Pawanindra Lal

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.

Evaluation of a Health Education Intervention on Knowledge and Attitudes of Food Handlers Working in a Medical College in Delhi, India

The present study assessed change in knowledge, attitudes, and self-reported hand-washing practices of 136 food handlers 3 months after providing them health education using posters and interactive sessions using a flip chart. There was a significant change in the proportion of study participants who named food borne or waterborne diseases, including gastroenteritis (79.4% to 91.9%), worm infestation (39.0% to 55.9%), cholera (16.2% to 42.7%), and typhoid (9.6% to 28.7%). Significant increase in knowledge about hand hygiene measures, namely, washing hands before handling food (23.5% to 65.4%) and keeping nails cut and clean (8.1% to 57.4%), was observed. Baseline self-reported hand-washing practices revealed low figures for washing hands after micturition (82.4%) and smoking (52.8%) and consistent use of soap at the workplace (24.3%) and after micturition (14.0%), which improved after health education but not to the desired extent. Findings highlight the importance of providing health education in food and personal hygiene to food handlers and incorporating the same in existing guidelines for food establishments laid down by civic agencies in Delhi and elsewhere.

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.

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.

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.

Rectourethral fistula after injection sclerotherapy for haemorrhoids, a rare complication

Injection sclerotherapy is widely used for grade 1 haemorrhoids. We report possibly the first case of rectourethral fistula following its use. A 35-year-old male attended as an emergency, complaining of perineal pain and foul-smelling discharge from the anal orifice for 4 days. There was a history of haemorrhoidal bleeding for 5 months, for which he had received injection sclerotherapy (5% phenol in almond oil) a week previously. On digital rectal examination and proctoscopy, there was a small, irregular mucosal defect with indurated edges at 12 o’clock about 6 cm from the anal verge. The haemoglobin was 9.4 g ⁄ dl, the total leukocyte count 12 600 (polymorphs 90%), the urea 16 mg% and blood sugar 98 mg ⁄ dl. Microscopic examination of the urine showed three or four red blood cells and eight to 10 pus cells per high-power field. An indwelling catheter was inserted, but to our surprise, it came out of the anal orifice, thus confirming the diagnosis of rectourethral fistula (Fig. 1). A suprapubic cystostomy was carried out, and the patient was started on ceftriaxone 1 g i.v. every 12 h and metronidazole 500 mg i.v. every 8 h. The patient responded well to this treatment, and at 6 weeks contrast radiology was normal. The suprapubic cystostomy was removed, and the patient was well thereafter.

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.

Correlation of D dimer and factor VIII levels with histopathology in patients with breast carcinoma.

INTRODUCTION There is evidence that the components of the coagulation/fibrinolytic system play a role in cancer biology and angiogenesis. Studies reveal that at the time of diagnosis, majority of the cancer patients have laboratory evidence of systemic coagulation activation. Our purpose was to investigate the significance of D-Dimer (product of fibrin degradation) and factor VIII levels in breast cancer and to evaluate its relationship with other variables such as histological characteristics, lymph node status and immunohistochemistry markers (ER, PR and Her-2neu). MATERIALS AND METHODS A prospective study was conducted in the Department of Surgery in collaboration with Departments of Medicine, Pathology and Radiodiagnosis & Imaging, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi. Fifty patients with diagnosed cancer breast who were treated in surgery department were evaluated for D Dimer and factor VIII levels. D-dimer and Factor VIII levels were measured three times i.e. at the time of commencement of treatment then after three cycles of Chemotherapy (CAF Regimen) and finally after six weeks of surgery. RESULTS Significantly higher levels of D Dimer and factor VIII were observed in tumors with significant lymphovascular and adipose tissue invasion in comparison to localized tumors. The reduction in D-dimer and Factor VIII values after Surgery was significant for both D-dimer (p value 0.000) and Factor VIII (p value 0.000). The reduction in D-dimer after 3 cycles of chemotherapy was significant for D-dimer (575.51 ± 572.47 ng/ml vs. 422.45 ± 363.58 ng/ml; p value 0.046) but not significant for Factor VIII (307.83 ± 184.47 ng/ml vs. 288.78 ± 163.02 ng/ml; p value 0.151). CONCLUSION D-dimer and factor VIII may be used as yardstick for systemic adjuvant therapy in node negative < 1 cm breast cancer. D-dimer may prove to be a safe, convenient and easily available biomarker which can be combined with conventional sentinel node biopsy in clinically node negative breast cancer to assess metastatic disease in axilla and reduce false negative results.