Harvinder Singh Pahwa

Video Endoscopic Inguinal Lymphadenectomy (VEIL) -a prospective critical perioperative assessment of feasibility and morbidity with points of technique in penile carcinoma

BackgroundInguinal lymph node involvement is an important prognostic factor in penile cancer. Inguinal lymph node dissection allows staging and treatment of inguinal nodal disease. However, it causes morbidity and is associated with complications, such as lymphocele, skin loss and infection. Video Endoscopic Inguinal Lymphadenectomy (VEIL) is an endoscopic procedure, and it seems to be a new and attractive approach duplicating the standard open procedure with less morbidity. We present here a critical perioperative assessment with points of technique.MethodsTen patients with moderate to high grade penile carcinoma with clinically negative inguinal lymph nodes were subjected to elective VEIL. VEIL was done in standard surgical steps. Perioperative parameters were assessed that is - duration of the surgery, lymph-related complications, time until drain removal, lymph node yield, surgical emphysema and histopathological positivity of lymph nodes.ResultsOperative time for VEIL was 120 to180 minutes. Lymph node yield was 7 to 12 lymph nodes. No skin related complications were seen with VEIL. Lymph related complications, that is, lymphocele, were seen in only two patients. The suction drain was removed after four to eight days (mean 5.1). Overall morbidity was 20% with VEIL.ConclusionIn our early experience, VEIL was a safe and feasible technique in patients with penile carcinoma with non palpable inguinal lymph nodes. It allows the removal of inguinal lymph nodes within the same limits as in conventional surgical dissection and potentially reduces surgical morbidity.

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.

Laparoscopic cholecystectomy in situs inversus: points of technique

Laparoscopic cholecystectomy is one of the most common surgical procedures carried out in the world today. Rarely do patients present with undiagnosed situs inversus with cholecystitis. Symptomatic gallstones in patients with situs inversus pose diagnostic and therapeutic challenges. We had one such patient who presented with episodes of pain in the left upper abdomen. She was found to be suffering from situs inversus with gallstones in a left-sided gall bladder. After thorough preoperative evaluation, we performed laparoscopic cholecystectomy by modifying the operative technique adopting a mirror image of port placement on the left side using the left subcostal port (5 mm) for dissection with the right hand and the subxiphoid port for retraction of Hartmanns pouch by the left hand of the surgeon. We can summarise that laparoscopic cholecystectomy in patients of situs inversus can be safely performed by an experienced surgeon.

Partial penile amputation due to penile tourniquet syndrome in a child troubled with primary nocturnal enuresis--a rare emergency.

Penile tourniquet syndrome (PTS) or acquired constriction ring syndrome (ACRS) is a rare emergency that can lead to a wide range of vascular and soft tissue injuries in the penis. We are presenting a case of penile tourniquet syndrome in an 8-year-old child who had tied a thread around his penis due to primary nocturnal enuresis. On exploration, a constricting thread ring was noticed that was causing partial circumferential distal penile amputation. The thread ring was cut and debridement with primary repair of the wound was done in layers. Prevention of complications needs early diagnosis, timely intervention, and removal of the constriction.

Unsuspected pheochromocytoma of the urinary bladder: reminder of an important clinical lesson

Bladder pheochromocytoma creates an extremely rare situation (0.06% of all bladder tumours). We came across a case with a complaint of intermittent episodes of haematuria. Cystoscopy revealed a solid, bluish submucosal growth with increased vascularity. Immediately after taking biopsy, the patient developed a sharp headache, chest heaviness and marked rise in blood pressure. The procedure was abandoned. Later, serum and urinary markers for pheochromocytoma were within normal limits. The histopathology report came out to be pheochromocytoma of the bladder. Later, partial cystectomy was carried out under general anaesthesia and histopathology confirmed the same. Thus, a surgeon/urologist should have a high index of suspicion for bladder pheochromocytoma while dealing with such cases if he comes across the characteristic symptoms of sharp headache, hypertension, palpitation, sweating, fainting or blurring of vision immediately after voiding or during the cystoscopic manipulation of tumour or cystoscopic findings of a submucosal supratrigonal vascular tumour with a bluish hue.

Anticoagulant-induced priapism progressing to penile gangrene: a devastating complication!

A 35-year-old man developed priapism with the use of low-molecular-weight heparin and warfarin following repair of left brachial artery sustained after gunshot injury. Priapism progressed to penile gangrene despite decompression and distal shunt procedure leading to total penectomy and perineal urethrostomy. We describe the mechanism of anticoagulant (heparin and warfarin)-induced penile gangrene and the possible methods to avert such a devastating complication.

Trans-anal barotrauma by compressed air leading to sigmoid perforation due to a dangerous practical joke

To present a case report of trans-anal barotrauma by high-pressure compressed air jet as a dangerous practical joke, that is, playful insufflation of high-pressure air jet through the anal orifice resulting in sigmoid perforation. The patient presented to emergency a day later with complaints of severe pain in the abdomen and abdominal distension following insufflation of high-pressure air jet through the anus. On examination, he had signs suggestive of perforation peritonitis and x-ray of the abdomen showed gas under the diaphragm. An emergency exploratory laparotomy was performed which revealed a 4-cm perforation in the sigmoid colon. Resection of the segment containing perforation along with the surrounding devitalised part was done with double-barrel colostomy. Reversal of colostomy was done after 8 weeks. Follow-up was uneventful.

Tubercular thyroid abscess.

We encountered a patient who presented with neck swelling, difficulty in swallowing, voice change along with systemic features such as evening rise of temperature, chronic cough and weight loss. Ultrasonography of the thyroid gland revealed two cystic swellings. An ultrasound guided fine needle aspiration cytology was suggestive of tubercular abscess. The patient responded well to antigravity aspiration of the swellings and antitubercular treatment.

A Prospective Randomized Controlled Trial Comparing Quality of Life Following Endoscopic Totally Extraperitoneal (TEP) Versus Open Stoppa Inguinal Hernioplasty

In inguinal hernia surgery, quality of life (QOL) has emerged as a striking issue. Evidence suggests better QOL of patients operated with laparoscopic procedure as compared with open anterior hernia repairs. However data are scarce with relation to open posterior repair in terms of QOL issues. A prospective randomized single-blind study from November 2014 to October 2015 including all patients who underwent elective primary endoscopic [totally extraperitoneal (TEP)] or open Stoppa inguinal hernia repair was undertaken. Mean operating time, intraoperative and postoperative complications, and QOL using short form-36 and Carolinas equation of QOL were analyzed. Physical functioning, mental health, bodily pain, and general health showed advantages of TEP over Stoppa repair in first month of postoperative period. Postoperative prediction of hernia discomfort after 1 year was found to be significantly more in Stoppa repair. Complications were slightly higher with open repair. To conclude TEP is associated with significant increased operative time, better QOL in early postoperative period, and less predicted discomfort after 1 year of surgery.

Multiple spontaneous enterocutaneous fistulae on back: a rare presentation of colonic malignancy.

We came across a case presenting with complaint of multiple fistulae present on back and lateral part of abdominal wall discharging faecal matter. Investigations revealed a fistulous tract arising from posterior wall of ascending colon. The patient did not respond to conservative management and therefore was subjected to exploratory laparotomy after thorough investigations. Peroperatively, an ileocaecal mass was found along with a fistulous tract which was arising from the posterior wall of ascending colon and communicating with the skin. A right haemicolectomy was performed followed by ileo-transverse anastomosis. Postoperative recovery was uneventful. The histopathology report came out to be adenocarcinoma of colon.