Sneh Agarwal

Variation in shape of the lingula in the adult human mandible.

The lingulae of both sides of 165 dry adult human mandibles, 131 males and 34 females of Indian origin, were classified by their shape into 4 types: 1, triangular; 2, truncated; 3, nodular; and 4, assimilated. Triangular lingulae were found in 226 (68.5%) sides, truncated in 52 (15.8%), nodular in 36 (10.9%) and assimilated in 16 (4.8%) sides. Triangular lingulae were found bilaterally in 110, truncated in 23, nodular in 17 and assimilated in 7 mandibles. Of the remaining 8 mandibles with different appearances on the 2 sides, 6 had a combination of triangular and truncated and 2 had nodular and assimilated. The incidence of triangular and assimilated types in the male and female mandibles are almost equal. In the truncated type it was double in the male mandibles while the nodular type was a little less than double in the female mandibles.

Anatomical footprint for safe laparoscopic cholecystectomy without using any energy source: a modified technique

BackgroundOver the last two decades, laparoscopic cholecystectomy has become the gold standard for treating cholecystolithiasis and an index operation for evaluation and assessment of laparoscopic surgical skills. Its wider application and continuous refinement have not been accompanied by a commensurate decrease in morbidity due to biliary, vascular, or visceral injuries. Use of an energy source, especially monopolar electrosurgery, has been identified as a culprit for many of these injuries. This study assessed the feasibility of performing laparoscopic cholecystectomy safely without using any energy source by taking advantage of the avascular anatomical planes.MethodPatients attending the surgery clinic of our center who were candidates for a laparoscopic cholecystectomy were enrolled. Informed consent was obtained from each patient before the procedure. The study was approved by the Ethical Review Board of the hospital and was conducted as per GCP guidelines.ResultsBetween June 2005 and July 2006, 83 patients were enrolled. All patients underwent laparoscopic cholecystectomy without any energy source being used. There was no incidence of biliary, vascular, or visceral injury. All patients remained hemodynamically stable. There was no conversion or mortality. The hospital stay was 8–16 h. Patients were followed up by telephone for the first 48 hours and then by regulat outpatient visits until they were well.ConclusionA safe laparoscopic cholecystectomy without using any energy source can be performed by following the proper anatomical footprint.

Can maternal serum placental growth factor estimation in early second trimester predict the occurrence of early onset preeclampsia and/or early onset intrauterine growth restriction? A prospective cohort study

To determine whether maternal serum placental growth factor (PlGF) estimation in early second trimester (20–22 weeks of gestation) can predict the occurrence of early onset preeclampsia and/or early onset intrauterine growth restriction (IUGR).

Transaxillary endoscopic excision of benign breast lumps : a new technique

BackgroundBenign breast lumps affect 10% of women in their lifetimes. Despite a favorable natural history enabling surveillance as an option, surgical excision continues to be popular. Avoiding a scar on the breast is an inherent feminine desire. Because the breast is a part with a high charge in the culture, women seek to keep it away from the surgical knife. Numerous minimally invasive approaches have evolved as a result of this psychology. These leave much to be desired. Circumareolar incision at best camouflages the scar, which still is sited on the breast. This scar is subject to the same sequelae as any other breast scar. The axilla, an anatomically contiguous space, provides easy access for endoscopic breast surgery. The authors used this access to excise benign breast lumps endoscopically. This spared the breast from a scar.MethodsBetween January 2002 and March 2005, 14 women with benign breast lumps underwent surgery. Transaxillary endoscopic excision of 18 such lumps was performed.ResultsA total of 14 women with 18 benign breast lumps underwent surgery. The mean operative time per patient was 66.78 min (range, 40–110 min). No axillary injury, bleeding, technical difficulty, surgical emphysema, conversion, hematoma, or rehospitalization occurred. All the women expressed their satisfaction and happiness with the operation.ConclusionEndoscopic excision of benign breast lumps is a safe and patient-friendly procedure.

Serum placental growth factor as a predictor of early onset preeclampsia in overweight/obese pregnant women

The purpose of this study was to analyze whether maternal serum placental growth factor (PlGF) could predict early onset preeclampsia (<32 weeks of gestation) in overweight/obese pregnant women, and whether it could do it more effectively than in normal/underweight pregnant women. A prospective cohort study was conducted on 1678 pregnant women with singleton pregnancies, who were grouped as underweight, normal, overweight, and obese on the basis of body mass index, followed by serum PlGF estimation at 20 to 22 weeks of gestation. A cut-off value of <144 pg/mL for PlGF was determined by Receiver Operating Characteristic curve analysis to identify risk of early onset preeclampsia. Univariate logistic regression analysis revealed significantly stronger association between PlGF <144 pg/mL and early onset preeclampsia in overweight/obese pregnant women (odds ratio 7.64; 95% confidence interval 5.34-10.12; P = .000) than in normal/underweight pregnant women (odds ratio 2.95; 95% confidence interval 1.74-4.26; P = .007). Weight and PlGF levels in study women had a significant negative correlation (r = 0.663; P = .002). Serum PlGF in early second trimester could be an effective predictor of early onset preeclampsia in overweight/obese pregnant women and may be more effective than in normal/underweight pregnant women.

Recurrent laryngeal nerve, phonation and voice preservation—energy devices in thyroid surgery—a note of caution

Reservations [1] about energized dissection (ED) in thyroidectomies (EDIT) and ED-induced iatrogenic catastrophes in laparoscopy exhort us to forsake adventurism, with technology un-benchmarked against standards of patient safety [2]. Surgeons embody Plato’s “techne iatrike”, Aristotle’s desire for dexterity, and artist’s sensibilities, remembering the technology as a double-edged sword, giving accolade and criticism equally [2]. The advocates of EDIT, reporting higher rate of insult to recurrent laryngeal nerve (RLN), confess to essentiality of meticulous surgical technique and await prospective randomized control trails (RCT), knowledge about thyroid specific heat dispersion and heat sink engineered ED. Even RCTs cannot negate the basics of surgical precision and hemostasis [3]. A few minutes gain should not be traded off against quadrupled complications. Redundancy of assistance is made a virtue violating the team-based “systems approach”, sounding contemptuous towards training. Surgeons train in heterogeneous fiscal atmospheres with universal concerns about ethics and safety. Time advantage remains unsupported by hepatectomy experiences where the collateral damageinduced biliary sealing is a virtue, but structures around thyroid cannot be bartered as collaterals for damage. “Patient-reported outcomes” are the proper “study end points” in this era of informed patients, and “technological toy”-wielding surgeon, as altered “phonation frequency range”, and vocal flitter reported in thyroidectomies with preserved RLN indicate invisible insult during dissection. Involuntary spread of invisible energy in ED insults the precision of cold sharp dissection, something regaining respect even in laparoscopic surgery [4]. History of thyroid surgery is a study of evolution of hemostasis. Advocacy of ED for hemostasis is contemptuous for pioneers whose names live on in the hemostats that we use, i.e., Schiebervorrichtung of Fricke, Kocher, Halsted, Mayo, Crile, and Lahey. Hemostatic techniques in thyroid surgeries are an index of surgical skills. It might surprise us that the hemostatic forceps were developed to replace cautery. Even Halsted castigated Cushing (co-inventor of Bovie) by saying “The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is hemorrhage”. The benchmark in hemostasis evolved despite criticism from Berry calling thyroidectomy “worse than useless” and Gross “No honest and sensible surgeon, it seems to me, would engage in it”. Invisible RLN insult from thermal spread goes undetected because only laryngeal electromyography can exclude such an insult. There are more vulnerable structures, i.e., parathyroid vasculature and the nerve of Amalita Galli Curci. ED is an environmental compromise too [4]. To submit all patients to something that has a small benefit in a small group of patients and yet has complications that are measurable in the larger group seems madness [5]. Langenbecks Arch Surg (2009) 394:911–912 DOI 10.1007/s00423-009-0504-x

The man—machine interface, a paradox of technology. Is the black box (BB) concept an angel or a demon?

Congratulations for publishing the article by Verdaasdonk et al. [1]. This is a testimony to the torch-bearer role of your August journal in advancing the progress of endoscopic surgery. Evolution of endosurgery has been aided and preceded by innovations in technologies such as endo-optics, cable connections, insufflators, energy sources, light sources [2], and recording apparatus. However, they are not immune to malfunction or malapplication and cannot replace human judgment. A good surgeon believes what he sees and not otherwise [3]. He dissects in avascular anatomical planes by sharp dissection [4] keeping the energy sources as standby only [5]. In laparoscopic cholecystectom, a range of skills can be performed without using energy sources [5], a potentially harmful yet necessary tool. Even in hernia surgery the potential harm from technology is being recognized and this is just the tip of the iceberg [6]. This scenario is alarming due to the aspersions cast upon our honesty [7], documentation [8], and politics [9]. To err is human and there is no aura to an error [10]. Adverse events may occur when least expected [11]. The chances of error increase in minimally invasive surgery due to over-reliance on technology [1]. We have been following the black box (BB) concept by recording all of our procedures with the satisfaction of being able to go back and analyze an unexpected outcome. This has given us increased confidence and peace of mind. Heightened awareness and demands from the society [12], the systems approach, and the desirability of mandatory reporting [10]mandate the adoption of the BB concept. Technology is rolling ahead like a steamroller, so it is better to be part of it, rather than be rolled over by it. Society is watching our attire [13], etiquette [14], whether we are technolgy savvy, and our communication skills [12]. We should assume this leadership [12] by voluntarily adopting the BB concept. This will be a useful tool for teaching, self-monitoring, and selfimprovement. Our demigod stature of past may not retun but surely a self-regulatory step such as the BB concept will enhance our prestige and esteem [15]. Shying away will not postpone this, but will be judged as contemptuous by the society. References

Association between placental growth factor levels in early onset preeclampsia with the occurrence of postpartum hemorrhage: A prospective cohort study.

OBJECTIVES To determine the association between PlGF (placental growth factor) estimation in early second trimester (22-24weeks of gestation), with the occurrence of postpartum hemorrhage in pregnant women with early onset preeclampsia and whether the mode of delivery (cesarean or vaginal) has any association with increased risk of developing postpartum hemorrhage. STUDY DESIGN A prospective cohort study was conducted on 788 pregnant women with singleton pregnancies diagnosed with early onset preeclampsia between March 2009 and June 2011. Maternal serum PlGF level estimation was done between 22 and 24weeks of gestation and a cut-off value of <122pg/ml was determined by receiver operating characteristic (ROC) curve analysis for identifying those at risk of developing postpartum hemorrhage. Association between serum PlGF level <122pg/ml and cesarean deliveries with the risk of developing postpartum hemorrhage was analyzed by logistic regression analysis and Odds ratio, which were computed. The results were considered statistically significant when P-value <0.05. MAIN OUTCOME MEASURES Proportion of study population developing postpartum hemorrhage. RESULTS Logistic regression analysis showed the association of serum PlGF <122pg/ml at 22-24weeks (Odds ratio 8.9516; 95% CI, 5.0728-15.7963) and that of cesarean delivery (Odds ratio 2.4252; 95% CI, 1.4573-4.0360) with the risk of developing postpartum hemorrhage. Both the associations were found to be statistically significant. CONCLUSION Maternal serum PlGF level <122pg/ml at 22-24weeks of gestation and cesarean delivery are both strongly associated with the risk of developing postpartum hemorrhage in pregnant women with early onset preeclampsia.

Surgical pilgrimage - The need to avoid navigation through drains, medicine or 'medisin': Our notes on NOTES

Mr. G. Buess and Sir A. Cuschieri must be congratulated for initiating the debate on natural-orifice transluminal endoscopic surgery (NOTES) [1]. To do so in the absence of any dissent to NOTES is not only commendable but the fulfillment of a role befitting them. While attending the World Congress 2006, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conference 2007, and the European Association for Endoscopic Surgery (EAES) conference 2007, I heard the outlandish propositions about NOTES and wondered if I was intellectually handicapped in not appreciating them in totality. Coming from the developing world, and having a perception of my own anonymity, I could not muster the courage to speak against or question the rationale of transgastric or transcolonic procedures. This is why I felt reassured and proud of whistleblowers like Buess and Cuschieri. It is well established that health intervention should be both effective and safe [2]. Even the word ‘‘safe’’ has to be used with caution while evaluating surgical techniques [2]. Endoscopic surgery has seduced the surgeon as well as society. Its appeal has been maintained by an endeavor to ethically duplicate the wisdom of the accumulated experience of the conventional surgery era [3]. As noted by the authors [1] the surgical breach in gastrointestinal continuity is absurd, unless part of the intended surgical benefit. It is astonishingly inhumane to be even reading things like transvesical thoracoscopy [4] and wondering for the helpless poor animals being wasted, more so in such nonsurvival models. These self-professed heroes have deviated from the basic tenet of our profession: primum non nocere (first, do no harm). Many a time they flaunt supporting statistical data. While statistical support may be an important tool in scientific pursuit it cannot be a substitute for humane clinical decision-making in surgery [5]. While endoluminal procedures, as noted by the authors [1], are a legitimate progress, the nomenclature of NOTES seems a veil to cover unholy transgression of surgical ethics and human dignity. The human body is sacred, while operating, a surgeon is akin to being on holy pilgrimage and you do not navigate through drains while on a pilgrimage. The society respects us and expects a reciprocal respect. In this era of easy access to information no amount of statistical evidence will be able to stand scrutiny in the event of unforeseen complications from a gastric, colonic or vesical leak. Any such leak is a surgeon’s nightmare even in well intended and necessary procedures. To say this will not happen is being dishonest. Things can go wrong when least expected and there is a probability even for the improbable [6]. Surely times are both challenging and exciting. Case volumes and reimbursements might be decreasing [7], forcing upon us the need to be seen as innovators. The lure B. B. Agarwal Journal of International Medical Sciences Academy, New Delhi, India

Spontaneous Rupture of Iatrogenic (Postinguinal Herniorrhaphy) Venovenous Malformation Managed Endoscopically

Complications of open inguinal hernia repair, such as wound infection, hematoma, seroma, and neuralgia, are known to occur. Vascular injuries during inguinal hernia repair are rare and documented as case reports only. Vascular malformations are known to occur after trauma or sharp injuries. Most of the venous malformations are congenital in origin and usually reported in relation to congenital heart disease or in visceral locations. We encountered an iatrogenic venovenous malformation (VVM) in the subcutaneous space of the left inguinal region following an open inguinal hernia repair. This VVM presented as a spontaneous rupture leading to widespread ecchymosis of the thigh. It was managed endoscopically.