Virinder Kumar Bansal

Single-port surgery and NOTES: from transanal endoscopic microsurgery and transvaginal laparoscopic cholecystectomy to transanal rectosigmoid resection.

Two different ways have been developed to perform endoscopic surgery. The standard way is multiport laparoscopic surgery. When entering through a natural orifice, we use single-port surgery for transanal work (transanal endoscopic microsurgery). In clinical routine, we moved from intralumenal surgery toward surgery in the perirectal area and finally the free abdomen. In the context of natural orifice translumenal endoscopic surgery, we have modified the length and diameter of optics and tube and developed new mechanisms for steering long curved instruments. This technology is then used for transvaginal cholecystectomy and transanal rectosigmoid resection. Global clinical application of transanal endoscopic microsurgery has proven superiority in preciseness and clinical results for adenomas and early cancer. The initial clinical study for transvaginal cholecystectomy is successfully performed in 6 female patients with an average operation time of 80 minutes and without major complication. Feasibility of transanal rectosigmoid resection is demonstrated in an ex vivo experimental model.

Sequential occurrence of preneoplastic lesions and accumulation of loss of heterozygosity in patients with gallbladder stones suggest causal association with gallbladder cancer.

Background:Causal association of gallbladder stones with gallbladder cancer (GBC) is not yet well established. Objective:To study the frequency of occurrence of preneoplastic histological lesions and loss of heterozygosity (LOH) of tumor suppressor genes in patients with gallstones. Methods:All consecutive patients with gallstones undergoing cholecystectomy from 2007–2011 were included prospectively. Histological examination of the gallbladder specimens was done for preneoplastic lesions. LOH at 8 loci, that is 3p12, 3p14.2, 5q21, 9p21, 9q, 13q, 17p13, and 18q for tumor suppressor genes (DUTT1, FHIT, APC, p16, FCMD, RB1, p53, and DCC genes) that are associated with GBC was tested from microdissected preneoplastic lesions using microsatellite markers. These LOH were also tested in 30 GBC specimens. Results:Of the 350 gallbladder specimens from gallstone patients, hyperplasia was found in 32%, metaplasia in 47.8%, dysplasia in 15.7%, and carcinoma in situ in 0.6%. Hyperplasia, metaplasia, and dysplasia alone were found in 11.7%, 24.6%, and 1.4% of patients, respectively. A combination of hyperplasia and dysplasia, metaplasia and dysplasia, and hyperplasia, metaplasia, and dysplasia was found in 3.4%, 6.3%, and 4.3% of patients, respectively. LOH was present in 2.1% to 47.8% of all the preneoplastic lesions at different loci. Fractional allelic loss was significantly higher in those with dysplasia compared with other preneoplastic lesions (0.31 vs 0.22; P = 0.042). No preneoplastic lesion or LOH was found in normal gallbladders. Conclusions:Patients with gallstones had a high frequency of preneoplastic lesions and accumulation of LOH at various tumor suppressor genes, suggesting a possible causal association of gallstones with GBC.

Laparoscopic pericystectomy for hydatid cyst of the liver.

The greatest disadvantage of conservative surgical procedures in the management of hydatid cyst of the liver is their association with high recurrence rates. Radical surgical procedures such as closed total pericystectomy avoids spillage thereby minimizing recurrences. The use of laparoscopy in performing these radical surgical procedures further reduces the morbidity associated with the open surgery. This study has been carried out to assess the safety and feasibility of laparoscopic pericystectomy in the management of hydatid cyst of liver. Small, peripherally located cysts lying away from major vessels are amenable to laparoscopic pericystectomy successfully whereas, cysts larger than 10 cm, posteriorly located cysts and those lying in close proximity to the major ducts and vessels required conversion owing to bleeding. Therefore, laparoscopic pericystectomy can be regarded as a gold standard for the management of hydatid cyst of the liver in selected patients.

Laparoscopic Suturing Skills Acquisition: A Comparison Between Laparoscopy-Exposed and Laparoscopy-Naive Surgeons

This study suggests that training improves laparoscopic suturing skills in experienced as well as inexperienced laparoscopic surgeons.

Massive scrotal hernias: problems and solutions.

BACKGROUND Massive incarcerated scrotal hernias are usually managed by an open method. Some experienced surgeons have successfully attempted laparoscopic management of such cases. Total extraperitoneal repair (TEP) is the laparoscopic technique of choice for the repair of groin hernia. Many authors have suggested that transabdominal preperitoneal (TAPP) is the preferred approach to these hernias. The purpose of this study is to show our results of TEP repair of giant scrotal hernias. PATIENTS AND METHODS In the present study a total of 21 (20 patients) out of 291 groin hernias (185 patients) were included and evaluated prospectively. TEP was successful in 14 (66.6%) with a conversion to TAPP in 4 (19.04%) and open procedure in 3 (14.28%) cases, respectively. Postoperative complications included scrotal hematoma in 5 (25%), spermatic cord edema in 6 (30%), and seroma in 14 (70%) patients. There was no recurrence of hernia noticed during mean follow-up of 36 months (range, 22-51). CONCLUSION Laparoscopic TEP repair was successful with excellent outcome in the management of massive incarcerated groin hernia in the hands of an experienced laparoscopic surgeon.

Duodenal perforation following blunt abdominal trauma

Duodenal perforation following blunt abdominal trauma is an extremely rare and often overlooked injury leading to increased mortality and morbidity. We report two cases of isolated duodenal injury following blunt abdominal trauma and highlight the challenges associated with their management. In both these patients, the diagnosis of the duodenal injuries was delayed, leading to prolonged hospital stay. The first patient had two perforations, one on the anterior and the other on the posterior wall of the duodenum, of which the posterior perforation was missed at initial laparotomy. In the other patient, the duodenal injury was missed during the initial assessment in the emergency department. He returned to the emergency department 24 hours after discharge with abdominal pain and vomiting. During trauma related laparotomy, complete kocherization (mobilization) of the duodenum must be mandatory, even in the presence of obvious injury on its anterior wall. We emphasize on keeping the management protocol simple by a “triple tube decompression”, i.e. duodenorrhaphy (simple closure), tube gastrostomy, reverse tube duodenostomy and a feeding jejunostomy.

A Prospective Randomized Controlled Blinded Study to Evaluate the Effect of Short-Term Focused Training Program in Laparoscopy on Operating Room Performance of Surgery Residents (CTRI /2012/11/003113)

INTRODUCTION Laparoscopic surgery requires certain specific skills. There have been several attempts to minimize the learning curve with training outside the operation room. Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Several randomized controlled trials and systematic reviews have demonstrated that the technical skills learned on these simulators transfer to the operating room. Currently, however, the integration of these simulated models into formal residency training curricula is lacking. In our institute, we have adopted the Tuebingen Trainer devised by Professor GF Buess from Germany. The purpose of this study was to evaluate the training of surgical residents on an ex vivo phantom model for basic laparoscopic skill acquisition and its transferability to the OR performance. MATERIALS AND METHODS Seventeen general surgery residents were randomized into 2 groups: Laparoscopic Training Group (n = 9, Group A) and Standard Training Group (n = 8, Group B). Group A underwent training in the Minimally Invasive Surgery Training Centre on the porcine phantom model and did 10 laparoscopic cholecystectomies, whereas Group B did not undergo training in the Minimally Invasive Surgery Training Centre. All the participants performed a laparoscopic cholecystectomy in the operation theater in the presence of a consultant who was blinded to the training status of the participants. The performance of the residents in both groups in the operation theater was assessed using GOALS criteria, surgical performance assessment parameters, task-specific checklists, and visual analog scale for gallbladder perforation difficulty and overall competence. RESULTS The Laparoscopic Training Group had better performance than the Standard Training Group regarding operation time, GOALS criteria, and Task-specific checklists. Although the surgical performance assessments, i.e. cystic duct and artery identification scores, gallbladder perforation scores, and liver injury scores, were better in the Laparoscopic Training Groups, they were not statistically significant. The overall difficulty of the surgery was comparable in both the groups. The Laparoscopic Training Group exhibited significant overall competence on visual analog scale scores. CONCLUSION Our study has clearly shown that training on the Tuebingen Trainer with integrated porcine organs results in a statistically significant improvement in the operating room performance of surgical residents as compared with the nontrained residents, thereby indicating a transfer of skills from training to the operating room.

Total extra-peritoneal repair of groin hernia: prospective evaluation at a tertiary care center

BackgroundThe laparoscopic repair of groin hernia is increasingly being used. However, the relative merits and demerits of laparoscopic repair are debatable. The present study was undertaken to evaluate the total extra-peritoneal (TEP) repair of groin hernia.MethodsThis prospective study was undertaken at a single surgical unit between January 2004 and June 2006. Consecutive patients with elective groin hernias were offered laparoscopic TEP repair. Indigenous balloon or telescopic dissection was used to create extra-peritoneal space. Polypropylene mesh was used in all of the patients and mesh fixation was performed with tackers.ResultsA total of 185 patients with age range 18–92 years were included; 180 were males. TEP repair was attempted in 298 groin hernias in 185 patients with a success rate of 89.5%. Indigenous balloon or telescopic dissection was used to create extra-peritoneal space. Thirty-one (31, 10.5%) TEP repairs were converted to transabdominal pre-peritoneal or open repair. Two patients developed recurrence during follow-up.ConclusionTEP is an excellent technique for laparoscopic groin hernia repair, with acceptable rates of complication.

Outcomes of renal transplant in patients with anti-complement factor H antibody-associated hemolytic uremic syndrome.

Atypical HUS associated with anti‐CFH autoantibodies is an uncommon illness associated with high risk of progression to end‐stage renal disease. Disease relapses after transplantation, observed in one‐third cases, often lead to graft loss. We report four patients with anti‐CFH antibody‐associated HUS who underwent renal transplantation 16–62 months from initial presentation. Two patients each received organs from deceased and living‐related donors. Anti‐CFH antibody titers were monitored during the illness and following transplantation. All patients received two doses of IV rituximab before or after transplantation; three patient each received 1–2 g/kg of IV immunoglobulin or underwent 2–5 sessions of plasma exchanges. The use of therapeutic plasma exchange, IV immunoglobulin, and rituximab in two cases enabled two‐third reduction in anti‐CFH antibody titers before transplantation. At 5‐ to 26‐month follow‐up, all patients showed satisfactory graft function without recurrence of HUS. This is the first report of patients with anti‐CFH antibody‐associated HUS who underwent living‐related renal transplantation. Clearance of anti‐CFH antibody by therapeutic plasma exchange and adjuvant immunosuppression aimed at decreasing antibody levels may enable successful transplantation and recurrence‐free survival.

Duodenal gastrinoma: a diagnostic dilemma

Preoperative assessment and localization is crucial in the management and outcome of patients with duodenal gastrinoma. Localization can be challenging because of small size and variable location. We describe our experience of managing 1 such patient by localizing the lesion during the preoperative period. Side-viewing endoscopy, endoscopic ultrasound, and somatostatin receptor scintigraphy determined the exact location of the tumor, which was confirmed during surgery on palpation, endoscopic transillumination, and duodenotomy. Antrectomy was performed, and the patient was asymptomatic after 8 months of follow-up and did not require antisecretory medications. His serum gastrin levels returned to normal during the postoperative period.