Pradeep Garg

A Review of Total Laparoscopic Hysterectomy Using LigaSure Uterine Artery-Sealing Device: AIIMS Experience

STUDY OBJECTIVE The aim of this study was to evaluate the efficacy and safety of total laparoscopic hysterectomy (TLH) by using the Ligasure system for the sealing of uterine arteries. DESIGN We conducted a retrospective review of cases who underwent TLH over 1.5 years. SETTINGS This study was conducted in a tertiary care hospital setting, at the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (New Delhi, India). PATIENTS A total of 110 patients of TLH done for uterine pathology [leiomyoma in 67 (60.9%), dysfunctional uterine bleeding in 34 (30.9%), and others in 9 (8.1%)]. INTERVENTIONS Total laparoscopic hysterectomy, using the LigaSure system (Valleylab Inc., Boulder, CO), was done by the sealing of uterine arteries and Prashant Mangeshikar uterine manipulator for elevation of the uterus. RESULTS The mean age of the patients was 43.1 +/- 0.602 years and mean body mass index was 25.19 +/- 0.39 kg/m(2). The mean operating time was 116.91 +/- 3.4 minutes, mean intraoperative blood loss was 173.09 +/- 11.64 mL, and the mean weight of the removed uterus was 224.14 +/- 17.62 g. Six patients were converted from a laparoscopic to an open procedure (large myoma in 4 and dense adhesion in 2) and 1 was converted to laparoscopically assisted vaginal hysterectomy (tear in vaginal cuff). One patient (0.9%) developed lung emphysema during the intraoperative period. Postoperative complications included paralytic ileus in 3 (2.7%), retention of urine in 2 (1.8%), and febrile morbidity in 12 (10.9%) patients. There were no bladder or bowel injuries. CONCLUSION Laparoscopic hysterectomy by uterine artery sealing with LigaSure is a safe, efficient procedure with a low complication rate.

Adrenal angiomyolipoma: A rare entity

Angiomyolipoma is apparently a part of a family of neoplasms that derive from perivascular epitheloid cells. It is a rare mesenchymal tumor, usually found in the kidney. Extrarenal angiomyolipoma is uncommon and the most common extrarenal site is the liver. Only two cases of adrenal angiomyolipoma are reported in English literature. Authors wish to add one more case to world literature. Because of its large size and symptomatic presentation of extremely rare tumor merits documentation.

Ectopic hydronephrotic kidney masquerading as an ovarian cyst during pregnancy

An ectopic iliopelvic kidney with hydronephrosis causing fetal malpresentation is a rare occurrence. We describe this case for its unusual presentation which was mistaken for an ovarian cyst. The difficulty in diagnosis and the need for a high index of suspicion is highlighted.

A Rare Case of Large Epididymal Cyst in Androgen Insensitivity Syndrome Removed Laparoscopically

Androgen insensitivity syndrome is a disorder of sexual differentiation with 46XY karyotype. The gonad is at risk (33% by 50 years of age) for development of malignant tumors. Hence, gonadectomy is warranted. We present a case of a 22-year-old woman diagnosed with androgen insensitivity syndrome during investigation of primary amenorrhea. Ultrasonography showed intraabdominally-located gonads, with a large, nontender cyst of 9.2 x 5.6 x 5.4 cm size, with limited mobility, to the right of the midline. There was also a partial septum, with a wall thickness of 1 to 2 mm and containing clear fluid. Because of suspicion of malignancy, complete surgery including laparoscopic peritoneal cytologic study, gonadectomy, lymphadenectomy, and omentectomy were performed. Histopathologic study showed testis with an epididymal cyst. Formation of epididymal cyst is rare in these cases. The patient did well in the postoperative period. She was put on hormone replacement therapy and is doing well.

Rectal perforation by impacted fecaloma—a new mechanism proposed

Editor: A fecaloma is a mass of accumulated feces that is much harder in consistency than a fecal impaction. The rectosigmoid area is the common site for fecalomas [1]. Fecal impaction, defined as a “compacted, immovable mass of feces filling the rectum,” is commonly seen in chronic constipated patients. It can result in obstipation, the inability to pass stool or gas, but can also present with diarrhea, because liquid stool can pass around the impaction. If untreated, fecal impaction may result in a variety of complications, including stercoral perforation [2]. We describe a patient with stercoral perforation with an atypical location. A 65-year-old female presented with nonpassage of flatus and stool for 8 days, abdominal distention for 5 days, vomiting and fever for 1 day, and a history of constipation for the last 5 years. On examination the pulse rate was 104/min and BP, 104/76 mmHg. The abdomen was distended, and generalized guarding was present. Per rectal examination revealed hard fecoliths. Plain X-ray of the abdomen (Fig. 1) showed radiopaque masses all over the colonic area. Ultrasonography of the abdomen showed content-filled gut loops with free fluid. Contrast-enhanced computed tomography of the abdomen revealed free air and fluid in the peritoneal cavity with prominent small and large bowel, suggestive of bowel perforation. The patient was explored urgently. On exploration about 1 L of foul-smelling blackish fluid was aspirated from the peritoneal cavity. A large gangrenous patch of size 5 cm × 5 cm was present in the upper rectum on the posterior wall with a stony hard fecolith protruding through the necrosed central part (Fig. 2). The entire colon was loaded with hard fecoliths which were extracted (Fig. 3). A segment of gangrenous rectosigmoid was resected, the rectal stump closed, and the distal cut end of the sigmoid colon brought out as an end colostomy. Fecal impaction causes the intraluminal pressure within the colon to increase and exceed the capillary perfusion pressure in the bowel wall, resulting in pressure necrosis of the wall and eventually ulceration and perforation. The most common sites of fecal impaction are the sigmoid and rectosigmoid colon, because here much of the water has already been reabsorbed from the feces, which can then develop into hardened masses or scybala [2]. In addition, the distal colon, particularly along the antimesenteric border, has a relatively poor blood supply, making it more susceptible to pressure necrosis from scybala. Finally, because these areas of the colon have the narrowest diameter, they allow the formation of higher intraluminal pressure in the event of fecal impaction which can lead to perforation [2]. Mauer et al. proposed four diagnostic criteria of stercoral perforation [3].

Post-sterilization regrets in Indian women.

BACKGROUND Tubal ligation is the most common form of contraception in India. We conducted this study to assess the factors associated with post-sterilization regrets. AIMS This study was designed to assess risk factors that are likely to cause regret following female sterilization in Indian women. SETTINGS AND DESIGN Questionnaire-based study. MATERIALS AND METHODS This was a questionnaire-based study to assess the level of satisfaction after tubal ligation in women attending family planning clinic at the hospital over a period of 1 year. Evaluation of data obtained through questionnaire from 236 women who had undergone tubal ligation was done. STATISTICAL ANALYSIS Univariate analysis to determine crude odds ratio was carried out. Subsequently, multiple regression analysis was used to find the adjusted odds ratio (and 95% confidence intervals) for each variable. RESULTS We found a strong co-relation between regrets and young age (less than 30 years), fewer number of children, few or no male children and lack of partner motivation prior to sterilization. Menstrual irregularities and dysmenorrhoea did not influence regret to a large extent. CONCLUSION Fertility-related factors, namely, age at sterilization, family size, number of male offspring, timing of sterilization and non-involvement of partner in decision making played a greater role in post-sterilization regrets than menstrual factors (menstrual irregularities and dysmenorrhoea).

Direct trocar insertion without the pneumoperitoneum in laparoscopic surgery - Is this a safe technique?

IntroductionThe classical closed method using the Veress needle and the open trocar placement technique with the Hasson cannula are commonly used to establish the pneumoperitoneum required for laparoscopic procedures. A less described and practiced technique is direct trocar insertion [DTI]. Those who are unfamiliar with DTI as an alternative procedure may be under the impression that it is hazardous.MethodIn this retrospective study, we analyzed DTI for peritoneal access and primary port placement in the first 100 consecutive cases of laparoscopic surgery and compared it against the first 100 cases using the Veress needle (VN) technique. Injuries were classed as major or minor depending on whether or not they significantly affected the performance of the procedure and the eventual outcome.ResultsNeither group suffered mortality or any major injuries. Minor injuries were infrequent. Peritoneal access and creation of laparoscopic workspace were attained faster and more efficiently by the direct trocar insertion technique. In the DTI group, the average time taken to establish pneumoperitoneum was one minute (42sec-3min04sec) while in the VN group it was 3.8minutes (2min40sec-8min10sec) which was significant (p<.05).ConclusionOur results and those of other studies suggest that the direct trocar insertion technique is a safe, fast and reliable alternative to traditional techniques of primary port placement in laparoscopic procedures.

Adult intussusception - a case series from rural India.

Intussusception (IS) is telescoping of one segment of gut into other, usually proximal segment into distal. It contributes 90% of intestinal obstruction in infancy and childhood and is the second most common abdominal emergency after appendicitis in children. Incidence of IS suddenly declines after second year of age. Paediatric IS present with classical triad of abdominal pain, bloodstained mucous discharge per rectum (red currant jelly stools) and palpable abdominal mass. IS is uncommon in adults. Symptomatology usually stretches over a long period often covering months or even years. The classic triad of paediatric IS is absent in adults and the physical signs are neither representative nor distinctive of this condition. More than 90% of cases of adult IS will have a lead point or specific aetiology as compared to IS in childhood where it is mostly idiopathic. Adult IS is frequently associated with malignancy of bowel in temperate areas while inflammatory lesions like polyps, worms, TB, etc., are common in tropical countries such as India. Too few cases appear in any one surgeon’s practice, or even in one hospital, to enable an overall picture of the condition to be formed. The paucity of reports in Indian literature prompted us to review the cases presenting to our department over a 10-year period.

Transvaginal repair of post-coital rectovaginal fistula in patients of vaginal agenesis

otherwise a normal pelvis. She had attended the A&E prior to her outpatient appointment with similar pelvic pains. Some 2 years previously, she was referred by her GP for secondary subfertility but had failed to attend any of her appointments. In her obstetric history, she had two vaginal deliveries at 37 and 35 weeks’ gestation, respectively, followed by a medical termination of pregnancy at 20 weeks’ gestation and a surgical termination of pregnancy at 10 weeks’ gestation, 3 years before her presentation. A transvaginal ultrasound scan showed a normal size uterus and ovaries with no adnexal abnormalities; however an irregular calcified shadow in the uterus was noted. She underwent an examination under anaesthesia and a diagnostic hysteroscopy and endometrial biopsy. This showed a normal uterine cavity other than several pieces of bony fragments in the anterior uterine wall, as well as some that were embedded in the cervical canal. These bones were removed using biopsy forceps followed by sharp curettage. The cavity was clear afterwards as confirmed by a repeat hysteroscopy. Histopathology showed a proliferative type endometrium with endometritis plus fragments of woven bone. Following the procedure, her symptoms resolved and the pain completely settled.

Disembowelment following unsafe home delivery: Young life lost!

Injuries to the bowel are seldom reported. Yet these pose serious problems associated with uterine perforation during deliveries that take place outside of hospitals. This is also true for abortions that are performed illegally in developing countries by persons without any medical training. This case study is about a 20 years old girl who lost her life following an unsafe delivery at home. To avoid morbidity and mortality associated with unsafe deliveries, it is necessary to understand the scope of this problem and the factors related to it: governments, nongovernmental organizations, religious groups and women groups.