Tehemton E Udwadia

This special issue

At its very first meeting the Editorial Board of the JMAS had decided to bring out one Special Issue of the Journal every year. The Journal could not have asked for a better, more balanced, more thought provoking first Special Issue than this one on Laparoscopy in Urology compiled by our Guest Editors Professor Ashok K. Hemal and Dr Rajeev Kumar. The Journal is indebted to them for this significant contribution to M.A.S. literature.

Single-incision laparoscopic cholecystectomy: How I do it?

Single-incision laparoscopic cholecystectomy (SILC) is a relatively new technique that is being increasingly used by surgeons around the world. Unlike the multi-port cholecystectomy, a standardised technique and detailed description of the operative steps of SILC is lacking in the literature. This article provides a stepwise account of the technique of SILC aimed at surgeons wishing to learn the procedure. A brief review of the current literature on SILC follows.

Laparoscopic biopsy in patients with abdominal lymphadenopathy

Background: Abdominal lymphadenopathy (AL) - a common clinical scenario faced by clinicians - often poses a diagnostic challenge. In the absence of palpable peripheral nodes, tissue has to be obtained from the abdominal nodes by image-guided biopsy or surgery. In this context a laparoscopic biopsy avoids the morbidity of a laparotomy. Aim: This retrospective analysis of prospectively collected data represents our experience with laparoscopic biopsy of abdominal lymph nodes. Materials and Methods: Between October 2000 and November 2005, 28 patients with AL underwent laparoscopic biopsy. Pre-operative radiological imaging studies had identified a nodal mass in 20, a solitary node in 1, a cold abscess in 1 and a mesenteric cystic lesion in 1 patient. In five patients with chronic right lower abdominal pain and normal ultra-sonographic findings mesenteric nodes were identified and biopsied during diagnostic laparoscopy. Results: The sites of biopsied lymph nodes included para-aortic (10), mesenteric (8), external iliac (3), left gastric (2), obturator (1), aorto-caval (1) and porta hepatis (1). One patient with enlarged peripancreatic nodes mass and another with a mesenteric cystic mass had cold abscesses drained in addition to biopsy. There were no perioperative complications and the median postoperative stay was 2 days (range 1-4 days). Histopathology revealed tuberculosis in 23 patients, reactive adenitis in 2, lymphoma in 1 metastatic carcinoma in 1, and a retroperitoneal sarcoma in 1. Conclusions: In patients with AL, laparoscopy provides a safe and effective means of obtaining biopsy. It is of particular value in patients in whom (a) the nodes are small or present in locations unsuitable for image-guided biopsy, (b) adequate tissue cannot be obtained by image-guided biopsy or (c) previously undiagnosed lymphadenopathy is encountered during diagnostic laparoscopy.

Ghee and honey dressing for infected wounds.

Ghee and honey has been advocated and used as dressing for infected wounds by Sushruta (600BC) and since 1991 in four Mumbai Hospitals. The gratifying results observed with the dressing have prompted this study which aims to establish its efficacy in five recalcitrant subset of chronic infected wounds over a three year period 2006–2009. A standardized ghee and honey dressing was used to treat: a) Eight cases of fungating malignant lesions. b) Thirteen chronic venous ulcers. c) Twenty nine diabetic foot ulcers. d) Eleven of infected ventral hernia mesh hernioplasty. e) Eleven patient with post-cesarean wound dehiscence. The dressing markedly reduced the foul odour and discharge, significantly improving the quality of life in malignant lesions. The results were equivocal in cases of venous ulcers. The results were uniformly good in the last three groups. In view of our results, as also result of innumerable Randomized Control Trials (RCTs) reported on honey dressing for infected wounds, there is substantial evidence that ghee and honey dressing has at least comparable results to other modes of treatment. The easy availability and low cost of this treatment makes it significant in developing countries. Further trials seem warranted.

Single-incision laparoscopic surgery: An overview.

Over the last two decades, conventional multi-port Minimal Access Surgery (MAS) has established itself as the gold standard for almost all abdominal surgical procedures. The procedure provides safety, ease, undisputed patient benefit at a cost acceptable to the healthcare system by surgeons from several specialties all over the world, in large hospitals as well as underprivileged rural areas. MAS has effectively addressed the patients’ right to less scarring, trauma (both of access and intra-abdominal manipulation), medication, pain, hospitalization, and early return to family and work.

Laparoscopic surgery for inguinal hernia: Current status and controversies

Repair of inguinal hernia is one of the commonest operations performed by surgeons around the world. The treatment of this common problem has seen an evolution from the pure tissue repairs to the prosthetic repairs and in the recent past to laparoscopic repair. The fact that so many hernia repairs are practiced is a testimony to the fact that probably none is distinctly superior to the other. This review assesses the current status of surgery for repair of inguinal hernia and examines the various controversial issues surrounding the subject.

Inguinal hernia repair: The total picture.

Bassini in 1988 posted a milestone in the history of not only hernia surgery but of all surgery when he reported a reduction in the recurrence rate from 100 to 10% with his operation which was a unique combination of understanding of anatomy and application of surgical thinking and technique. This 10% recurrence rate was achieved at a period without antibiotics, primitive anaesthesia and when patients suffered their hernia to giant size before submitting to surgery. Over nine decades Bassini’s tissue repair procedures – with several modifications (Halsted, McVay, Tanner, Shouldice....) has helped preserve useful life in hundreds of thousands cases. While most “herniologists” view tissue repair as a method in disrepute to be discarded, its very economical cost structure makes it even today the commonest form of hernia repair in most part of the developing world and even in Canada tissue repair (Shouldice) accounts for 25% of all inguinal hernia repair.

Temporary obturator nerve paresis after spray of local anesthetic during laparoscopic extraperitoneal inguinal hernia repair.

To the Editor: Laparoscopic totally extraperitoneal repair (TEP), a well-accepted treatment of inguinal hernia, is often performed on an outpatient basis and the patients are invariably encouraged to mobilize early. It is a common practice to infiltrate the incisions with local anesthetic and spray the same in the extraperitoneal space (spray) in an effort to reduce postoperative pain. We report an unusual complication that occurred in a patient undergoing a bilateral TEP who had received a spray. TEP using 3 midline ports was performed in a 58-year-old man (body mas index, 32 kg) with bilateral direct hernias. A 15 12-cm polypropylene mesh (Prolene, Johnson and Johnson, Mumbai, India) was placed on each side and fixed with 3 5-mm tacks. At the conclusion of the procedure, 15mL of 0.25% bupivacaine (Sensorcaine; AstraZeneca Pharma India Pvt. Ltd., Bangalore, India) was sprayed in the extraperitoneal space and the incisions were infiltrated with a further 15mL of 0.25% bupivacaine. A few hours after returning to the room the patient complained of difficulty in getting out of bed. A neurological examination was normal except weakness of adduction of the right hip. He was advised bed rest till this was resolved. After around 6 hours he was able to move his right lower limb without difficulty and ambulated satisfactorily. He was discharged after a further 36 hours of observation and remains well at follow-up. It was concluded that the spray had resulted in a temporary paresis of the right obturator nerve, which had resolved spontaneously. Postoperative pain after TEP is attributed to the skin incisions and also to the wide dissection of the peritoneum. Although some researchers point to the beneficial effect of the spray in reducing postoperative pain, a recent randomized trial showed no difference in postoperative pain, supplementary analgesic requirements, or hospital stay in patients receiving the spray. It has been suggested that the visceral pain fibers that are more diffuse in distribution and innervation contribute to the pain in TEP. These are considered to be more refractory to blockade with local anesthetics and nonsteroidal anti-inflammatory drugs than somatic fibers. Temporary femoral nerve palsy after the use of local anesthetic, either as a field block or as a part of local infiltration into the operative field, is a rare but well-documented complication of open inguinal hernia repair. Patients attempting to weight bear have been described to develop fracture of the tibia and fibula and minor head injury from a fall. Postsurgical nerve lesions are uncommon after TEP, except for rare instances of neuralgia related to improper placement of fixation devices. Paralysis of the femoral nerve has been described in a patient undergoing TEP in whom neither sutures nor tacks were used for fixation of the mesh. Extensive evaluation failed to identify a possible cause for the palsy, which resolved gradually over a period of time. The second author (D.B.), who was the primary surgeon for this case, has used spray in over 200 hernias (TEP and transabdominal preperitoneal) but has never experienced this complication before. As our case shows that the common and seemingly innocuous step carries a small but definite risk of temporary nerve paresis. This has implications for the early mobilization of patients. In some day case units, nurses assess active extension of the knee in patients having open inguinal hernia repair under a local anesthetic before allowing them to weight bear. Should all patients in whom a spray is to be used be counseled about the likelihood of temporary muscle weakness preoperatively? Should the muscle strength in the lower limbs be assessed before the patient is allowed to ambulate? Both these steps seem rather cumbersome to implement but may carry a medicolegal implication if a patient in whom the spray had been used, was to develop a fall and injure himself. As the literature fails to prove the benefits of spray during TEP, should this practice be abandoned altogether? We have done so since operating on the patient described here. Gaurav Mittal, DNB Deepraj Bhandarkar, MS, FRCS, FACS, FICS Avinash Katara, MS, FRCS Tehemton E. Udwadia, MS, FRCS, FACS, FICS Division of Minimal Access Surgery Hinduja Hospital Mahim Mumbai, India

Single-incision bilateral laparoscopic oophorectomy

Although single-incision laparoscopic surgery made an appearance on the surgical scene only recently, it is being increasingly applied in the treatment of a variety of disorders. We report single-incision bilateral laparoscopic oophorectomy and salpingooophorectomy performed in two patients who had previously undergone breast conservation surgery for early breast cancer. Each procedure was undertaken using two 5-mm and one 3-mm ports inserted through a 2-cm transverse supraumbilical incision and standard laparoscopic instruments. The operative time was 50 and 65 min respectively and the blood loss negligible. The patients were discharged 36 and 24 h after surgery, required minimal postoperative analgesia and remain well at a follow up of 19 and 17 months, respectively. With the benefit of improved cosmesis, the single-incision approach holds the potential to replace the traditional bilateral laparoscopic oophorectomy.

Use of Nathanson retractor during laparoscopic splenectomy for supermassive spleens.

Background: Although feasibility of laparoscopic splenectomy for supermassive spleens has been described, obtaining uniform and uninterrupted retraction of a heavy spleen to ensure safe hilar dissection is challenging. We describe a technique of retraction of supermassive spleens using a Nathanson retractor. Methods: This technique was used in 4 patients, and the demographic data as well as data related to the surgery were retrospectively collected. Results: The spleens weighed between 2.5 and 3.5 kg. The median operative time was 190 minutes (155−220 min) and the median intraoperative blood loss was 870 mL (600−1230 mL). The postoperative hospital stay ranged from 3 to 5 days. Conclusions: A Nathanson retractor provides sustained retraction of a supermassive spleen during laparoscopic splenectomy and this technique should be considered a useful adjunct to the armamentarium of surgeons undertaking these challenging procedures.