Jagdish Chander

Laparoscopic total extraperitoneal (TEP) inguinal hernia repair: overcoming the learning curve.

Background: Total extraperitoneal (TEP) laparoscopic inguinal hernia repair is preferred to the transabdominal preperitoneal (TAPP) repair since it preserves peritoneal integrity. However, in general it is considered to be more difficult than the latter because of the peculiarity of anatomy and limitation of working space. Therefore it has been assigned with a “steep learning curve” that the surgeon needs to climb steadily and slowly. This paper offers a working protocol, which is aimed at reducing the steep limb of this curve. Methods: A total of 61 patients were studied between April 2000 and September 2002. Of these, five patients had a open unilateral Stoppa’s preperitoneal operation to learn the detailed anatomy of the extraperitoneal space. Thereafter, laparoscopic TEP procedure was started in the following 56 cases by P.L. In case of difficulty, the procedure was to be converted to the open preperitoneal operation only. Of the first 10 cases, five were converted to unilateral Stoppa’s preperitoneal operation for various reasons, and one case was converted after 30 cases. Thus a total of 11 cases were completed by open unilateral Stoppa’s preperitoneal operation and 50 cases were completed laparoscopically. The first 30 cases started initially as laparoscopic operations were analyzed in groups of 10 each and compared to another study from Netherlands (evaluating four surgeons) wherein the initial laparoscopic procedures were started with the assistance of a surgeon well experienced in laparoscopic TEP operation. Results: The comparison of our first 30 cases with the Netherlands group showed that while the conversions (five cases) to open operation were higher in the first 10 cases, there were no conversions in the next 20 cases. Also, there were no complications or recurrences in the present study, in striking contrast to three recurrences and 10 complications in the comparative study. The following 26 cases were associated with no recurrence or major complication. Conclusion: In this study we performed a total of 11 open unilateral Stoppa’s preperitoneal procedures in our attempt to learn the anatomy of this extraperitoneal space better, and in the absence of any surgeon experienced in laparoscopic TEP procedure. We were able to place a large mesh in each and every case and also recognize double hernias in six cases, thus preventing recurrences and complications. We strongly recommend a minimum of 10 open Stoppa’s preperitoneal procedures, to enable a trained laparoscopic surgeon to start laparoscopic TEP operation independently and in the absence of another trained laparoscopic hernia surgeon, whose presence may not prevent complications and recurrences.

Rectus abdominis muscle flap for high-output duodenal fistula: novel technique.

Duodenal fistula after closure of peptic ulcer perforation, though rare, is difficult to manage and carries a high mortality. The high mortality is associated with the poor nutritional status of the patient, high output from the fistula, and late development of peritonitis and septicemia. The various techniques described in the literature for the closure of the postsurgical external duodenal fistulas range from conservative management with total parenteral nutrition (TPN), serosal patch repair, and Roux-en-y procedures to radical surgery like Billroth II gastrectomy. Total parenteral nutrition achieves spontaneous closure in 70% to 80% of cases, but it is very expensive and requires prolonged hospitalization. In addition, some surgical procedures have yielded poor results in our setting, so we sought a new modality of treatment. We describe a novel technique for repair of postsurgical external fistula of the duodenum with a rectus abdominis muscle flap. The rectus abdominis muscle is detached from its superior attachment and mobilized from the rectus sheath. The flap, based on the deep inferior epigastric artery, is raised and sutured to the duodenal fistula with thick silk sutures. We treated six patients with post-surgical duodenal fistulas with this technique between 1995 and 2002. The leak was completely sealed in all patients. One patient died of septicemia. We recommend this technique for the management of postsurgical external duodenal fistula as an alternative to other surgical techniques.RésuméLes fistules duodénales après fermeture de perforation d’ulcère, bien que rares, sont difficiles à traiter et sont associées à une mortalité élevée, essentiellement en rapport avec le mauvais état nutritionnel du patient, le débit élevé de la fistule, et la présentation tardive avec péritonite et septicémie. Les différentes techniques décrites dans la littérature pour la fermeture des fistules duodénales externes post-chirurgicales varient, depuis un traitement conservateur avec une alimentation parentérale totale (APT), la réparation par patch, les interventions comportant une anse en Y, jusqu’au traitement radical par gastrectomie de type Billroth II. Par l’APT on obtient une fermeture dans 70 à 80% des cas, mais, il s’agit d’un traitement coûteux et qui nécessite une hospitalisation prolongée. Les autres procédés ont des résultats médiocres, d’où la nécessité d’une nouvelle modalité thérapeutique. Nous décrivons une nouvelle technique de cure de fistule externe du duodénum post-chirurgicale à l’aide d’un lambeau musculaire aux dépens du muscle droit de l’abdomen. Le lambeau musculaire muscle est mobilisé dans la gaine des droits après libération de ses attaches supérieures. Le lambeau est pédiculisé à partir de l’artère épigastrique inférieure profonde et suturé au pourtour de la fistule à l’aide de sutures de soie de gros calibre. Entre 1995 et 2002, nous avons traité ainsi avec cette technique six patients porteurs de fistule post-chirurgicale. La fistule s’est complètement tarie chez tous les patients. Un patient atteint d’une septicémie, est décédé. Nous recommandons cette technique dans le traitement de fistule duodénale externe postchirurgicale.ResumenAunque la fistula duodenal tras sutura de una perforation por ulcéra péptica es poco frecuente, su tratamiento es dificil cursando con elevada mortalidad. La mortalidad es debida no solo al estado de malnutrición del paciente sino también al gran débite de la fistula y a su tardfa aparición cuando ya se ha instaurado una peritonitis y una septicemia. En la literatura médica se han descrito numerosas técnicas para conseguir el cierre de una fístula externa duodenal postquirúrgica. Desde el tratamiento conservador con nutrición parenteral total (TPN) hasta la reparación con parche de serosa, pasando por la utilización de la Y de Roux, proponiéndose incluso una cirugía radical similar a una gastrectomía tipo Billroth II. La nutrición parenteral total consigue, en el 70–80% de los casos, la oclusión espontánea de la fístula, pero es un tratamiento caro que exige ademàs una prolongada hospitalización. Otros tratamientos quirúrgicos ofrecen pobres resultados; por ello hemos buscado una nueva modalidad de tratamiento. Describimos una nueva técnica para el tratamiento de una fístula externa postquirúrgica del duodeno mediante la utilizanción de un colgajo del músculo recto anterior. El m. recto anterior se secciona en su extremo superior y se moviliza tras apertura de la vaina de los rectos. El colgajo con base inferior, irrigado por la arteria profunda epigástrica inferior se superpone, suturándose a la fístula duodenal con puntos gruesos de seda. Con este proceder hemos tratado desde 1995 al 2002 a 6 pacientes. La fuga quedó completamente sellada en todos ellos. Uno murió por septicemia. Recomendamos esta técnica en el tratamiento de fistulas externas postquirúrgicas del duodeno como proceder alternativo a otras técnicas quirúrgicas.

Transurethral resection of the prostate as catheter‐free day‐care surgery

To evaluate the feasibility of transurethral resection of the prostate (TURP) as catheter‐free day‐care surgery.

Alteration in coagulation profile and incidence of DVT in laparoscopic cholecystectomy

INTRODUCTION Although laparoscopic cholecystectomy appears to be less traumatic to the patients than open surgery, decreased venous return from lower extremities and hypercoagulability occurring in patients undergoing elective laparoscopic cholecystectomy with CO(2) pneumoperitoneum makes it a potent risk factor for deep venous thrombosis. METHODS The observational study of 50 patients undergoing elective laparoscopic cholecystectomy was designed to study alteration in PT, APTT, D-dimer and antithrombin III, which were measured preoperatively, 6 and 24h postoperatively. It was accompanied by color duplex ultrasound of bilateral lower limbs preoperatively and 7th day postoperatively to look for evidence of deep venous thrombosis. RESULTS Significant postoperative decrease in APTT and antithrombin III suggested activation of coagulation while decrease in d-dimer suggested activation of fibrinolysis. Values of PT had no statistically significant postoperative changes. Age, body mass index and duration of pneumoperitoneum were found to correlate with significant activation of coagulation and fibrinolysis. None of the patients developed clinical or radiological evidence of deep venous thrombosis in the postoperative period. CONCLUSIONS CO(2) pneumoperitoneum enhances the activation of coagulation and fibrinolysis associated with laparoscopic cholecystectomy. Patients with risk factors like old age, obesity or with expected long duration of laparoscopic surgery are likely to have significant activation of coagulation, making them a vulnerable risk group for development of postoperative deep vein thrombosis, warranting some form of thromboprophylaxis.

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.

A randomized trial comparing the use of endobiliary stent and T-tube for biliary decompression after laparoscopic common bile duct exploration.

Purpose: To compare the use of a biliary stent with T-tube for biliary decompression after laparoscopic common bile duct (CBD) exploration. Methods: Between September 2004 and March 2008, 60 patients undergoing laparoscopic CBD exploration for CBD stones were randomized to choledochotomy closure over either a biliary stent or a T-tube after CBD clearance. Patients at high risk for surgery and unremitting cholangitis requiring preoperative endoscopic biliary drainage were excluded. Results: There were 29 and 31 patients in the T-tube and stenting groups, respectively. The 2 groups were comparable with respect to their demographic profile and disease characteristics. Patients in the stent group had a significantly shorter operative time and postoperative stay with an earlier return to normal activity (P<0.0001). Conclusions: Choledochotomy closure over a stent results in a shorter postoperative stay and an earlier return to normal activity compared with closure over a T-tube without any increase in morbidity.

A technique for open trocar placement in laparoscopic surgery using the umbilical cicatrix tube

BackgroundIncreasingly the open method for placement of the initial or first trocar is replacing the conventional technique with the Veress needle. Indeed, it is preferred because it affords peritoneal access under direct vision. A number of methods have been described in the literature using a variety of approaches and different instruments.MethodsWe describe a method of open trocar placement in the supra- or subumbilical region that follows a stepwise procedure and employs specific instruments sequentially, while utilizing the umbilical cicatrix pillar or tube.ResultsThis technique has been done in 525 cases with no complications or port site hernias.ConclusionThis is a simple technique that is safe and easy to learn. It can be performed rapidly and is a reliable method for the insertion of the first port under vision.

Paratesticular Spindle Cell Rhabdomyosarcoma.

Spindle cell rhabdomyosarcoma is a rare variant of embryonal rhabdomyosarcoma that affects young males and most commonly involves the paratesticular region. We report a case of paratesticular spindle cell rhabdomyosarcoma in a 14-year-old boy, who presented with a painless scrotal mass. Left inguinal orchidectomy was performed. Histopathological and immunohistochemical examination of the mass revealed spindle cell rhabdomyosarcoma of the paratesticular region.

A prospective nonrandomized comparison of laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication in Indian population using detailed objective and subjective criteria

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) is a commonly performed procedure for the treatment of gastro esophageal reflux disease (GERD) worldwide. However, unfavourable postoperative sequel, including gas bloat and dysphagia, has encouraged surgeons to perform alternative procedures such as laparoscopic Toupet fundoplication (LTF). This prospective nonrandomized study was designed to compare LNF with LTF in patients with GERD. MATERIALS AND METHODS: Hundred and ten patients symptomatic for GERD were included in the study after having received intensive acid suppression therapy for a minimum of 8 weeks. A 24-hour pH metry was done on all patients. Fifty patients having reflux on 24-hour pH metry were taken up for the surgery. Patients were further divided into group-A (LNF) and group-B (LTF). RESULTS: The median percentage time with esophageal pH < 4 decreased from 10.18% and 12.31% preoperatively to 0.85% and 1.94% postoperatively in LNF and LTF-groups, respectively. There was a significant and comparable increase in length of lower esophageal sphincter (LES), length of intraabdominal part of LES and LES pressure at respiratory inversion point in both the groups. In LNF-group, five patients had early dysphagia that improved afterwards. There were no significant postoperative complications. CONCLUSION: LNF and LTF are highly effective in the management of GERD with significant improvement in symptoms and objective parameters. LNF may be associated with significantly higher incidence of short onset transient dysphagia that improves with time. Patients in both the groups showed excellent symptom and objective control on 24-hour pH metry on short term follow-up.

Laparoscopic Nissen Fundoplication Is an Excellent Modality for GERD: Early Experience from a Tertiary Care Hospital in India

BACKGROUND Surgical management for gastroesophageal reflux disease (GERD) is indicated for reflux uncontrolled on medical therapy. Few studies have been reported from the Indian subcontinent evaluating laparoscopic fundoplication in GERD. The study was designed to evaluate laparoscopic Nissen fundoplication (LNF) in proven cases of GERD and to evaluate the procedure from using detailed symptomatic, objective parameters. METHODS Forty-nine patients symptomatic for GERD and with esophagitis on endoscopy were included in the study. Symptoms were evaluated by DeMeesters score (DS) and modified Visick grade (MVG). All patients underwent an upper gastrointestinal endoscopy with biopsy, ultrasound abdomen, Barium swallow, esophageal manometry, and 24-hour pH metry. Twenty-five of 49 patients showing reflux on 24-hour pH metry underwent LNF. They were followed-up postoperatively at 1, 3, and 6 weeks. Esophageal manometry and 24-hour pH metry were repeated at 6 weeks. The data were compared from using Wilcoxon signed rank test, the Students t-test, and Spearmans correlation coefficient. RESULTS At 6 weeks postoperatively, percentage time with esophageal pH <4 decreased from 10.18% preoperatively to 0.85%. Length of lower esophageal sphincter (LES), length of intra-abdominal part of LES and LES pressure at the respiratory inversion point increased significantly from 2.08 cm, 0.85 cm, and 7.82 mm Hg to 3.36 cm, 2.13 cm, and 22.00 mm Hg, respectively. Median DS and MVG decreased from 4.00 and 3.35 preoperatively to 0 and 1, respectively. There was no conversion to open surgery and no mortality. Five patients developed temporary dysphagia to solids, which was relieved before 6 weeks postoperatively. Mean time to return to work was 12.60 days. CONCLUSIONS LNF proved highly effective in the management of Indian patients with GERD who have failed medical therapy and provides significant symptomatic improvement postoperatively with a low incidence of side effects.