There was a reported higher incidence of common bile duct injuries when laparoscopic cholecystect... more There was a reported higher incidence of common bile duct injuries when laparoscopic cholecystectomy was first introduced about a decade ago. With any new procedure, there is a likelihood of an increase in the number of complications during the learning curve. With increasing experience the areas or situations having a higher probability of causing the complication get identified. Seventy percent of these injuries are claimed to occur in surgeries classified as simple laparoscopic cholecystectomy. With our experience of over 9000 laparoscopic cholecystectomies, we have identified certain anatomical situations where there is a higher likelihood of injuring the CBD. These situations include a sessile gall bladder, especially with a narrow CBD, a lax CBD getting easily tented by traction on Hartmann pouch and a short cystic duct with the CBD in close proximity to the duct and posterior gall bladder wall. Also, other well documented factors known to contribute to a greater incidence of ...
Achalasia Cardia is a rare functional oesophageal disorder which is characterized by impairment o... more Achalasia Cardia is a rare functional oesophageal disorder which is characterized by impairment of relaxation at the lower oesophageal sphincter in response to normal oesophageal peristaltic activity. The pathologic finding is an absence, decrease or degeneration of ganglion cells in the myenteric plexus of the lower oesophageal sphincter. The condition being essentially irreversible the treatment is directed at achieving symptomatic relief. The treatment may be medical i.e. Pneumatic dilatation, or surgical which up to now was open oesophagocardiomyotomy. Medical treatment was preferred up to now, being associated with minimal morbidity and a reasonably good symptomatic relief, making it highly acceptable for the patient. We present Laparoscopic Oesophagocardiomyotomy which should be considered the treatment of choice as it gives excellent results comparable to the open procedure minus all the incision related morbidity associated with the latter. A total of nine (9) patients have ...
Laparoscopic adrenalectomy is indicated for patients with adrenal masses, pheochromocytoma and cu... more Laparoscopic adrenalectomy is indicated for patients with adrenal masses, pheochromocytoma and cushings syndrome. It can be performed either by a retroperitoneal approach or a transperitoneal approach. Retroperitoneal approach is the procedure of choice as in open surgery but a transperitoneal approach may be required for large adrenal masses. Majority of these patients undergoing adrenalectomy are severely moribund and immunocompromised. Large open incisions thus add on to their morbidity and suffering. The majority of adrenal gland tumors are amenable to laparoscopic excision because most adrenal neoplasms are small and pathologically benign. We review the basic principles and technical aspects of a transperitoneal laparoscopic approach to adrenelectomy i.e. right and left adrenal gland. Laparoscopic adrenalectomy has now because the procedure of choice for adrenal masses in all the advanced laparoscopic centres having all the advantages of minimal access surgery including decreas...
Seven patients with Achalasia Cardia underwent laparoscopic Oesophagocardiomyotomy at our centre ... more Seven patients with Achalasia Cardia underwent laparoscopic Oesophagocardiomyotomy at our centre between October 1998 and October 2001. Of these, one patient was subjected to pneumatic dilatation once and three patients twice, with unsatisfactory results. Three patients were offered surgery without pneumatic tlilatation. The procedure was completed entirely laparoscopically in all seven patients. The approach was transabdominal and the average length of the myotomy incision was 6 cms, including 1 cm of proximal stomach musculature. A partial anterior fundoplication was performed along with cardiomyotomy in six patients. The average post operative stay was 2-6 days. All patients reported a significant amelioration of symptoms, patient response varying from good in the first patient, to excellent in the last two patients
Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallb... more Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy. Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up. Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct. Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.
Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common lap... more Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. With the advent of laparoscopic surgery and its continuous development, the focus has shifted to 'scarless' surgery. In recent times, the innovative technique of single-incision laparoscopic surgery (SILS) has been applied in gallbladder removal and even more complex biliopancreatic procedures to further minimize the invasiveness of the surgery. Newer developments in laparoscopic equipments and instrumentation have helped to further evolve this field of minimally invasive surgery. Literature search was performed using the following online search engines: Google, Medline, PubMed, Cochrane, and the online Springer link library. The terms used for the search were as follows: SILS, LESS, singleincision laparoscopic surgery, single-port laparoscopic surgery, SILS cholecystectomy, and SILS pancreatic surgery. Articles that matched the search criteria were selected and extensively reviewed. Moreover, pertinent information on instrumentation and technology for SILS and LESS was obtained by accessing websites of manufacturers. Although SILS represents the search for an essentially scarless surgery, there is still not a widespread use and uniformity of this procedure. SILS is performed either by single-or multiple-port technique. In the present article, we present a review of the potential benefits, limitations, and risks of SILS in biliary and pancreatic diseases. There are many studies showing benefits in cholecystectomy. A few case reports have also emerged about its feasibility in procedures such as cystogastrostomy and limited pancreatic resection. Further research and development of this technique is needed to arrive at a tangible conclusion about the perceived benefits of SILS. Randomized studies to compare SILS with traditional laparoscopy are essential.
To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecut... more To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecutive patients who underwent laparoscopic adrenalectomy in our department. Twenty four patients underwent laparoscopic adrenalectomy between September 2000 and August 2005. There were 12 males and 12 females with a mean age of 44.6 years (range 25-68 years). The indications for adrenalectomy were pheochromocytoma (13 patients), Cushing's syndrome (5 patients), myelolipoma (2 patients), adrenal cyst (2 patients), aldosteronoma (1 patient) and adrenal incidentaloma (1 patient). Nineteen of our patients with functioning adrenal tumours were prepared preoperatively for periods ranging up to 2 weeks by the endocrinologist. All laparoscopic adrenalectomies were performed via lateral transperitoneal approach using standard four-port technique. Patients with pheochromocytoma and Cushing's syndrome were monitored in the surgical intensive care unit during immediate postoperative period. The...
Surgical laparoscopy, endoscopy & percutaneous techniques, Jan 19, 2014
We present our experience with 10 patients with infected meshes after laparoscopic inguinal herni... more We present our experience with 10 patients with infected meshes after laparoscopic inguinal hernia repair in whom we explanted infected meshes laparoscopically. On retrospective analysis over 5 years (2007 to 2012), we identified 10 patients (6 TAPP/4 TEP) with localized deep-seated mesh infections in whom infected meshes were explanted laparoscopically. Peritoneum was incised, associated abscesses were drained, meshes were identified, separated, and extracted through 10/12 mm port. Nine patients experienced resolution of symptoms after 3 weeks of surgical intervention and remained asymptomatic at mean follow-up of 20 months (range, 4 to 42 mo). One patient with recurrent abscess required surgical drainage twice. Mean hospital stay was 2.2 days (range, 1 to 9 d). Two patients developed recurrent hernia at 6 and 8 months after mesh explantation. Laparoscopic explantation of infected meshes after laparoscopic hernia repair leads to less scarring and early recovery. Contamination of an...
Ingestion of foreign body is a serious problem commonly encountered in our clinical practice. Mos... more Ingestion of foreign body is a serious problem commonly encountered in our clinical practice. Most of them pass spontaneously, whereas in others endoscopic or surgical intervention is required because of complications or non-passage from the gastrointestinal tract. We present here a case of teaspoon ingestion, which did not pass spontaneously. Laparoscopic retrieval of teaspoon was done from mid jejunum after enterotomy and the patient recovered uneventfully. Right intervention at the right time is of paramount importance.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2003
Laparoscopic ventral hernia repair was reported for the first time early in the 1990s. It uses in... more Laparoscopic ventral hernia repair was reported for the first time early in the 1990s. It uses intraperitoneal onlay mesh placement to achieve a tension-free repair of the hernia. In the recent years, however there has been a rising concern regarding certain long-term complications involving intraperitoneal mesh placement. There is an evidence of mesh adhesion, fistula formation, and mesh migration into hollow organs including the small bowel, large bowel, and oesophagus resulting in various acute abdominal events. Due to such significant, though uncommon adverse events, some surgeons have favoured sublay repair for ventral and incisional hernias. There has been a search for a laparoscopic approach for ventral and incisional hernias that might preclude the mesh-induced visceral complications seen after intraperitoneal onlay mesh repair. This article aims to review and highlight the currently available methods and technical details of laparo-endoscopic extraperitoneal repair for ventral hernia, their potential advantages and disadvantages.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2004
An unusual case of ectopic retroplaced gall bladder is reported. In our patient, this congenital ... more An unusual case of ectopic retroplaced gall bladder is reported. In our patient, this congenital anomaly was detected on ultrasonography and confirmed by CT scan, MRCP, and ERCP. Laparoscopic cholecystectomy was performed without complications. The importance of proper preoperative investigations is emphasized for accurate diagnosis, to rule out biliary tract anomalies, and to properly plan surgical approach and management.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2004
Intraoperatively, it may be prudent at times to abandon or defer the intended therapeutic procedu... more Intraoperatively, it may be prudent at times to abandon or defer the intended therapeutic procedure due to adverse prevailing conditions. A decision to abandon or defer an endoscopic procedure would necessarily result in less morbidity compared with conventional open surgery. A retrospective review of endoscopic procedures that were abandoned or deferred and subsequent patient outcomes were noted. Between January 1998 to May 2003, 48 procedures out of a total of 11,550 endoscopic surgical procedures had to be abandoned. Previously unsuspected intraabdominal malignancy was the cause in 32 patients. Anesthesia-related problems led to the decision in 6 patients. Coincidental tuberculosis and failure in accessing the target organ were the cause in two patients each. An ectopic gallbladder, an absent gallbladder, a pancreatic phlegmon, and a failure to achieve proper single-lung ventilation led to the decision in one patient each. In two patients, presence of dense intraabdominal adhesions that precluded further progress led the surgeon to abandon the surgery. The patients with intraabdominal malignancy were staged for their disease and treated accordingly. Nine patients without malignancy who had their operation deferred due to diverse reasons were operated on a later date, whereas 4 patients were lost to follow-up. The 9 patients who underwent operation at a later date are well on follow-up. Four patients with intraabdominal malignancy died, whereas the others are well in follow-up after being treated according to the stage of their disease. Certain adverse situation encountered intraoperatively may lead the surgeon to change the approach to surgery and abandon the procedure. He may consider operation at a suitable time later or consider a different treatment altogether. The morbidity consequent to such a decision is much less if the operative approach is an endoscopic one.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2002
Paravertebral and paraspinal tumors in the posterior mediastinum are predominantly neurogenic in ... more Paravertebral and paraspinal tumors in the posterior mediastinum are predominantly neurogenic in origin. The treatment comprises surgical extirpation. We report a case of a 40-year-old man with a 2-month history of pain epigastrium, radiating to the left scapula, and marked (10 kg) weight loss. Preoperative CT scan showed a paraspinal mass 8 cm in diameter at the level of the tenth thoracic vertebra. A CT scan-guided fine-needle aspiration cytologic analysis revealed the mass to be of neurogenic origin. Transabdominal laparoscopic excision of this lower posterior mediastinal neurogenic tumor was attempted and accomplished safely. The approach was through the left crural fibers, which were split to access the lower posterior mediastinum. Operating time was 122 minutes. Postoperatively, a left intercostal drain was inserted. The patient was discharged on the third postoperative day, after intercostal drain removal. Lower posterior mediastinal paraspinal tumors can be resected laparoscopically with careful preoperative investigation for tumor localization and a meticulous laparoscopic technique. A major advantage of transabdominal laparoscopic resection, as compared with open or thoracoscopic (VATS) excision, is that the patient recovers rapidly with minimal operative and anesthetic morbidity.
Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period b... more Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period between July 1998 and July 2003, the authors attempted hepaticojejunostomy by a total laparoscopic approach in 10 patients with benign stricture disorders of the extrahepatic biliary tree. Six of these patients had type 1 (extrahepatic, fusiform) choledochal cyst and presented with pain, fever, and jaundice. Four of the patients had iatrogenic biliary strictures after cholecystectomy (2 patients after laparoscopic cholecystectomy and 2 patients after open cholecystectomy). These patients had a variable presentation 1 to 3 weeks after the primary procedure, with peritonitis and/or cholangitis or only progressive jaundice. For nine of the patients (90%), the procedure was completed entirely laparoscopically. The mean operative time was 326.6 min for the patients with choledochal cysts and 268 min for the patients with iatrogenic strictures. One patient with stricture after open cholecystectomy underwent conversion to an open repair because of severe anatomic distortion and fibrosis. Four patients drained bile postoperatively for 5 to 7 days. One patient with iatrogenic biliary stricture after open cholecystectomy required open revision of the anastomosis 18 months after laparoscopic hepaticojejunostomy because of recurrent cholangitis. The remaining eight patients (80%) were doing well a mean follow-up period of 3.1 years (range, 3 months to 5 years). Total laparoscopic hepaticojejunostomy is feasible for a select group of patients, but requires advanced laparoscopic skills, including intracorporeal suturing. It must be attempted only in centers well versed in advanced laparoscopic surgery.
Jejunoileal diverticulae, also referred to as non-Meckelian diverticulae, are very uncommon. Thes... more Jejunoileal diverticulae, also referred to as non-Meckelian diverticulae, are very uncommon. These diverticulae are considered to be acquired pulsion diverticulae and they mostly occur in older people. Their prevalence increases with age. About 80% of these diverticulae occur in jejunum and are usually multiple. Patients with jejunoileal diverticulae present with nonspecifi c symptoms. The clinical picture of a complicated jejunoileal diverticulae can be confused with other intra-abdominal acute conditions such as appendicitis, cholecystitis, perforated ulcer, etc. Nonmechanical or pseudoobstruction is related to the dyskinesia associated with this condition. The diagnosis is made by a small bowel contrast study, enteroclysis, endoscopy or computed tomography. A surgical approach is the best form of treatment for complicated jejunoileal diverticulae. Laparoscopy is very useful in diagnosing and treating this condition. The current report is about a patient who presented with recurrent subacute intestinal obstruction and was managed by laparoscopy.
Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than tho... more Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than those of open surgery, especially in inexperienced hands and hence are best avoided. It is possible to avoid most of these complications if one follows a set of well-defined steps and principles of endoscopic inguinal hernia surgery. Complications are known to occur at each and every step of hernia surgery. Applying caution while performing each step can save the patient from a lot of morbidity. One starts by applying strict patient selection criteria for endoscopic hernia repair, especially in the initial part of ones learning curve. A thorough knowledge of anatomy goes a long way in avoiding most of the complications seen in hernia repair. This anatomy needs to be relearned from what one is used to, as the approach is totally different from an open hernia repair. And finally, learning and mastering the right technique is an essential prerequisite before one ventures into inguinal hernia repair. Although there has been an increased incidence of complications reported in endoscopic repair in the earlier series, this can be explained partly by the fact that it was in the early part of the learning curve of most endoscopic surgeons. As the experience grew and the techniques were standardized, the incidences of complications have also reduced and have come to be on par with open hernia surgery. The various complications and precautions to be taken to avoid them will be discussed.
Background: Numerous classifications for groin and ventral hernias have been proposed over the pa... more Background: Numerous classifications for groin and ventral hernias have been proposed over the past five to six decades. The old, simple classification of groin hernia in to direct, inguinal and femoral components is no longer adequate to understand the complex pathophysiology and management of these hernias.The most commonly followed classification for ventral hernias divide them into congenital, acquired, incisional and traumatic, which also does not convey any information regarding the predicted level of difficulty. Aim: All the previous classification systems were based on open hernia repairs and have their own fallacies particularly for uncommon hernias that cannot be classified in these systems. With the advent of laparoscopic/ endoscopic approach, surgical access to the hernia as well as the functional anatomy viewed by the surgeon changed. This change in the surgical approach and functional anatomy opened the doors for newer classifications. The authors have thus proposed a classification system based on the expected level of intraoperative difficulty for endoscopic hernia repair. Classification: In the proposed classification higher grades signify increasing levels of expected intraoperative difficulty. This functional classification grades groin hernias according to the: a) Pre-operative predictive level of difficulty of endoscopic surgery, and b) Intraoperative factors that lead to a difficult repair. Pre operative factors include multiple or pantaloon hernias, recurrent hernias, irreducible and incarcerated hernias. Intraoperative factors include reducibility at operation, degree of descent of the hernial sac and previous hernia repairs. Hernial defects greater than 7 cm in diameter are categorized one grade higher. Conclusion: Though there have been several classification systems for groin or inguinal hernias, none have been described for total classification of all ventral hernias of the abdomen. The system proposed by us includes all abdominal wall hernias and is a final classification that predicts the expected level of difficulty for an endoscopic hernia repair.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 2006
Background: Cholecystoenteric fistulas are a rare complication of gallstone disease and affect 3-... more Background: Cholecystoenteric fistulas are a rare complication of gallstone disease and affect 3-5% of patients with cholelithiasis. Most fistulas are diagnosed intraoperatively. Materials and Methods: Between January 1997 and June 2003, 12428 patients underwent laparoscopic cholecystectomy at our department. Cholecystoenteric fistula was diagnosed intraoperatively and treated in 63 patients: 45 patients (71.4%) had cholecystoduodenal fistulas, while cholecystogastric and cholecystocolic fistulas were found in 9 patients (14.3%) and 4 patients (6.3%), respectively; and 5 patients (7.9%) were found to have Mirizzi syndrome type I along with a cholecytoenteric fistula. The operation could be completed laparoscopically in 59 patients. An endostapler was used in 47 patients to transect the fistula and in 12 patients the defect in the bowel was repaired with intracorporeal sutures. Results: Major morbidity occurred in 3 patients (4.76%). One patient developed a loculated subdiaphragmatic collection which was treated by ultrasound guided aspiration and antibiotic therapy. Prolonged biliary drainage occurred in 2 patients. In addition, 7 patients (11.11%) had minor postoperative complications. The mean postoperative hospital stay was 5.2 days. All the patients are asymptomatic at a mean follow-up of 2.4 years. Conclusion: Cholecystoenteric fistula is a difficult problem usually diagnosed intraoperatively. A high degree of suspicion at operation is mandatory. A stapled cholecystofistulectomy may be the procedure of choice since it avoids contamination of the peritoneal cavity. Complete laparoscopic management of cholecystoenteric fistulas is possible in well-equipped high-volume centers.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 2007
Emergency cholecystectomy for acute cholecystitis in critically ill patients with organ failure a... more Emergency cholecystectomy for acute cholecystitis in critically ill patients with organ failure and sepsis carries a high risk of morbidity and mortality. Temporizing interventions such as laparoscopic cholecystostomy can help the patient to recover from the critical illness by deferring the definitive procedure to a later, safer period. We describe our experience of laparoscopic cholecystostomy performed in two critically ill patients. In the first case, a 56-year-old man with hypertension, diabetes, and ischemic heart disease, was admitted for evaluation of malena. During the course of his stay, he developed acute calculous cholecystitis, acute renal failure, and right pleural effusion. In the second case, a 68-year-old man presented with diabetes, hypertension, diabetic nephropathy, acute chronic renal failure, and acute calculous cholecystitis. Both patients failed to improve with conservative measures and underwent laparoscopic cholecystostomy under local anesthesia and sedation in view of severe comorbidities and sepsis. Both patients recovered from sepsis. Laparoscopic cholecystectomy was performed uneventfully after six and eight weeks, respectively, and both patients were doing well at one-year follow-up.
There was a reported higher incidence of common bile duct injuries when laparoscopic cholecystect... more There was a reported higher incidence of common bile duct injuries when laparoscopic cholecystectomy was first introduced about a decade ago. With any new procedure, there is a likelihood of an increase in the number of complications during the learning curve. With increasing experience the areas or situations having a higher probability of causing the complication get identified. Seventy percent of these injuries are claimed to occur in surgeries classified as simple laparoscopic cholecystectomy. With our experience of over 9000 laparoscopic cholecystectomies, we have identified certain anatomical situations where there is a higher likelihood of injuring the CBD. These situations include a sessile gall bladder, especially with a narrow CBD, a lax CBD getting easily tented by traction on Hartmann pouch and a short cystic duct with the CBD in close proximity to the duct and posterior gall bladder wall. Also, other well documented factors known to contribute to a greater incidence of ...
Achalasia Cardia is a rare functional oesophageal disorder which is characterized by impairment o... more Achalasia Cardia is a rare functional oesophageal disorder which is characterized by impairment of relaxation at the lower oesophageal sphincter in response to normal oesophageal peristaltic activity. The pathologic finding is an absence, decrease or degeneration of ganglion cells in the myenteric plexus of the lower oesophageal sphincter. The condition being essentially irreversible the treatment is directed at achieving symptomatic relief. The treatment may be medical i.e. Pneumatic dilatation, or surgical which up to now was open oesophagocardiomyotomy. Medical treatment was preferred up to now, being associated with minimal morbidity and a reasonably good symptomatic relief, making it highly acceptable for the patient. We present Laparoscopic Oesophagocardiomyotomy which should be considered the treatment of choice as it gives excellent results comparable to the open procedure minus all the incision related morbidity associated with the latter. A total of nine (9) patients have ...
Laparoscopic adrenalectomy is indicated for patients with adrenal masses, pheochromocytoma and cu... more Laparoscopic adrenalectomy is indicated for patients with adrenal masses, pheochromocytoma and cushings syndrome. It can be performed either by a retroperitoneal approach or a transperitoneal approach. Retroperitoneal approach is the procedure of choice as in open surgery but a transperitoneal approach may be required for large adrenal masses. Majority of these patients undergoing adrenalectomy are severely moribund and immunocompromised. Large open incisions thus add on to their morbidity and suffering. The majority of adrenal gland tumors are amenable to laparoscopic excision because most adrenal neoplasms are small and pathologically benign. We review the basic principles and technical aspects of a transperitoneal laparoscopic approach to adrenelectomy i.e. right and left adrenal gland. Laparoscopic adrenalectomy has now because the procedure of choice for adrenal masses in all the advanced laparoscopic centres having all the advantages of minimal access surgery including decreas...
Seven patients with Achalasia Cardia underwent laparoscopic Oesophagocardiomyotomy at our centre ... more Seven patients with Achalasia Cardia underwent laparoscopic Oesophagocardiomyotomy at our centre between October 1998 and October 2001. Of these, one patient was subjected to pneumatic dilatation once and three patients twice, with unsatisfactory results. Three patients were offered surgery without pneumatic tlilatation. The procedure was completed entirely laparoscopically in all seven patients. The approach was transabdominal and the average length of the myotomy incision was 6 cms, including 1 cm of proximal stomach musculature. A partial anterior fundoplication was performed along with cardiomyotomy in six patients. The average post operative stay was 2-6 days. All patients reported a significant amelioration of symptoms, patient response varying from good in the first patient, to excellent in the last two patients
Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallb... more Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy. Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up. Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct. Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.
Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common lap... more Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. With the advent of laparoscopic surgery and its continuous development, the focus has shifted to 'scarless' surgery. In recent times, the innovative technique of single-incision laparoscopic surgery (SILS) has been applied in gallbladder removal and even more complex biliopancreatic procedures to further minimize the invasiveness of the surgery. Newer developments in laparoscopic equipments and instrumentation have helped to further evolve this field of minimally invasive surgery. Literature search was performed using the following online search engines: Google, Medline, PubMed, Cochrane, and the online Springer link library. The terms used for the search were as follows: SILS, LESS, singleincision laparoscopic surgery, single-port laparoscopic surgery, SILS cholecystectomy, and SILS pancreatic surgery. Articles that matched the search criteria were selected and extensively reviewed. Moreover, pertinent information on instrumentation and technology for SILS and LESS was obtained by accessing websites of manufacturers. Although SILS represents the search for an essentially scarless surgery, there is still not a widespread use and uniformity of this procedure. SILS is performed either by single-or multiple-port technique. In the present article, we present a review of the potential benefits, limitations, and risks of SILS in biliary and pancreatic diseases. There are many studies showing benefits in cholecystectomy. A few case reports have also emerged about its feasibility in procedures such as cystogastrostomy and limited pancreatic resection. Further research and development of this technique is needed to arrive at a tangible conclusion about the perceived benefits of SILS. Randomized studies to compare SILS with traditional laparoscopy are essential.
To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecut... more To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecutive patients who underwent laparoscopic adrenalectomy in our department. Twenty four patients underwent laparoscopic adrenalectomy between September 2000 and August 2005. There were 12 males and 12 females with a mean age of 44.6 years (range 25-68 years). The indications for adrenalectomy were pheochromocytoma (13 patients), Cushing's syndrome (5 patients), myelolipoma (2 patients), adrenal cyst (2 patients), aldosteronoma (1 patient) and adrenal incidentaloma (1 patient). Nineteen of our patients with functioning adrenal tumours were prepared preoperatively for periods ranging up to 2 weeks by the endocrinologist. All laparoscopic adrenalectomies were performed via lateral transperitoneal approach using standard four-port technique. Patients with pheochromocytoma and Cushing's syndrome were monitored in the surgical intensive care unit during immediate postoperative period. The...
Surgical laparoscopy, endoscopy & percutaneous techniques, Jan 19, 2014
We present our experience with 10 patients with infected meshes after laparoscopic inguinal herni... more We present our experience with 10 patients with infected meshes after laparoscopic inguinal hernia repair in whom we explanted infected meshes laparoscopically. On retrospective analysis over 5 years (2007 to 2012), we identified 10 patients (6 TAPP/4 TEP) with localized deep-seated mesh infections in whom infected meshes were explanted laparoscopically. Peritoneum was incised, associated abscesses were drained, meshes were identified, separated, and extracted through 10/12 mm port. Nine patients experienced resolution of symptoms after 3 weeks of surgical intervention and remained asymptomatic at mean follow-up of 20 months (range, 4 to 42 mo). One patient with recurrent abscess required surgical drainage twice. Mean hospital stay was 2.2 days (range, 1 to 9 d). Two patients developed recurrent hernia at 6 and 8 months after mesh explantation. Laparoscopic explantation of infected meshes after laparoscopic hernia repair leads to less scarring and early recovery. Contamination of an...
Ingestion of foreign body is a serious problem commonly encountered in our clinical practice. Mos... more Ingestion of foreign body is a serious problem commonly encountered in our clinical practice. Most of them pass spontaneously, whereas in others endoscopic or surgical intervention is required because of complications or non-passage from the gastrointestinal tract. We present here a case of teaspoon ingestion, which did not pass spontaneously. Laparoscopic retrieval of teaspoon was done from mid jejunum after enterotomy and the patient recovered uneventfully. Right intervention at the right time is of paramount importance.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2003
Laparoscopic ventral hernia repair was reported for the first time early in the 1990s. It uses in... more Laparoscopic ventral hernia repair was reported for the first time early in the 1990s. It uses intraperitoneal onlay mesh placement to achieve a tension-free repair of the hernia. In the recent years, however there has been a rising concern regarding certain long-term complications involving intraperitoneal mesh placement. There is an evidence of mesh adhesion, fistula formation, and mesh migration into hollow organs including the small bowel, large bowel, and oesophagus resulting in various acute abdominal events. Due to such significant, though uncommon adverse events, some surgeons have favoured sublay repair for ventral and incisional hernias. There has been a search for a laparoscopic approach for ventral and incisional hernias that might preclude the mesh-induced visceral complications seen after intraperitoneal onlay mesh repair. This article aims to review and highlight the currently available methods and technical details of laparo-endoscopic extraperitoneal repair for ventral hernia, their potential advantages and disadvantages.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2004
An unusual case of ectopic retroplaced gall bladder is reported. In our patient, this congenital ... more An unusual case of ectopic retroplaced gall bladder is reported. In our patient, this congenital anomaly was detected on ultrasonography and confirmed by CT scan, MRCP, and ERCP. Laparoscopic cholecystectomy was performed without complications. The importance of proper preoperative investigations is emphasized for accurate diagnosis, to rule out biliary tract anomalies, and to properly plan surgical approach and management.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2004
Intraoperatively, it may be prudent at times to abandon or defer the intended therapeutic procedu... more Intraoperatively, it may be prudent at times to abandon or defer the intended therapeutic procedure due to adverse prevailing conditions. A decision to abandon or defer an endoscopic procedure would necessarily result in less morbidity compared with conventional open surgery. A retrospective review of endoscopic procedures that were abandoned or deferred and subsequent patient outcomes were noted. Between January 1998 to May 2003, 48 procedures out of a total of 11,550 endoscopic surgical procedures had to be abandoned. Previously unsuspected intraabdominal malignancy was the cause in 32 patients. Anesthesia-related problems led to the decision in 6 patients. Coincidental tuberculosis and failure in accessing the target organ were the cause in two patients each. An ectopic gallbladder, an absent gallbladder, a pancreatic phlegmon, and a failure to achieve proper single-lung ventilation led to the decision in one patient each. In two patients, presence of dense intraabdominal adhesions that precluded further progress led the surgeon to abandon the surgery. The patients with intraabdominal malignancy were staged for their disease and treated accordingly. Nine patients without malignancy who had their operation deferred due to diverse reasons were operated on a later date, whereas 4 patients were lost to follow-up. The 9 patients who underwent operation at a later date are well on follow-up. Four patients with intraabdominal malignancy died, whereas the others are well in follow-up after being treated according to the stage of their disease. Certain adverse situation encountered intraoperatively may lead the surgeon to change the approach to surgery and abandon the procedure. He may consider operation at a suitable time later or consider a different treatment altogether. The morbidity consequent to such a decision is much less if the operative approach is an endoscopic one.
Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2002
Paravertebral and paraspinal tumors in the posterior mediastinum are predominantly neurogenic in ... more Paravertebral and paraspinal tumors in the posterior mediastinum are predominantly neurogenic in origin. The treatment comprises surgical extirpation. We report a case of a 40-year-old man with a 2-month history of pain epigastrium, radiating to the left scapula, and marked (10 kg) weight loss. Preoperative CT scan showed a paraspinal mass 8 cm in diameter at the level of the tenth thoracic vertebra. A CT scan-guided fine-needle aspiration cytologic analysis revealed the mass to be of neurogenic origin. Transabdominal laparoscopic excision of this lower posterior mediastinal neurogenic tumor was attempted and accomplished safely. The approach was through the left crural fibers, which were split to access the lower posterior mediastinum. Operating time was 122 minutes. Postoperatively, a left intercostal drain was inserted. The patient was discharged on the third postoperative day, after intercostal drain removal. Lower posterior mediastinal paraspinal tumors can be resected laparoscopically with careful preoperative investigation for tumor localization and a meticulous laparoscopic technique. A major advantage of transabdominal laparoscopic resection, as compared with open or thoracoscopic (VATS) excision, is that the patient recovers rapidly with minimal operative and anesthetic morbidity.
Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period b... more Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period between July 1998 and July 2003, the authors attempted hepaticojejunostomy by a total laparoscopic approach in 10 patients with benign stricture disorders of the extrahepatic biliary tree. Six of these patients had type 1 (extrahepatic, fusiform) choledochal cyst and presented with pain, fever, and jaundice. Four of the patients had iatrogenic biliary strictures after cholecystectomy (2 patients after laparoscopic cholecystectomy and 2 patients after open cholecystectomy). These patients had a variable presentation 1 to 3 weeks after the primary procedure, with peritonitis and/or cholangitis or only progressive jaundice. For nine of the patients (90%), the procedure was completed entirely laparoscopically. The mean operative time was 326.6 min for the patients with choledochal cysts and 268 min for the patients with iatrogenic strictures. One patient with stricture after open cholecystectomy underwent conversion to an open repair because of severe anatomic distortion and fibrosis. Four patients drained bile postoperatively for 5 to 7 days. One patient with iatrogenic biliary stricture after open cholecystectomy required open revision of the anastomosis 18 months after laparoscopic hepaticojejunostomy because of recurrent cholangitis. The remaining eight patients (80%) were doing well a mean follow-up period of 3.1 years (range, 3 months to 5 years). Total laparoscopic hepaticojejunostomy is feasible for a select group of patients, but requires advanced laparoscopic skills, including intracorporeal suturing. It must be attempted only in centers well versed in advanced laparoscopic surgery.
Jejunoileal diverticulae, also referred to as non-Meckelian diverticulae, are very uncommon. Thes... more Jejunoileal diverticulae, also referred to as non-Meckelian diverticulae, are very uncommon. These diverticulae are considered to be acquired pulsion diverticulae and they mostly occur in older people. Their prevalence increases with age. About 80% of these diverticulae occur in jejunum and are usually multiple. Patients with jejunoileal diverticulae present with nonspecifi c symptoms. The clinical picture of a complicated jejunoileal diverticulae can be confused with other intra-abdominal acute conditions such as appendicitis, cholecystitis, perforated ulcer, etc. Nonmechanical or pseudoobstruction is related to the dyskinesia associated with this condition. The diagnosis is made by a small bowel contrast study, enteroclysis, endoscopy or computed tomography. A surgical approach is the best form of treatment for complicated jejunoileal diverticulae. Laparoscopy is very useful in diagnosing and treating this condition. The current report is about a patient who presented with recurrent subacute intestinal obstruction and was managed by laparoscopy.
Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than tho... more Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than those of open surgery, especially in inexperienced hands and hence are best avoided. It is possible to avoid most of these complications if one follows a set of well-defined steps and principles of endoscopic inguinal hernia surgery. Complications are known to occur at each and every step of hernia surgery. Applying caution while performing each step can save the patient from a lot of morbidity. One starts by applying strict patient selection criteria for endoscopic hernia repair, especially in the initial part of ones learning curve. A thorough knowledge of anatomy goes a long way in avoiding most of the complications seen in hernia repair. This anatomy needs to be relearned from what one is used to, as the approach is totally different from an open hernia repair. And finally, learning and mastering the right technique is an essential prerequisite before one ventures into inguinal hernia repair. Although there has been an increased incidence of complications reported in endoscopic repair in the earlier series, this can be explained partly by the fact that it was in the early part of the learning curve of most endoscopic surgeons. As the experience grew and the techniques were standardized, the incidences of complications have also reduced and have come to be on par with open hernia surgery. The various complications and precautions to be taken to avoid them will be discussed.
Background: Numerous classifications for groin and ventral hernias have been proposed over the pa... more Background: Numerous classifications for groin and ventral hernias have been proposed over the past five to six decades. The old, simple classification of groin hernia in to direct, inguinal and femoral components is no longer adequate to understand the complex pathophysiology and management of these hernias.The most commonly followed classification for ventral hernias divide them into congenital, acquired, incisional and traumatic, which also does not convey any information regarding the predicted level of difficulty. Aim: All the previous classification systems were based on open hernia repairs and have their own fallacies particularly for uncommon hernias that cannot be classified in these systems. With the advent of laparoscopic/ endoscopic approach, surgical access to the hernia as well as the functional anatomy viewed by the surgeon changed. This change in the surgical approach and functional anatomy opened the doors for newer classifications. The authors have thus proposed a classification system based on the expected level of intraoperative difficulty for endoscopic hernia repair. Classification: In the proposed classification higher grades signify increasing levels of expected intraoperative difficulty. This functional classification grades groin hernias according to the: a) Pre-operative predictive level of difficulty of endoscopic surgery, and b) Intraoperative factors that lead to a difficult repair. Pre operative factors include multiple or pantaloon hernias, recurrent hernias, irreducible and incarcerated hernias. Intraoperative factors include reducibility at operation, degree of descent of the hernial sac and previous hernia repairs. Hernial defects greater than 7 cm in diameter are categorized one grade higher. Conclusion: Though there have been several classification systems for groin or inguinal hernias, none have been described for total classification of all ventral hernias of the abdomen. The system proposed by us includes all abdominal wall hernias and is a final classification that predicts the expected level of difficulty for an endoscopic hernia repair.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 2006
Background: Cholecystoenteric fistulas are a rare complication of gallstone disease and affect 3-... more Background: Cholecystoenteric fistulas are a rare complication of gallstone disease and affect 3-5% of patients with cholelithiasis. Most fistulas are diagnosed intraoperatively. Materials and Methods: Between January 1997 and June 2003, 12428 patients underwent laparoscopic cholecystectomy at our department. Cholecystoenteric fistula was diagnosed intraoperatively and treated in 63 patients: 45 patients (71.4%) had cholecystoduodenal fistulas, while cholecystogastric and cholecystocolic fistulas were found in 9 patients (14.3%) and 4 patients (6.3%), respectively; and 5 patients (7.9%) were found to have Mirizzi syndrome type I along with a cholecytoenteric fistula. The operation could be completed laparoscopically in 59 patients. An endostapler was used in 47 patients to transect the fistula and in 12 patients the defect in the bowel was repaired with intracorporeal sutures. Results: Major morbidity occurred in 3 patients (4.76%). One patient developed a loculated subdiaphragmatic collection which was treated by ultrasound guided aspiration and antibiotic therapy. Prolonged biliary drainage occurred in 2 patients. In addition, 7 patients (11.11%) had minor postoperative complications. The mean postoperative hospital stay was 5.2 days. All the patients are asymptomatic at a mean follow-up of 2.4 years. Conclusion: Cholecystoenteric fistula is a difficult problem usually diagnosed intraoperatively. A high degree of suspicion at operation is mandatory. A stapled cholecystofistulectomy may be the procedure of choice since it avoids contamination of the peritoneal cavity. Complete laparoscopic management of cholecystoenteric fistulas is possible in well-equipped high-volume centers.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 2007
Emergency cholecystectomy for acute cholecystitis in critically ill patients with organ failure a... more Emergency cholecystectomy for acute cholecystitis in critically ill patients with organ failure and sepsis carries a high risk of morbidity and mortality. Temporizing interventions such as laparoscopic cholecystostomy can help the patient to recover from the critical illness by deferring the definitive procedure to a later, safer period. We describe our experience of laparoscopic cholecystostomy performed in two critically ill patients. In the first case, a 56-year-old man with hypertension, diabetes, and ischemic heart disease, was admitted for evaluation of malena. During the course of his stay, he developed acute calculous cholecystitis, acute renal failure, and right pleural effusion. In the second case, a 68-year-old man presented with diabetes, hypertension, diabetic nephropathy, acute chronic renal failure, and acute calculous cholecystitis. Both patients failed to improve with conservative measures and underwent laparoscopic cholecystostomy under local anesthesia and sedation in view of severe comorbidities and sepsis. Both patients recovered from sepsis. Laparoscopic cholecystectomy was performed uneventfully after six and eight weeks, respectively, and both patients were doing well at one-year follow-up.
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Papers by Vandana Soni