Ramanathan Saranga Bharathi

Minimal access surgery of pediatric inguinal hernias : a review

Inguinal hernia is a common problem among children, and herniotomy has been its standard of care. Laparoscopy, which gained a toehold initially in the management of pediatric inguinal hernia (PIH), has managed to steer world opinion against routine contralateral groin exploration by precise detection of contralateral patencies. Besides detection, its ability to repair simultaneously all forms of inguinal hernias (indirect, direct, combined, recurrent, and incarcerated) together with contralateral patencies has cemented its role as a viable alternative to conventional repair. Numerous minimally invasive techniques for addressing PIH have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal, extraperitoneal), use of ports (three, two, one), endoscopic instruments (two, one, or none), sutures (absorbable, nonabsorbable), and techniques of knotting (intracorporeal, extracorporeal). In addition to the surgeons’ experience and the merits/limitations of individual techniques, it is the nature of the defect that should govern the choice of technique. The emerging techniques show a trend toward increasing use of extracorporeal knotting and diminishing use of working ports and endoscopic instruments. These favor wider adoption of minimal access surgery in addressing PIH by surgeons, irrespective of their laparoscopic skills and experience. Growing experience, wider adoption, decreasing complications, and increasing advantages favor emergence of minimal access surgery as the gold standard for the treatment of PIH in the future. This article comprehensively reviews the laparoscopic techniques of addressing PIH.

Laparoscopic ligation of internal ring-three ports versus single-port technique: are working ports necessary?

BACKGROUND From three ports, technical refinements in laparoscopy have facilitated the ligation of the internal ring (IR) with a single port. OBJECTIVES The aims of this study were to determine whether, when, and where working ports are needed by assessing the differences in outcome between the three-port technique (TPT) and the single-port technique-subcutaneous endoscopically assisted ligation (SEAL). METHODS Short-term outcomes of 163 children operated on by either technique (51 with TPT, and 112 with SEAL) were audited. Technical difficulties, operation time, intra- and postoperative complications, and postoperative stay were studied. RESULTS IR could be ligated faster by SEAL than TPT (unilateral: 15 vs. 25 minutes; P = 0.0005; bilateral: 25 vs. 40 minutes; P = 0.001). SEAL proved cosmetically more appealing (one 5-mm vs. three 5-mm scars). Complication rates, recovery, and hospital stay were similar. Recurrences were marginally higher following SEAL (4.8 vs. 2.98%; P = 0.49). Intracorporeal suturing and knotting were the limiting steps in TPT, while wide rings (>10 mm) and thick abdominal wall were the limitations of SEAL. CONCLUSIONS Both TPT and SEAL are safe and efficacious day-care procedures. In the ligation of average-sized IR of thin patients, working ports may not be necessary, as SEAL proves cosmetically and temporally efficacious over TPT. However, patients with wide rings and thick anterior abdominal walls may need the placement of working ports for successful laparoscopic repair.

Evidence based switch to perianal block for ano-rectal surgeries

BACKGROUND Evidence suggests that switch from spinal/general anaesthesia (SA/GA) to perianal block (PAB) may prove advantageous for proctologic surgeries. This study evaluates the practicability of this evidence based switch. METHODS Feasibility and efficacy of PAB for proctologic surgeries was prospectively evaluated on 100 consecutive patients over 11 months. Thirty ml of local anesthetic (0.25% bupivacaine+1% lignocaine with adrenaline) was infiltrated into the anal sphincter and perianal skin, under sedation, for achieving PAB. Time taken for onset of anesthesia; success/failure of block; conversion rate to GA; operative ease; operative time; post operative recovery; duration of analgesia; post operative pain based on verbal response score (VRS; scale: 0-100); and complications were analyzed. RESULTS 54 open haemorrhoidectomies; 27 fistulectomies and 19 lateral sphincterotomies were performed. Average of 3 min (range 2-5 min) was needed for onset. Block was successful in 97% of cases. 3% needed conversion to GA. Good anesthesia and sphincter relaxation ensured operative ease. Median operative time was 20 min (range 10-35 min). Analgesia lasted a median of 5 hours (range 3-10 hrs). Subsequent pain ranged between VRS 10-40, tapering off, along with analgesic requirement, over a week. Trivial injection site hematoma (1%) and reactionary bleeding (1%) were the complications observed. Post operative recovery was uniformly smooth in all patients. CONCLUSIONS Perianal block is a safe, feasible, reliable, and reproducible mode of anesthesia for ano-rectal surgeries. Its evident efficacy justifies its adoption as anesthesia of choice.

Intra-peritoneal duodenal perforation caused by delayed migration of endobiliary stent: A case report

Endoscopic biliary stenting is an accepted modality of palliation of malignant biliary obstructions. Delayed stent migration causing intra-peritoneal perforation of duodenum, is a rare life threatening complication. Proximal adhesion of stent to the tumor is believed to increase the intensity of distal trauma produced by the intra-duodenal segment, preventing its adaptation to intestinal peristalsis and causing perforation. Low bacterial load and containment of leak by gut and omentum blunts the clinical features. Unexplained abdominal discomfort in stented patients should alert the clinician to its possibility, irrespective of the delay between stent placement and onset of symptoms. Early diagnosis and treatment is desirable but aggressive surgical management with gastro-biliary diversion, tube duodenostomy, antibiotics, bowel rest and parenteral alimentation followed by distal alimentation, may make up for the delay in those presenting late. A case of 7 days old intra-peritoneal duodenal perforation following delayed migration (3 months) of endobiliary stent presenting with atypical features is reported. Stents distal end was protruding through the duodenum with its proximal end in CBD. Mortality, fistulization, abscesses and sepsis are known complications but were not observed in our case. Much of the management can be done minimally invasively, if recognized early.

Simplifying minilap cholecystectomy.

Three to five centimeter midline incision is made (Fig. 1) and the peritoneal cavity is entered to the right of falciform ligament. Air is allowed to enter the supra-hepatic space to facilitate manipulation of liver/gallbladder. Gallbladder fundus is held up and an abdominal swab is pushed into the wound (Fig. 1). With the bladder retractor and tongue depressor in place, Hartmann’s pouch is pulled upward and laterally whilst the fundus is swept under the abdominal wall, away from operation site, to expose the Calot’s triangle optimally (Fig. 2). Two ligatures each, around cystic duct and artery, are tied sufficiently apart using fingers (Fig. 3). When space restricts tying sutures apart, then solitary ligatures are tied individually around cystic duct and artery. Hartmann’s pouch is then released and fundus is pulled back into operating field (Fig. 4). Gallbladder is sharply dissected off liver and excised by cutting between the ligatures (Figs. 4 and 5). When cystic duct and artery are secured using solitary ligatures, the gallbladder is excised by clamping its neck and cutting between the clamp and ligatures.

Ectopic thymoma with pure red cell aplasia – Ambiguity with indolence

Two cases of thymomas with pure red cell aplasia (PRCA) are presented, highlighting variability in their anatomic location, ambiguity in presentation, indolence of course and unpredictability of response to treatment. Multi-modality approach is necessary for both diagnosis and management of this combination. Duration and side effects of treatment determine the overall prognosis.

Synchronous Adenocarcinomas of Pancreatic Body and Gastro-Esophageal Junction: Management Strategy.

Synchronous presentation of locally advanced adenocarcinomas of pancreatic body and gastro-esophageal junction (GEJ) is, hitherto, unreported, rendering the treatment challenging. Such a situation calls for the management strategy, both surgical and adjuvant, to be customized to tackle both the tumors, appropriately. This article describes the unique case and elaborates the modifications that were made in the composite resection, subsequent reconstruction, and adjuvant chemotherapy, of both tumors, along with the rationale behind the modifications.

Buttressing hepaticojejunostomy's with hepatic round ligament flap may be beneficial

BACKGROUND Bile leaks and anastomotic strictures are important complications of hepaticojejunostomy (HJ). Evidence suggests that the use of hepatic round ligament (HRL) to buttress HJ may be beneficial. This study evaluates the feasibility of this approach. METHODS HJs performed over 2 years (Jun 2014- May 2016), with HRL reinforcement, were analyzed. Operative outcomes measured included technical difficulty, blood loss, time necessary for flap harvest, and reinforcement of HJ. The postoperative outcomes measured were the presence of bile leak and anastomotic stricture. RESULTS Forty-one patients (27 M: 14 F), aged 2-79 years, median age of61 years, underwent HJ with HRL buttress; 27 for periampullary/ head of the pancreas carcinoma; 4 for choledochal cysts; 4 for chronic pancreatitis; 3 for gallbladder carcinoma; 3 for benign biliary stricture. The time for harvesting HRL flaps and buttressing HJ was <10 minutes. No blood was lost during harvesting the flaps. One patient (2.5 %) had grade A leak following radical cholecystectomy, and structures were not observed during a median follow-up of 18 months (6 months to 2years). CONCLUSION HRL-based buttressing of HJ can reduce the bile leak and/or stricture rate.

Artery first approach for resecting ganglioneuroma encasing superior mesenteric artery

Ganglioneuromas are rare and account for 1% of primary retroperitoneal tumors.1, 2 Their origin from sympathetic chain predisposes them to be inconveniently abutted to major vessels, rendering their excision exigent.1, 2 We present a case of ganglioneuroma which had encased the superior mesenteric artery (SMA), which was excised, successfully, using the artery first approach.

Performing Laparoscopic Cholecystectomy using Diagnostic Laparoscope : Our Adaptations

Cholecystectomy is among the commonest operations in general surgical practice. With the advent of laparoscopy and NOTES, minimal access surgery has justly replaced conventional surgery as procedure of choice for most surgeries [1], especially cholecystectomy. Although laparoscopy has well been incorporated in post graduate surgical training, surgical laparoscopy sets are not available in all field/rural hospitals. This leads to unnecessary referrals to higher centre, which not only adversely affects the image of the local hospital, but also overloads the apex hospitals with routine surgeries. The silver lining is availability of basic gynecology laparoscopy set (one 10 mm – 0 degree telescope, two 10 mm ports, one 5 mm port, 1 Maryland, 1 non toothed grasper) in most hospitals for diagnostic laparoscopy and sterilization. This article describes the technical modifications made in successful use of this set in performing laparoscopic cholecystectomy.