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   Table of Contents - Current issue
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April-June 2017
Volume 13 | Issue 2
Page Nos. 81-163

Online since Thursday, March 09, 2017

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META-ANALYSIS  

Laparoscopic versus percutaneous endoscopic gastrostomy placement in children: Results of a systematic review and meta-analysis p. 81
Nutnicha Suksamanapun, Femke A Mauritz, Josephine Franken, David C van der Zee, Maud YA van Herwaarden-Lindeboom
DOI:10.4103/0972-9941.181776  PMID:27251841
Background: Percutaneous endoscopic gastrostomy (PEG) and laparoscopic-assisted gastrostomy (LAG) are widely used in the paediatric population. The aim of this study was to determine which one of the two procedures is the most effective and safe method. Methods: This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses statement. Primary outcomes were success rate, efficacy of feeding, quality of life, gastroesophageal reflux and post-operative complications. Results: Five retrospective studies, comparing 550 PEG to 483 LAG placements in children, were identified after screening 2347 articles. The completion rate was similar for both procedures. PEG was associated with significantly more adjacent bowel injuries (P = 0.047), early tube dislodgements (P = 0.02) and complications that require reintervention under general anaesthesia (P < 0.001). Minor complications were equally frequent after both procedures. Conclusions: Because of the lack of well-designed studies, we have to be cautious in making definitive conclusions comparing PEG to LAG. To decide which type of gastrostomy placement is best practice in paediatric patients, randomised controlled trials comparing PEG to LAG are highly warranted.
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ORIGINAL ARTICLES Top

The anatomy of Rouviere's sulcus as seen during laparoscopic cholecystectomy: A proposed classification p. 89
Mohinder Singh, Neeraj Prasad
DOI:10.4103/0972-9941.201731  PMID:28281470
Introduction: Although Rouviere's sulcus is being increasingly mentioned as the first landmark to be seen so as to begin dissection during laparoscopic cholecystectomy to prevent bile duct injuries, the anatomy of the sulcus has not been described in clear and simple terms. Objectives: To define the detailed anatomy of Rouviere sulcus as seen during laparoscopic surgery in simple terms for the surgeons to refer to and begin their dissection from this, always staying above this sulcus in order to eliminate bile duct injury. Methods: 100 recordings of laparoscopic cholecystectomy were analysed to define the anatomy of the Rouviere's sulcus. Results: Majority of the sulci (71) were seen as a deep sulcus and were labelled as simply the 'sulcus'. This was further seen to be of two types – open (60) or closed (11). Some of the sulci (23) were small and so narrow and shallow as to be labelled as a 'slit'. Rarely, the sulcus was found to be fused and represented by a white fusion line (6 cases), and this was simply labelled as a 'scar'. Conclusions: The Rouviere's sulcus can now be defined in three simple terms – a deep sulcus, or a slit or a scar. We recommend that as a first step in laparoscopic cholecystectomy, the surgeon must look for this reference point (whether it is in the form of a scar, or a slit or a real sulcus) which will be the plane of the main bile duct, and thus avoid any dissection below this point in order to eliminate any danger to the bile duct during surgery.
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Robotic Roux-en-Y gastric bypass: Our centre's technique with short-term experience p. 96
Mohit Bhandari, Winni Mathur, Arun Kumar Mishra, Daksha Chandorkar
DOI:10.4103/0972-9941.201728  PMID:28281471
Background: Roux-en-Y gastric bypass (RYGB) is one of the most widely performed bariatric surgeries in the world. Performing an RYGB by a Da Vinci Surgical System is a new advancement. The aim of this study is to describe single docking-single quadrant technique and its short-term results. Materials and Methods: Between January 2013 and December 2013, 140 robotic RYGB were performed. The RYGB was performed through single docking, single quadrant approach. The data were analysed retrospectively. Intra- and post-operative details of every patient were documented. Follow-up was done as per protocol at 6 months; 1 and 2 years. In total, 120 patients completed the follow-up protocol as per our database. Results: Mean age of the patients was 42.7 ± 12.11 years. Ratio of males: females were equal. The mean operative time was 97.48 ± 23.79 min. Early mortality was seen 7 days post-surgery. Two late complications were documented with no late mortality. The average length of stay was 2.89 ± 1.06 days. Average blood loss was 55.79 ± 11.91 ml. There was no hospital re-admission after the surgery. Conclusion: Single docking-single quadrant technique is simple, effective and time saving without having complicated port position, multiple docking with minimal complications.
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Impact of concomitant laparoscopic sleeve gastrectomy and hiatal hernia repair on gastro-oesophageal reflux disease in morbidly obese patients p. 103
Harshit Garg, Balasubiramaniyan Vigneshwaran, Sandeep Aggarwal, Vineet Ahuja
DOI:10.4103/0972-9941.201730  PMID:28281472
Background: The aim of this study was to analyse the impact of hiatal hernia repair (HHR) on gastro-oesophageal reflux disease (GERD) in morbidly obese patients with hiatus hernia undergoing laparoscopic sleeve gastrectomy (LSG). Materials and Methods: It is a retrospective study involving ten morbidly obese patients with large hiatus hernia diagnosed on pre-operative endoscopy who underwent LSG and simultaneous HHR. The patients were assessed for symptoms of GERD using a Severity symptom score (SS) questionnaire and anti-reflux medications. Results: Of the ten patients, five patients had GERD preoperatively. At the mean follow-up of 11.70 ± 6.07 months after surgery, four patients (80%) showed complete resolution while one patient complained of persistence of symptoms. Endoscopy in this patient revealed resolution of esophagitis indicating that the persistent symptoms were not attributable to reflux. The other five patients without GERD remained free of any symptom attributable to GERD. Thus, in all ten patients, repair of hiatal hernia (HH) during LSG led to either resolution of GERD or prevented any new onset symptom related to GER. Conclusion: In morbidly obese patients with HH with or without GERD undergoing LSG, repair of the hiatus hernia helps in amelioration of GERD and prevents any new onset GER. Thus, the presence of HH should not be considered as a contraindication for LSG.
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Stealth surgery: Subcutaneous endoscopic excision of benign lesions of head, neck and trunk in children p. 109
Veeramaneni Shravan Teja, Prakash Agarwal, Raj Kishore Bagdi
DOI:10.4103/0972-9941.201729  PMID:28281473
Background: Subcutaneous endoscopic excision of benign lesions of the head, neck and trunk is a new dimension in paediatric minimally invasive surgery. This study is a case series where cases are operated endoscopically with minimal scars. Patients and Methods: This is a prospective study where in 13 patients who underwent Stealth surgery were enrolled in this study. Factors such as intraoperative time, blood loss, intraoperative complications, postoperative recovery and appearance and placing of minimal scars at inconspicuous sites were taken into consideration. Results: All patients underwent successful surgery without converting to open surgery. Out of 13 patients, five were torticollis, four were suprasternal dermoid, one had chest wall swelling, one had swelling of arm, one had back lipoma and one had forehead lipoma. The mean operation time was 50 min (range 32-70). All patients were followed up regularly postoperatively. All patients were operated as daycare, less postoperative pain, no evident scars, lower complications related to scars. Conclusion: Subcutaneous endoscopic surgery addresses concerns related to scarring by replacing large visible incisions with smaller incisions placed in inconspicuous locations. This is a safe and effective procedure of early recovery.
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Combined laparoscopic and transanal total mesorectal excision for rectal cancer: Initial experience and early results p. 113
Morten Holt Thomsen, Henrik Ovesen, Jens Ravn Eriksen
DOI:10.4103/0972-9941.195586  PMID:28281474
Introduction: Incomplete specimens resulting in residual mesorectum in the patient and an increased risk of local recurrence remains a problem. We have introduced transanal-total mesorectal excision (Ta-TME) in our department to potentially overcome this problem due to more direct access to the lower pelvis in patients undergoing TME for rectal cancer and this article presents our initial experience with the new procedure. Materials and Methods: Patients with a T1-T3 mid or low rectal cancer eligible for TME or intersphincteric abdominoperineal excision were selected for a combined transanal and transabdominal laparoscopic resection. The primary aim of the study was to evaluate the feasibility and efficacy of the method with a special focus on the quality of the specimen. Results: During a 9-month period, 11 patients were operated with this technique. All procedures resulted in complete or nearly complete specimen. We did, however, find the procedure technically demanding and experienced several complications with three anastomotic leaks (all with preserved intestinal continuity) and a urethral lesion. Conclusion: Ta-TME is feasible and might be the answer to obtaining good quality specimens and overcome some of the technical difficulties that can be encountered in the obese narrow male pelvis. The procedure however is technically demanding.
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Single incision laparoscopic cholecystectomy: Less scar, less pain p. 118
Shantanu Tyagi, Rajeev Sinha, Aarti Tyagi
DOI:10.4103/0972-9941.186686  PMID:28281475
Context and Aims: Our study aims to evaluate the post-operative pain and cosmesis of single-incision laparoscopic cholecystectomy (SILC) in comparison with the standard, 3-port laparoscopic cholecystectomy (SLC) with respect to the length of incision, cosmetic scores, post-operative pain scores and duration of hospital stay. Settings and Design: This comparative randomised study was conducted in a tertiary care centre teaching hospital between September 2012 and 2014. One hundred and fifty consecutive patients, who qualified as per inclusion criteria, were included in the study. Subjects and Methods: Seventy-five patients were included in the SLC arm and 75 in the SILC arm. SILC procedure was carried out as transumbilical multiport technique and SLC as 3-port technique utilizing - 5, 5, 10 mm ports. Statistical Analysis Used: The data for the primary observations (post-operative pain scores, cosmetic score and incision length) and secondary observation (post-operative hospital stay) were noted. Weighted mean difference was used for calculation of quantitative variables, and odds ratios were used for pooling qualitative variables. Results: Pain scores at 4 and 24 h were significantly better for SILC arm than SLC arm (at 4 h - 4.84 ± 0.95 vs. 6.17 ± 0.98, P < 0.05 and at 24 h - 3.84 ± 0.96 vs. 5.17 ± 0.09, P < 0.05). Length of incision was significantly smaller (SILC - 2.631 ± 0.44 cm vs. SLC - 5.11 ± 0.44 cm), P < 0.05 and cosmetic score was significantly better in SILC arm (6.25 ± 1.24) than SLC arm (4.71 ± 1.04), P < 0.05. Difference between the hospital stay is insignificant for two arms SILC (2.12 ± 0.34) and SLC (2.13 ± 0.35), P > 0.05. Discussion: Significant difference was found in duration and intensity of pain between two procedures at 4 and 24 h. Cosmesis was significantly better in SILC than SLC group, the sample size in our study was small to arrive at a definite conclusion. The procedure can be selectively and judiciously performed by surgeons trained in regular laparoscopic surgery. Furthermore, the threshold for conversion should be low in learning phase. Widespread application must await Level 1 evidence from prospective trials.
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Objective ergonomic risk assessment of wrist and spine with motion analysis technique during simulated laparoscopic cholecystectomy in experienced and novice surgeons Highly accessed article p. 124
Twinkle Yogesh Dabholkar, Sujata Sudhir Yardi, Sanjay Narahari Oak, Sneha Ramchandani
DOI:10.4103/0972-9941.195574  PMID:28281476
Introduction: There is a rise in prevalence of work-related musculoskeletal disorders in surgeons performing laparoscopic surgeries due to lack of ergonomic considerations to the minimal access surgical environment. The objective of this study was to assess the physical ergonomics in experienced and novice surgeons during a simulated laparoscopic cholecystectomy. Methodology: Thirty-two surgeons participated in this study and were distributed in two groups (experienced and novices) based on the inclusion criteria. Both groups were screened for the spinal and wrist movements on the orientation sensor-based, motion analysis device while performing a simulated laparoscopic cholecystectomy. Simultaneous video recording was used to estimate the other joint positions. The RULA (Rapid Upper Limb Assessment) ergonomic risk scores were estimated with the acquired data. Results: We found that surgeons in both novice and experienced groups scored a high on the RULA. Limited awareness of the influence of monitor position on the postural risk caused surgeons to adopt non-neutral range cervical postures. The thoracolumbar spine is subjected to static postural demand. Awkward wrist postures were adopted during the surgery by both groups. There was no statistically significant difference in the RULA scores between the novice and experienced, but some differences in maximum joint excursions between them as detected on the motion analysis system. Conclusion: Both experienced and novice surgeons adopted poor spinal and wrist ergonomics during simulated cholecystectomy. We concluded that the physical ergonomic risk is medium as estimated by the RULA scoring method, during this minimally invasive surgical procedure, demanding implementation of change in the ergonomic practices.
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Impact of seniority on operative time and short-term outcome in laparoscopic cholecystectomy: Experience of an academic Surgical Department in a developing country p. 131
Amine Souadka, Mohammed Sayed Naya, Badr Serji, Hadj Omar El Malki, Raouf Mohsine, Lahsen Ifrine, Abdelkader Belkouchi, Amine Benkabbou
DOI:10.4103/0972-9941.186687  PMID:28281477
Introduction: Resident participation in laparoscopic cholecystectomy (LC) is one of the first steps of laparoscopic training. The impact of this training is not well-defined, especially in developing countries. However, this training is of critical importance to monitor surgical teaching programmes. Objective: The aim of this study was to determine the impact of seniority on operative time and short-term outcome of LC. DESIGNS AND SETTINGS: We performed a retrospective study of all consecutive laparoscopic cholecystectomies for gallbladder lithiasis performed over 2 academic years in an academic Surgical Department in Morocco. Participants: These operations were performed by junior residents (post-graduate year [PGY] 4–5) or senior residents (PGY 6), or attending surgeons assisted by junior residents, none of whom had any advanced training in laparoscopy. All data concerning demographics (American Society of Anesthesiologists, body mass index and indications), surgeons, operative time (from skin incision to closure), conversion rate and operative complications (Clavien–Dindo classification) were recorded and analysed. One-way analysis of variance, Student's t-test and Chi-square tests were used as appropriate with statistical significance attributed to P < 0.05. Results: One hundred thirty-eight LC were performed. No differences were found on univariate analysis between groups in demographics or diagnosis category. The overall rate of operative complications or conversions and hospital stay were not significantly different between the three groups. However, mean operative time was significantly longer for junior residents (n = 27; 115 ± 24 min) compared to senior residents (n = 37; 77 ± 35 min) and attending surgeons (n = 66; 55 ± 17 min) (P < 0.001). Conclusion: LC performed by residents appears to be safe without a significant difference in complication rate; however, seniority influences operative time. This information supports early resident involvement in laparoscopic procedures and also the need to develop cost-effective laboratory training programmes.
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UNUSUAL CASES Top

Single port laparoscopic splenectomy for wandering spleen with splenomegaly in a patient with Wolf-Hirschhorn syndrome p. 135
Ricardo Zorron, Silvio Henriques Cunha, Mariana Caetano Barreto, Henrique Neubarth Phillips
DOI:10.4103/0972-9941.195567  PMID:28281478
Wolf-Hirschhorn syndrome is a rare genetic condition characterized by typical facial appearance, growth delay, psychomotor retardation and seizures, with a mosaic of other abnormalities reported in the literature. The occurrence of symptomatic wandering spleen with massive splenomegaly and with an indication for splenectomy has not been yet described for this disease. This study reports the first case in the literature of single port splenectomy for this rare condition. In a 21-year-old female patient with Wolf-Hirschhorn syndrome, with abdominal pain and the diagnosis of wandering spleen with splenomegaly (25 cm diameter) led to an indication of elective splenectomy. In supine position under general anesthesia, single port umbilical splenectomy was performed without laparoscopic assistance, splenic vessels were ligated by sutures, and the specimen was transumbilically extracted. Operative time was 85 min, with minimal bleeding, and resumed oral intake on the same day. No intraoperative or post-operative complications occurred, and the patient was discharged in 48 h. Single port access splenectomy is feasible and is evolving as an attractive alternative therapy for hematological diseases requiring splenectomy.
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Mesh erosion into urinary bladder following laparoscopic inguinal hernia repair p. 139
Arjun Singh Sandhu, Ameet Kumar, Bharath N Kumar
DOI:10.4103/0972-9941.195579  PMID:28281479
Along with advantages, evolving surgical techniques bring unique complications. A young male developed urinary symptoms a few months after undergoing laparoscopic inguinal hernia repair. On evaluation, mesh erosion into the urinary bladder was found. Removal of mesh with repair of bladder was done. A vesico-cutaneous fistula resulted which was managed with repeat surgery. We review all such cases reported in literature; discuss the etiopathogenesis, presentation, management and possible preventive measures. To the best of our knowledge, this is only the 12th case being reported.
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Portomesenteric venous thrombosis: A rare but probably under-reported complication of laparoscopic surgery: A case series p. 143
Yan Mei Goh, Ajay Tokala, Tarek Hany, Kishore G Pursnani, Ravindra S Date
DOI:10.4103/0972-9941.195582  PMID:28281480
Portomesenteric venous thrombosis (PMVT) is a rare but well-reported complication following laparoscopic surgery. We present three cases of PMVT following laparoscopic surgery. Our first case is a 71-year-old morbidly obese woman admitted for elective laparoscopic giant hiatus hernia (LGHH) repair. Post-operatively, she developed multi-organ dysfunction and computed tomography scan revealed portal venous gas and extensive small bowel infarct. The second patient is a 51-year-old man with known previous deep venous thrombosis who also had elective LGHH repair. He presented 8 weeks post-operatively with severe abdominal pain and required major bowel resection. Our third case is an 86-year-old woman who developed worsening abdominal tenderness 3 days after laparoscopic right hemicolectomy for adenocarcinoma and was diagnosed with an incidental finding of thrombus in the portal vein. She did not require further surgical intervention. The current guidelines for thromboprophylaxis follow-up in this patient group may not be adequate for the patients at risk. Hence, we propose prolonged period of thromboprophylaxis in the patients undergoing major laparoscopic surgery.
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A novel method of minimally invasive rectus abdominis muscle flap harvest: Laparoscopic surgeons take note p. 146
Tabish Aijaz, Dhruv Singhal, Sanda A Tan, Atif Iqbal
DOI:10.4103/0972-9941.186688  PMID:28281481
The rectus abdominis muscle (RAM) is a workhorse flap to fill or repair abdominal defects. A drawback of an open RAM harvest is donor site morbidity, and minimally invasive techniques for flap harvesting have been previously proposed but involve vertical division of the rectus fascia. We present a case of a 52-year-old woman with a recurrent rectovaginal fistula in a radiated field treated with a laparoscopic low anterior resection with simultaneous RAM flap harvest utilising a single Pfannenstiel incision. Our novel modified laparoscopic-assisted RAM harvest technique prevents longitudinal violation of the anterior and posterior rectus sheaths, thereby promoting a quick recovery, improved cosmesis and decreased post-operative morbidity.
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Laparoscopic spleen-preserving distal pancreatectomy for a primary hydatid cyst mimicking a mucinous cystic neoplasia p. 148
Tugan Tezcaner, Yahya Ekici, Onur Huseyin Aydın, Gonca Barit, Gökhan Moray
DOI:10.4103/0972-9941.195578  PMID:28281482
Pancreatic hydatid cysts are fairly rare. The disease can be encountered concurrently with systemic involvement or as an isolated pancreatic involvement. We report the first case of spleen-preserving laparoscopic distal pancreatectomy for a pancreatic hydatid cyst. There was no complication or recurrence. A 55-year-old woman was admitted to our centre with epigastric and back pain. Upper abdominal magnetic resonance imaging revealed a solitary cystic lesion with septations at the pancreatic tail level measuring 24 mm × 18 mm, which was initially thought to be a pancreatic mucinous cystic neoplasia. She underwent laparoscopic spleen-preserving distal pancreatectomy and cholecystectomy. Her post-operative course was uneventful and histopathological examination revealed a hydatid cyst in the pancreatic tail.
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An adolescent with prolapsed omentum per rectum: Spontaneous rectal perforation managed laparoscopically p. 151
Ameet Kumar, Chandra K Jakhmola, Yogesh Kukreja, SS Kumar, Arjun Singh Sandhu
DOI:10.4103/0972-9941.195564  PMID:28281483
Spontaneous rupture of the rectum is a rare occurrence. A total laparoscopic approach to rectal perforation has only occasionally been reported. We report an unusual case of a young boy who developed a spontaneous rupture of the rectum following a trivial fall. A magnetic resonance imaging revealed a tear in the rectum at the peritoneal reflection with the omentum plugging it. He denied any history of rectal instrumentation or abnormal sexual activity. He had no history of constipation or rectal prolapse. The tear was repaired laparoscopically and a covering loop sigmoid colostomy was added. He made an uneventful post-operative recovery. Spontaneous rupture of the rectum can occur in younger age groups and even in the absence of significant trauma. One needs to diligently bring out a history of rectal trauma. Equally important is to rule out any underlying pathological condition. A laparoscopic approach is feasible, especially in early cases.
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Laparoscopic management of symptomatic residual appendicular tip: A rare case report p. 154
R Parthsarathi, Samrat V Jankar, Bhushan Chittawadgi, Sandeep C Sabnis, S Sarvana Kumar, S Rajapandian, P Senthilnathan, P Praveen Raj, C Palanivelu
DOI:10.4103/0972-9941.199610  PMID:28281484
Appendectomy is one of the most common emergency surgical procedures. Stump appendicitis is well-recognised entity has been described in the literature. Still, with recent advance in imaging technique, it remains as a clinical challenge for diagnosis and effective treatment. We present a case of 13-year-old boy who underwent laparoscopic appendectomy 3 months back and presented to us with acute abdomen associated with vomiting and fever. Imaging revealed the presence of a tubular residual inflamed tip of the appendix of size 4 cm laying in paracaecal position with approximately 50cc purulent collection around it. Subsequently, the patient underwent successful laparoscopic completion appendectomy with uneventful postoperative recovery. Histopathological examination confirmed that resected structure as an inflammatory residual appendix. For our knowledge, after an extensive search of English literature, no study had described about laparoscopic completion appendectomy for residual tip appendicitis. We authors hereby would like to emphasise the importance of complete removal of appendix not only stump part but also tip, especially in certain locations such as paracaecal, retrocaecal and subhepatic. Laparoscopy can be an option for the management of these patients, in selected cases, and with available expertise.
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HOW I DO IT DIFFERENTLY Top

Laparoscopic resection of duodenal gastrointestinal stromal tumour p. 157
Tammy Zioni, Vitaliy Dizengof, Boris Kirshtein
DOI:10.4103/0972-9941.195576  PMID:28281485
Only a few studies have revealed using laparoscopic technique with limited resection of gastrointestinal stromal tumour (GIST) of the duodenum. A 68-year-old man was admitted to the hospital due to upper gastrointestinal (GI) bleeding. Evaluation revealed an ulcerated, bleeding GI tumour in the second part of the duodenum. After control of bleeding during gastroduodenoscopy, he underwent a laparoscopic wedge resection of the area. During 1.5 years of follow-up, the patient is disease free, eats drinks well, and has regained weight. Surgical resection of duodenal GIST with free margins is the main treatment of this tumour. Various surgical treatment options have been reported. Laparoscopic resection of duodenal GIST is an advanced and challenging procedure requiring experience and good surgical technique. The laparoscopic limited resection of duodenal GIST is feasible and safe, reducing postoperative morbidity without compromising oncologic results.
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IMAGES IN LAPAROSCOPY Top

A rare case of post-splenectomy gastric volvulus managed by laparoscopic anterior gastropexy p. 161
Rahul Amreesh Gupta, Rinki Das, Ganga Ram Verma
DOI:10.4103/0972-9941.195581  PMID:28281486
We report an extremely rare case of recurrent gastric volvulus after open splenectomy for hereditary spherocytosis. The initial episode was managed by endoscopic derotation. Later, for recurrent symptoms, she was successfully managed by laparoscopic anterior gastropexy.
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04