Avinash Katara

Single-incision laparoscopic cholecystectomy: How I do it?

Single-incision laparoscopic cholecystectomy (SILC) is a relatively new technique that is being increasingly used by surgeons around the world. Unlike the multi-port cholecystectomy, a standardised technique and detailed description of the operative steps of SILC is lacking in the literature. This article provides a stepwise account of the technique of SILC aimed at surgeons wishing to learn the procedure. A brief review of the current literature on SILC follows.

Laparoscopic biopsy in patients with abdominal lymphadenopathy

Background: Abdominal lymphadenopathy (AL) - a common clinical scenario faced by clinicians - often poses a diagnostic challenge. In the absence of palpable peripheral nodes, tissue has to be obtained from the abdominal nodes by image-guided biopsy or surgery. In this context a laparoscopic biopsy avoids the morbidity of a laparotomy. Aim: This retrospective analysis of prospectively collected data represents our experience with laparoscopic biopsy of abdominal lymph nodes. Materials and Methods: Between October 2000 and November 2005, 28 patients with AL underwent laparoscopic biopsy. Pre-operative radiological imaging studies had identified a nodal mass in 20, a solitary node in 1, a cold abscess in 1 and a mesenteric cystic lesion in 1 patient. In five patients with chronic right lower abdominal pain and normal ultra-sonographic findings mesenteric nodes were identified and biopsied during diagnostic laparoscopy. Results: The sites of biopsied lymph nodes included para-aortic (10), mesenteric (8), external iliac (3), left gastric (2), obturator (1), aorto-caval (1) and porta hepatis (1). One patient with enlarged peripancreatic nodes mass and another with a mesenteric cystic mass had cold abscesses drained in addition to biopsy. There were no perioperative complications and the median postoperative stay was 2 days (range 1-4 days). Histopathology revealed tuberculosis in 23 patients, reactive adenitis in 2, lymphoma in 1 metastatic carcinoma in 1, and a retroperitoneal sarcoma in 1. Conclusions: In patients with AL, laparoscopy provides a safe and effective means of obtaining biopsy. It is of particular value in patients in whom (a) the nodes are small or present in locations unsuitable for image-guided biopsy, (b) adequate tissue cannot be obtained by image-guided biopsy or (c) previously undiagnosed lymphadenopathy is encountered during diagnostic laparoscopy.

Laparoscopic management of antenatally-diagnosed abdominal cysts in newborns.

We report two newborns each detected to have a large intra-abdominal cyst on antenatal ultrasonography. Postnatal imaging confirmed presence of the cysts and showed a complex cyst with multiple septae in the first patient and evidence of bleeding in both. Laparoscopy performed on the 14th and 19th day of life, respectively, showed ovarian cysts with hemorrhage and torsion. The cysts were treated successfully by laparoscopic oopherectomy. Histopathology revealed an ovarian gonadoblastoma in the first patient and a simple cyst with calcification in the second. Both patients remain well at a follow up of six and four months. Laparoscopic treatment of antenatally detected cystic abdominal masses is a feasible option in the newborn.

Laparoscopic resection of a large paraganglioma arising in the organ of Zuckerkandl: Report of a case and review of the literature

Paragangliomas are catecholamine-secreting neuroendocrine tumours arising from chromaffin tissue at extra-adrenal sites. The commonest site for a paraganglioma is the organ of Zuckerkandl. Traditional treatment of paraganglioma of organ of Zuckerkandl (POZ) involves open surgical resection, and only a few cases of laparoscopic approach to this pathology have been reported. We report the successful laparoscopic resection of a large POZ in a 22-year-old woman and review the previous cases reporting a laparoscopic approach to this rare tumour.

Laparoscopic management of renal hilar pheochromocytomas.

Although laparoscopic adrenalectomy is well established for the treatment of adrenal pheochromocytomas, there is scant literature on a laparoscopic approach to extra-adrenal pheochromocytomas (EAP). We report on 2 patients with renal hilar pheochromocytomas treated by a laparoscopic resection. A 56-year-old hypertensive man was found to have a 3.5-cm tumor in the right renal hilum, which was confirmed to be a pheochromocytoma on the basis of elevated urinary vanillylmandelic acid levels and a positive 131I-MIBG scan. After pharmacological preparation, he underwent a laparoscopic excision. The recovery was uneventful and the final histopathology confirmed an EAP. The second patient, a 17-year-old hypertensive girl, was shown to have a 2.5-cm tumor in close proximity to the left renal vessels and a poorly functioning left kidney on a computed tomography scan. Subsequent isotope renogram showed 4% function in the left kidney. After adequate preparation, she underwent a laparoscopic left nephrectomy along with resection of the tumor. The postoperative period was uneventful. Histopathology showed an EAP. The kidney showed ischemic changes along with severe renal artery stenosis. The patients remain well 49 and 14 months post-surgery. In conclusion, careful preoperative preparation, expert intraoperative anesthetic management, and surgery performed by an experienced surgeon make laparoscopic resection of renal hilar pheochromocytomas a safe and feasible treatment option.

Temporary obturator nerve paresis after spray of local anesthetic during laparoscopic extraperitoneal inguinal hernia repair.

To the Editor: Laparoscopic totally extraperitoneal repair (TEP), a well-accepted treatment of inguinal hernia, is often performed on an outpatient basis and the patients are invariably encouraged to mobilize early. It is a common practice to infiltrate the incisions with local anesthetic and spray the same in the extraperitoneal space (spray) in an effort to reduce postoperative pain. We report an unusual complication that occurred in a patient undergoing a bilateral TEP who had received a spray. TEP using 3 midline ports was performed in a 58-year-old man (body mas index, 32 kg) with bilateral direct hernias. A 15 12-cm polypropylene mesh (Prolene, Johnson and Johnson, Mumbai, India) was placed on each side and fixed with 3 5-mm tacks. At the conclusion of the procedure, 15mL of 0.25% bupivacaine (Sensorcaine; AstraZeneca Pharma India Pvt. Ltd., Bangalore, India) was sprayed in the extraperitoneal space and the incisions were infiltrated with a further 15mL of 0.25% bupivacaine. A few hours after returning to the room the patient complained of difficulty in getting out of bed. A neurological examination was normal except weakness of adduction of the right hip. He was advised bed rest till this was resolved. After around 6 hours he was able to move his right lower limb without difficulty and ambulated satisfactorily. He was discharged after a further 36 hours of observation and remains well at follow-up. It was concluded that the spray had resulted in a temporary paresis of the right obturator nerve, which had resolved spontaneously. Postoperative pain after TEP is attributed to the skin incisions and also to the wide dissection of the peritoneum. Although some researchers point to the beneficial effect of the spray in reducing postoperative pain, a recent randomized trial showed no difference in postoperative pain, supplementary analgesic requirements, or hospital stay in patients receiving the spray. It has been suggested that the visceral pain fibers that are more diffuse in distribution and innervation contribute to the pain in TEP. These are considered to be more refractory to blockade with local anesthetics and nonsteroidal anti-inflammatory drugs than somatic fibers. Temporary femoral nerve palsy after the use of local anesthetic, either as a field block or as a part of local infiltration into the operative field, is a rare but well-documented complication of open inguinal hernia repair. Patients attempting to weight bear have been described to develop fracture of the tibia and fibula and minor head injury from a fall. Postsurgical nerve lesions are uncommon after TEP, except for rare instances of neuralgia related to improper placement of fixation devices. Paralysis of the femoral nerve has been described in a patient undergoing TEP in whom neither sutures nor tacks were used for fixation of the mesh. Extensive evaluation failed to identify a possible cause for the palsy, which resolved gradually over a period of time. The second author (D.B.), who was the primary surgeon for this case, has used spray in over 200 hernias (TEP and transabdominal preperitoneal) but has never experienced this complication before. As our case shows that the common and seemingly innocuous step carries a small but definite risk of temporary nerve paresis. This has implications for the early mobilization of patients. In some day case units, nurses assess active extension of the knee in patients having open inguinal hernia repair under a local anesthetic before allowing them to weight bear. Should all patients in whom a spray is to be used be counseled about the likelihood of temporary muscle weakness preoperatively? Should the muscle strength in the lower limbs be assessed before the patient is allowed to ambulate? Both these steps seem rather cumbersome to implement but may carry a medicolegal implication if a patient in whom the spray had been used, was to develop a fall and injure himself. As the literature fails to prove the benefits of spray during TEP, should this practice be abandoned altogether? We have done so since operating on the patient described here. Gaurav Mittal, DNB Deepraj Bhandarkar, MS, FRCS, FACS, FICS Avinash Katara, MS, FRCS Tehemton E. Udwadia, MS, FRCS, FACS, FICS Division of Minimal Access Surgery Hinduja Hospital Mahim Mumbai, India

Single-incision bilateral laparoscopic oophorectomy

Although single-incision laparoscopic surgery made an appearance on the surgical scene only recently, it is being increasingly applied in the treatment of a variety of disorders. We report single-incision bilateral laparoscopic oophorectomy and salpingooophorectomy performed in two patients who had previously undergone breast conservation surgery for early breast cancer. Each procedure was undertaken using two 5-mm and one 3-mm ports inserted through a 2-cm transverse supraumbilical incision and standard laparoscopic instruments. The operative time was 50 and 65 min respectively and the blood loss negligible. The patients were discharged 36 and 24 h after surgery, required minimal postoperative analgesia and remain well at a follow up of 19 and 17 months, respectively. With the benefit of improved cosmesis, the single-incision approach holds the potential to replace the traditional bilateral laparoscopic oophorectomy.

Laparoscopic repair of left paraduodenal hernia: Report of two cases and review of the literature.

Internal hernia is the cause of only 1% of intestinal obstructions, and left paraduodenal hernias (PDH) comprise about 50% of these cases. As the presentation of PDH is varied, diagnosis is often delayed. Here, we report two patients with left PDH presenting in a subacute manner and diagnosed rapidly with the help of a CT scan. Both underwent successful laparoscopic repair; one patient had closure of the defect, and the other required excision of the sac prior to the closure. We review 21 cases of left PDH treated laparoscopically that were previously reported in the literature, including 14 from Asian countries.

Laparo-endoscopic single-site left adrenalectomy using conventional ports and instruments

Laparo-endoscopic single-site adrenalectomy (LESS-A) is commonly performed using specialized access devices and/or instruments. We report a LESS-A in a 47-year-old woman with a left aldosteranoma via a subcostal approach utilizing conventional laparoscopic ports and instruments. The feasibility and cost-effectiveness of this approach are highlighted and the literature on the subject is reviewed.

Use of Nathanson retractor during laparoscopic splenectomy for supermassive spleens.

Background: Although feasibility of laparoscopic splenectomy for supermassive spleens has been described, obtaining uniform and uninterrupted retraction of a heavy spleen to ensure safe hilar dissection is challenging. We describe a technique of retraction of supermassive spleens using a Nathanson retractor. Methods: This technique was used in 4 patients, and the demographic data as well as data related to the surgery were retrospectively collected. Results: The spleens weighed between 2.5 and 3.5 kg. The median operative time was 190 minutes (155−220 min) and the median intraoperative blood loss was 870 mL (600−1230 mL). The postoperative hospital stay ranged from 3 to 5 days. Conclusions: A Nathanson retractor provides sustained retraction of a supermassive spleen during laparoscopic splenectomy and this technique should be considered a useful adjunct to the armamentarium of surgeons undertaking these challenging procedures.