Indian J Surg
· 2018 Apr · PMID 29915489
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The main goals of reconstruction of nasal defects are to restore the topographic subunit outline, thereby maintaining the aesthetic three-dimensional facial contours and more importantly ensuring a patent airway. Wide ex...The main goals of reconstruction of nasal defects are to restore the topographic subunit outline, thereby maintaining the aesthetic three-dimensional facial contours and more importantly ensuring a patent airway. Wide excision of tumours of the external nose can at times result in complex defects causing significant facial disfigurement and this poses a significant reconstructive challenge. Nasal reconstruction with only micro-vascular free flaps can at times produce poor aesthetic outcomes as distant skin often appears as a mismatched patch within the surrounding normal facial skin. We describe a novel technique for external nose reconstruction using a combination two well described local flaps, superiorly based nasolabial flap alongside a paramedian forehead flap.
Indian J Surg
· 2018 Apr · PMID 29915488
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A 60-year-old lady presented with symptoms of chronic iron deficiency anaemia. On evaluation with routine chest X-ray, it surprisingly revealed an irregular mass-like opacity in proximal part of stomach suggesting gastri...A 60-year-old lady presented with symptoms of chronic iron deficiency anaemia. On evaluation with routine chest X-ray, it surprisingly revealed an irregular mass-like opacity in proximal part of stomach suggesting gastric cancer. The diagnosis was later confirmed with upper GI endoscopy and CT scan abdomen. Hence, in modern era of advanced diagnostics, chest X-ray findings should not be overlooked.
Indian J Surg
· 2018 Apr · PMID 29915487
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We present a case of a 35-year-old gentleman with a submandibular duct stone measuring 12 × 6 mm. Considering the literature, most stones are less than 5 mm, and stones more than 10 mm are quite unusual. This gentleman h...We present a case of a 35-year-old gentleman with a submandibular duct stone measuring 12 × 6 mm. Considering the literature, most stones are less than 5 mm, and stones more than 10 mm are quite unusual. This gentleman had typical symptoms of chronic sialadenitis, who was clinically diagnosed to have sialolithiasis, which was later confirmed by imaging studies. He was operated upon to remove the stone along with the submandibular gland. The term sialolithiasis is derived from the Greek words (saliva) and (stone), and the Latin meaning "process" or "morbid condition". Sialolithiasis affects the submandibular gland in 80-90% of cases because of the curved course of submandibular duct and the secretions being more mucous. Pain is the most common presenting feature during mastication and surgical removal of the sialolithiasis is the treatment of choice. The incision depends on the location of the stone in the duct.
Singh AN, Kilambi R, Madhusudhan KS
… +1 more, Pal S
Indian J Surg
· 2018 Apr · PMID 29915486
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Massive gastrointestinal bleeding after corrosive intake is a rare complication that generally mandates a surgical intervention for control. Angioembolization for control of gastrointestinal bleeding in the setting of ac...Massive gastrointestinal bleeding after corrosive intake is a rare complication that generally mandates a surgical intervention for control. Angioembolization for control of gastrointestinal bleeding in the setting of acute corrosive injury has not been described. Here, we present our experience of a case of acute corrosive injury presenting with massive upper gastrointestinal bleeding in the delayed phase which was successfully managed by angioembolization. We discuss the case in light of the literature available and describe markers which may serve to identify potential candidates for angioembolization.
Indian J Surg
· 2018 Apr · PMID 29915485
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Interstitial hernias are a rare subtype of abdominal hernias, where sac is present in between the abdominal wall layers. Although, difficult to diagnose clinically, they are usually detected on imaging studies. Interstit...Interstitial hernias are a rare subtype of abdominal hernias, where sac is present in between the abdominal wall layers. Although, difficult to diagnose clinically, they are usually detected on imaging studies. Interstitial hernias presenting with undescended testis are common. Even after a meticulous online search of the medical literature, we could not find a case report of 'Strangulation of Interstitial hernia, with a strangulated undescended testis in an elderly man. We hereby present this extremely rare case, and possibly, this could be the first of its kind, case report in the medical literature. Our aim is to present a combination of rare presentations in an elderly cryptorchid person with strangulated interstitial hernia. A 65-year male patient presented with 4 days of pain abdomen and vomiting. He was having features of toxaemia. Ultrasonography revealed interstitial hernia with bowel loops. During surgery, gangrenous bowel loops with the sac between the interstitial planes, with strangulated cryptorchid testis, were found. Strangulated interstitial hernia in elderly cryptorchid person, leading to the strangulation of the undescended testis, is extremely rare, and this could be the first case reported in the medical literature.
Indian J Surg
· 2018 Apr · PMID 29915484
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Venous ulcer is an extremely common aetiology of lower extremity ulceration, which affects approximately 1% population in most of the countries, and the incidence rate increases with age and female gender. Proper assessm...Venous ulcer is an extremely common aetiology of lower extremity ulceration, which affects approximately 1% population in most of the countries, and the incidence rate increases with age and female gender. Proper assessment and diagnosis of both the patient and ulcer are inevitable in order to differentiate venous ulcers from other lower extremity ulceration and to frame an adequate and individualised management plan. Venous ulcers generally persist for weeks to many years and are typically recurrent in nature. This consensus aims to present an evidence-based management approach for the patients with venous ulcers. Various management options for venous ulcers include compression therapy, minimally invasive procedures like sclerotherapy and ablation techniques, surgical procedures, debridement and medical management with micronised purified flavonoid fraction (MPFF). Compression therapy is the mainstay treatment for venous ulcer. However, in failure cases, surgery can be preferred. Medical management with MPFF as an adjuvant therapy to standard treatment has been reported to be effective and safe in patients with venous ulcer. In addition to standard therapy, diet and lifestyle modification including progressive resistance exercise, patient education, leg elevation, weight reduction, maintaining a healthy cardiac status and strong psychosocial support reduces the risk of recurrence and improves the quality of life in patients with venous ulcer.
Indian J Surg
· 2018 Apr · PMID 29915483
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Anastomotic leak (AL) can be a devastating complication in colorectal surgery. While it is less frequent in the modern era, it still results in significant morbidity and mortality, prolonged hospital stays and increases...Anastomotic leak (AL) can be a devastating complication in colorectal surgery. While it is less frequent in the modern era, it still results in significant morbidity and mortality, prolonged hospital stays and increases the costs and demands on health services. There is inevitable interplay between patient physiology and technical factors that predispose a patient to AL. Obesity, preoperative total proteins, male gender, ongoing anticoagulant treatment, intraoperative complication and number of hospital beds have been identified as independent risk factors. This has led to an online risk calculator for AL. Non-steroidal anti-inflammatory drugs and neoadjuvant chemoradiotherapy have also been implicated, but no significant evidence has yet been found to support causation. In addition, technical factors such as type of anastomosis, mechanical bowel preparation, drains, omentoplasty and faecal diversion have failed to show significant differences in AL rates. Early diagnosis and intervention in AL is essential in reducing the rates of morbidity and mortality. Clinical assessment has high sensitivity but low specificity and should be used in combination with imaging techniques to get a diagnosis. C-reactive protein is also a useful marker. The management will depend on the grade of AL and the clinical state of the patient. Management options include conservative measures such as antibiotics and/or percutaneous drainage to more invasion procedures such as open drainage and/or Hartmann's procedure. In conclusion, ALs will forever pose challenges to the surgeon in diagnosis and management. It is often the yardstick by which each surgeon is measured and is the source of significant morbidity to patients and health care services worldwide. As a result, a low threshold for investigation and intervention is mandatory to ensure better outcomes and lower overall mortality and morbidity.
Chiappa A, Bertani E, Pravettoni G
… +12 more, Zbar AP, Foschi D, Spinoglio G, Bonanni B, Polvani G, Ambrogi F, Cossu ML, Ferrari C, Venturino M, Crosta C, Bocciolone L, Biffi R
Indian J Surg
· 2018 Apr · PMID 29915482
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To analyze treatment and survival in a series of resected patients with primary or recurrent retroperitoneal sarcoma (RPS) treated and prospectively followed at a single institution. Between July 1994 and December 2015,...To analyze treatment and survival in a series of resected patients with primary or recurrent retroperitoneal sarcoma (RPS) treated and prospectively followed at a single institution. Between July 1994 and December 2015, 89 patients (36 M, 53 F; mean age 60 years, range 25-79) were evaluated. For the purpose of analysis, complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins. Eighty-three out of the 89 patients (93%), 46 of whom affected by primary RPS, and 37 by recurrent RPS, underwent surgical exploration. Sixty-two had a grossly and microscopically complete resection. Fifty-three out of 83 patients (64%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil and significant preoperative complications occurred in six cases only (7%). High-grade tumor pointed out to be a significant variable for a worse survival in all 83 patients amenable to undergo surgical resection (57% 5 years survival for low grade vs 14% for high grade; = 0.0004). Among completely resected patients, only histologic grade clearly affected disease-free survival (72% 5 years survival for low grade vs 50% for high grade; = 0.04), while the role of preoperative blood transfusions (67% 5 years survival for non-transfused patients vs 29% for transfused patients; = 0.05) has to be evaluated in connection to patient complexity. Histological grade and recurrence are the most valuable prognostic predictors; in this clinical subset, an aggressive surgical approach in both primary and recurrent RPS is associated with a best long-term survival and disease-free survival.
Zhang Y, Lu X, Xu J
… +4 more, Yang H, Deng X, Chen K, Chen Y
Indian J Surg
· 2018 Apr · PMID 29915481
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Segment 7 is considered an unfavorable portion for laparoscopic hepatectomy because of technical difficulties in exposure and controlling bleeding. We compared intermittent Pringle with continuous half-Pringle maneuver i...Segment 7 is considered an unfavorable portion for laparoscopic hepatectomy because of technical difficulties in exposure and controlling bleeding. We compared intermittent Pringle with continuous half-Pringle maneuver in laparoscopic liver resections of tumors in segment 7. A retrospective analysis was conducted in a total of 36 consecutive patients with tumors in segment 7 undergoing laparoscopic liver resections between July 2011 and February 2016 (16 in the Pringle group versus 20 in the half-Pringle group). The two groups were well matched in baseline characteristics. The operative time (274.5 ± 34.3 versus 237.6 ± 41.8 min), overall declamping time (28.4 ± 8.6 versus 2.3 ± 2.5 min), and ischemic duration (69.7 ± 16.5 versus 52.7 ± 13.2 min) were significantly longer in the Pringle group ( < 0.05). The amount of intraoperative blood loss (612.5 ± 222.3 versus 417.4 ± 163.8 mL) and transfusion (335.2 ± 58.7 versus 224.8 ± 76.2 mL) was significantly greater in the Pringle group ( < 0.05). The Pringle group was associated with significantly lower postoperative albumin and higher C-reactive protein levels on postoperative days 1, 3, and 7 ( < 0.05). Laparoscopic hepatectomy for tumors in segment 7 can be performed safely and effectively with successful exposure of surgical field and proper hepatic blood flow occlusion. Continuous half-Pringle maneuver offers the advantages of less operative time and blood loss, less injury, and better recovery.
Indian J Surg
· 2018 Apr · PMID 29915480
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The purpose of revascularization in lower extremity arterial occlusive disease is to prevent amputation and improve walking ability. Many surgical techniques for peripheral vascular disease (PAD) have been reported. The...The purpose of revascularization in lower extremity arterial occlusive disease is to prevent amputation and improve walking ability. Many surgical techniques for peripheral vascular disease (PAD) have been reported. The hybrid operation composed of open surgery and endovascular procedure has been increasingly used for multilevel revascularization. The goal of this study is to evaluate feasibility of simultaneous hybrid femoral endarterectomy and endovascular treatment in patients who need multilevel revascularization with critical limb ischemia. Between March 2011 and July 2014, 38 consecutive patients (43 limbs) with multilevel peripheral arterial disease in critical limb ischemia were treated by simultaneous hybrid operation by single surgeon. The hybrid operation which combines common femoral artery endarterectomy and additive interventional procedure was simultaneously performed for multilevel revascularization. The measurements of primary outcome were primary patency rates, secondary patency rates, and limb salvage rates. Patients who underwent single procedure of surgery or intervention were excluded. The mean age was 72.48 years old and 92.1% were male. The primary and secondary patency rates at 24 months were 67.3 and 72.1%, respectively. The preoperative mean ABI of 0.51 ± 0.27 increased to postoperative mean ABI of 0.88 ± 0.35. The limb salvage rate was 95.3%. Major amputation was performed in 2 out of 43 limbs. There was no early postoperative mortality. The simultaneous hybrid operation for multilevel revascularization may be feasible to treat in multilevel PAD with high technical success and limb salvage rates, thus providing an attractive alternative to larger open surgery or endovascular procedures.
Kumar T, Krishanappa R, Pai E
… +5 more, Sringeri R, Singh TB, Swain J, Kondapavuluri S, Pandey M
Indian J Surg
· 2018 Apr · PMID 29915479
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Very limited data is present which compares completely linear stapled to handsewn cervical esophagogastric anastomosis. Primary objective was to determine whether linearly stapled (LS) anastomosis has lower clinically ap...Very limited data is present which compares completely linear stapled to handsewn cervical esophagogastric anastomosis. Primary objective was to determine whether linearly stapled (LS) anastomosis has lower clinically apparent leaks, when compared to handsewn anastomosis (HS). Secondary objectives were morbidity, mortality, overall leak and stricture rates, and presence of a symptomatic cervical stricture. This is a comparative study of 77 patients who underwent LS ( = 29) and HS ( = 48) cervical anastomosis. Anastomotic leak was found to be 19.4% (15/77). In the HS group, 27.08% (13/48) and in the LS group, 6.89% (2/29), respectively, leaked ( = 0.03), relative risk (RR)-3.93 (95% CI 1.21-15.25). 32.5% (23/77) patients remained admitted for more than 14 days. 52.1% (25/48) patients in the HS group were discharged within 14 days of surgery; whereas; 93.1% (27/29) were discharged in LS group ( = 0.001), RR-6.95 (95% CI 2.13-25.94). Overall, 90-day mortality was 7.8% (6/77). In the HS group, 8.3% (4/48) patients died while in the LS group, 6.8% (2/29) patients died ( = 0.82), RR-1.21(95% CI 0.27-5.53). In the HS group, 6.25% (3/48) patients were diagnosed with stricture compared to 6.8% (2/29) patients in the LS group ( = 0.9), RR-0.91 (95% CI 0.19-4.44). Overall stricture rate was 6.4% (5/77). Cervical anastomosis done with linear staplers has less leak rates compared to handsewn anastomosis.
Indian J Surg
· 2018 Apr · PMID 29915478
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Two major issues with laparoscopic inguinal hernia (IH) repair are recurrences and chronic groin pain (CGP). The procedure involves fixing the mesh with the tackers which is believed to increase the rate of CGP due to ne...Two major issues with laparoscopic inguinal hernia (IH) repair are recurrences and chronic groin pain (CGP). The procedure involves fixing the mesh with the tackers which is believed to increase the rate of CGP due to nerve injuries. Thus, non-fixation of mesh is being proposed but concerns remain regarding increased recurrences. We sought to look at our outcomes after we switched over to non-fixation of mesh in totally extraperitoneal repair (TEP). Retrospective review of prospectively maintained database of 171 repairs was done on 122 patients (fixation 59 and non-fixation 112) during a period of 4 years with an endeavor to complete a minimum of 1 year of clinical follow-up. The primary objective was to assess the recurrence rates and CGP and the secondary objective was to assess operative times, immediate post-op pain, incidence of urinary retention, duration of hospital stay, days taken to return to activity, and cost. The mean operative times for unilateral IH for the fixation and non-fixation groups were 41.8 ± 11.4 and 35.9 ± 9.7 min, respectively ( = 0.021), whereas for bilateral were 66.2 ± 15.6 and 55.3 ± 14.2 min, respectively ( = 0.018). The mean pain score was 3.44 ± 1.2 versus 3.01 ± 1.0; ( = 0.037) in the two groups, respectively. At a mean follow-up of 33.2 ± 17.0 and 18.7 ± 6.2 months, the incidence of CGP was 02 (3.4%) and 3 (2.7%) ( = 1.000) and recurrences were 02 (3.4%) in the two groups, respectively ( = 0.118). Non-fixation of mesh in TEP does not lead to increased recurrence though it does not decrease the incidence of chronic groin pain. Collateral advantage would be decreased operative times, lesser post-operative pain, and decreased costs.
Sonbare DJ, Abraham DT, Rajaratnam S
… +4 more, Thomas N, Manipadam MT, Pai R, Jacob PM
Indian J Surg
· 2018 Apr · PMID 29915477
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Re-operative adrenal surgery for recurrent pheochromocytoma/paraganglioma (PCC/PGL) is a therapeutic situation not commonly encountered. The recurrence rate of pheochromocytoma is estimated to be 6.1-16.5% of patients fr...Re-operative adrenal surgery for recurrent pheochromocytoma/paraganglioma (PCC/PGL) is a therapeutic situation not commonly encountered. The recurrence rate of pheochromocytoma is estimated to be 6.1-16.5% of patients from published retrospective series; there are no reports from the Asian continent. A retrospective analysis of the departmental database was performed on patients who had undergone surgery for PCC/PGL from January 2004 to December 2014 at the Christian Medical College Hospital, Vellore, India. Among 99 patients identified during the study period, there were 14 recurrent tumours and 13 patients underwent re-operative surgery. We located eight recurrences on the right side, three on the left side and three in the midline. All 14 recurrences were functioning, and the biochemical analysis as well as imaging studies were positive in 13 of them. The mean duration to recurrence from the time of the primary surgery was 76.3 months (range 6-180 months). Of the 89 patients who underwent their first operation at our centre, 67.4% reported for follow-up for a mean period of 25 months (range 4-132 months). Four of these required re-operation with a recurrence rate of 4.5% (4/89). The open approach was used for all but one of the recurrent tumours. Recurrence following surgery for PCC/PGL is a rarely studied though significant problem. Right adrenal tumour recurrences were most common, and all these recurrences were in the retrocaval region; this typical phenomenon may be dubbed the 'right retrocaval trap'. The reason for this was presumably due to difficult access and inadequate exposure of this area in open and laparoscopic surgery, resulting in incomplete dissection.
Indian J Surg
· 2018 Apr · PMID 29915476
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Robotic surgery can help to overcome some technical limitations of laparoscopic pancreaticoduodenectomy thanks to EndoWrist instrumentations and the 3D view. Despite the potential benefits, its employment is still low an...Robotic surgery can help to overcome some technical limitations of laparoscopic pancreaticoduodenectomy thanks to EndoWrist instrumentations and the 3D view. Despite the potential benefits, its employment is still low and controversial. We focused on some important technical details crucial for a safe robotic pancreatectomy. After performing 52 robotic pancreatic resections that included 10 pancreatoduodenectomies, the authors describe their technique. The review of literature on robotic and laparoscopic duodenopancreatectomy is also performed in order to evaluate possible benefits of the robotic platform. We describe the step-by-step surgical procedure, analyzing all possible troubleshooting occurring in an initial center experience. The estimated blood loss as well as the length of stay was reduced by the robotic approach. We did not observe any significant increase of pancreatic fistula rate and all other postoperative complications despite our initial learning curve. Robotic pancreatoduodenectomy is a technically advanced procedure that requires important laparoscopic and robotic skills but it shows to be safe, feasible with some clear advantages in the bleeding control and in the reconstructive phase of the procedure.
Singh A, Parihar US, Kumawat G
… +2 more, Samota R, Choudhary R
Indian J Surg
· 2018 Apr · PMID 29915475
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Although acute appendicitis is one of the most common surgical emergencies worldwide, timely accurate diagnosis is always difficult for a surgeon even after availability of recent diagnostic tools. Our study is to determ...Although acute appendicitis is one of the most common surgical emergencies worldwide, timely accurate diagnosis is always difficult for a surgeon even after availability of recent diagnostic tools. Our study is to determine validation of RIPASA score in diagnosis of acute appendicitis and histopathological correlation. A prospective study of 200 patients presented to emergency or surgical opd with right iliac fossa pain and suspected to have acute appendicitis were included in our study. RIPASA score calculated but appendectomy done on the basis of clinical assessment and hospital protocol and histopathological correlation done with a score. A score of 7.5 is cut off threshold, results compared with previous studies. In our study of 200 patients, M:F ratio of 1.56:1. Sensitivity of the RIPASA score was 95.89℅ with specificity 75.92% and diagnostic accuracy of 90.5%, expected and observed rate of negative appendectomy were 8.5 and 12.35%, respectively. So there is net reduction in negative appendectomy rate by 3.85%. Data analysis done with Statistical Package for Social Science (SPSS) version 21.0. RIPASA score at a cutoff value of 7.5 is easier, cheap, and better diagnostic tool in equivocal case of right iliac fossa pain in Indian scenario of limited availability of recent diagnostic tool in remote areas and affordability of these tool in the available set up, simultaneously, it also helps to reduce negative appendectomy rates.
Indian J Surg
· 2018 Apr · PMID 29915474
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The non-recurrent inferior laryngeal nerve (NRLN) represents a risk factor for nerve injury during thyroid surgery. The aim of this study is to investigate the traveling patterns of NRLNs and its relationships to inferio...The non-recurrent inferior laryngeal nerve (NRLN) represents a risk factor for nerve injury during thyroid surgery. The aim of this study is to investigate the traveling patterns of NRLNs and its relationships to inferior thyroid arteries (ITAs). We had 11 patients showing NRLNs on the right side who underwent thyroidectomies. The NRLNs were classified into four different types, according to the traveling patterns. We evaluated the anatomical position of the ITA as follows: (1) three types according to the joint location with the thyroid gland; and (2) three types according to the level of the retro-esophageal subclavian artery (RSA). The traveling patterns of NRLN could be classified into four types, descending, vertical, ascending, and V-shaped. ITA was joined variably with the thyroid gland on the superior, middle, and inferior positions. The levels of the RSA were also located at different positions, the first thoracic vertebra, the second vertebra, and the third vertebra. During thyroid surgery, the surgeon must be aware of the existence of anatomical variations of NRLNs and ITAs. The anatomy of the NRLN and the ITA are frequently irregular, and there is no correlation between the traveling pattern of NRLN and the level of the RSA.
Anehosur V, Ghosh R, Joshi A
… +2 more, Jayade B, Kumar N
Indian J Surg
· 2018 Feb · PMID 29581697
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Drains are essential in most surgeries. Primary need is elimination of dead space and related consequences but drains per se do have their share of complications, one of them being dislodgment. Complications related to d...Drains are essential in most surgeries. Primary need is elimination of dead space and related consequences but drains per se do have their share of complications, one of them being dislodgment. Complications related to dislodgment can range from inactive drains to damage to critical areas like anastomosis sites. Securing drains using this technique was described by Jayaraj et al. in 1988. Since then, no study was done to determine the efficacy and outcomes of this method. An audit was conducted from 2009 to 2014 at SDM Craniofacial unit to determine the utility of drain fixation. Data was collected of a total of 143 patients from the medical records. This useful technique has the advantage of preventing the drain from displacement and its consequent complications.