers. The patient had an uneventful recovery. The histopathology report showed a mature teratoma with ectodermal, mesodermal and endodermal elements. The teratoma was reported to be confined to the bladder wall with no extension outside. The excised right ovary and tube did not reveal any pathology. Dermoid cysts are developmental anomalies and are considered teratomas. Leblanc in 1831 coined the term dermoid cyst when he removed a lesion at the base of a horse’s skull, which he called a “kyste dermoid”. Developmentally, dermoid cysts are a result of the sequestration of skin along the lines of embryonic closure that contain mature skin complete with hair follicles and sweat glands, sometimes clumps of long hair, and often pockets of sebum, blood, fat, bone, nails, teeth, eyes, cartilage and thyroid tissue. Because it contains mature tissue, a dermoid cyst is almost always benign. Dermoid cysts are rare in the urinary bladder and can pose a diagnostic problem. A review of the literature revealed just nine reported cases. The passage of hair in the urine (pilimictia) is a pathognomonic sign of urinary bladder dermoid. The origin from primordial germ cells is now the most widely accepted theory of pathogenesis of dermoid cysts. Dermoids are recognized as often being trigerminal and containing practically any type of tissue. The treatment should be conservative considering the benign nature of the entity.

Pseudocyst of the spleen caused by tuberculosis: a rare entity.

Splenic cysts can be primary or secondary, depending upon the aetiology and pathology. Secondary cysts can be of inflammatory, infective, degenerative or traumatic aetiology. Splenic cysts can be true (lined by epithelium) or secondary (pseudocyst, not lined by epithelium). True splenic cysts are mainly congenital and pseudocysts are mainly traumatic in origin. Pseudocyst of the spleen due to tuberculosis is extremely rare .We report one such case of pseudocyst of the spleen caused by tuberculosis together with a relevant review of literature. Our case probably represents the first reported case of tubercular pseudocyst of the spleen.

Biliary duct communication in massive hepatic hydatidosis managed with minimally invasive techniques

Hydatid cyst most commonly involves the liver. Intrabiliary rupture is one of the complications of hepatic hydatidosis. We present a case of 45-year-old lady with a large hydatid cyst occupying the left lobe of the liver with jaundice and upper gastrointestinal pressure symptoms. Contrast-enhanced computed tomography revealed a large hepatic cyst with rupture of contents into the left hepatic duct. The patient underwent laparoscopic excision of the cyst with closure of the biliary communication. Bilious drainage was observed from intra-cavitory drain in the postoperative period for which patient underwent endoscopic retrograde cholangiopancreatography with selective left duct stenting following which bile output decreased over 1-week. The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. Laparoscopic treatment is an effective mode of treatment for biliary fistulas complicating hepatic hydatid cyst in well-selected patients.

The Veress needle causes most laparoscopic injuries and should be abandoned: FOR: The open technique is safer and saves time

Over the last 25 years laparoscopic surgery has become increasingly popular, as it offers numerous advantages over open surgery; however, laparoscopy also involves complications, some of which are related to the process of gaining access to the peritoneal cavity. Various studies have time and again reiterated the need to find a safe and reliable method to achieve laparoscopic entry to reduce the associated morbidity and mortality. One study reported that 83% of vascular injuries, 75% of bowel injuries, and 50% of local haemorrhage were caused during the primary trocar insertion (Champault et al. Surg Laparosc Endosc 1996;6:367–70).