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   Table of Contents - Current issue
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April-June 2022
Volume 18 | Issue 2
Page Nos. 167-325

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SYSTEMATIC REVIEWS  

Performance of three-dimensional and ultra-high-definition (4K) technology in laparoscopic surgery: A systematic review and meta-analysis p. 167
Vitish Singla, Hemanga K Bhattacharjee, Ekansh Gupta, Deepti Singh, Ashwani K Mishra, Dalim Kumar
DOI:10.4103/jmas.jmas_122_21  PMID:35313429
Background: The technology in the field of laparoscopy is rapidly evolving and is primarily focussed on increasing the quality of image and depth perception in the form of 4K and three-dimensional (3D) technology. There has been no conclusion yet regarding the better technology. Methods: A systematic search was performed independently by two authors across MEDLINE, Google Scholar and Embase using the PRISMA guidelines. All randomised control trials comparing 3D and 4K technologies were included. Meta-analysis was conducted using random-effects statistics for time taken for different tasks across the studies. Results: The search strategy revealed a total of 1835 articles, out of which nine studies were included. Three studies showed no superiority of 3D over 4K, while the remaining six did. Meta-analysis for the time taken for peg transfer favoured 3D over 4K (overall effect: Z = 2.12; P = 0.03). Forest plots for time taken for suturing (Z = 1.3; P = 0.19) and knot tying (Z = 1.7; P = 0.09) also favoured 3D over 4K; the results however were statistically insignificant. Path length was reported by two studies and was found to be lesser in the 3D group. Two studies measured the workload by NASA/Surg-TLX score, which was lower in the 3D group. Visual side effects were found to be higher in the 3D group. Conclusion: 3D technology is likely to result in a shorter operative time and better efficiency of movement as compared to the 4K technology by the virtue of its better depth perception.
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Patient selection for ambulatory laparoscopic cholecystectomy: A systematic review p. 176
Weiwei Chen, Qiang Wu, Ning Fu, Zhiming Yang, Jingcheng Hao
DOI:10.4103/jmas.jmas_255_21  PMID:35313430
Background: Currently, there is no consensus on patient selection for ambulatory laparoscopic cholecystectomy (LC). This study is a systematic review of previously published patient selection for ambulatory LC. Methods: A comprehensive search was done in PubMed, Web of Science, Embase and Google Scholar Database up to March 2020 to summarise previously reported medical or surgical selection criteria used for inclusion and exclusion of patients, as well as successful same-day discharge rates and readmission rate after discharge. Results: Fifty-nine studies with a total of 13,219 patients were included in this systematic review. In total, the median same-day discharge rate was 90% (range: 63%–99.4%), and median readmission rate was 2.22% (range: 0%–16.9%). The most considered medical criteria were American Society of Anesthesiologists classification I and II, age <70, and body mass index <35. Surgical criteria varied greatly. The top three accessible exclusion variables were (1) common bile duct stones, cholangitis, or jaundice (27 publications, 45.8%); (2) history of abdominal surgery (12 publications, 20.3%) and (3) history of pancreatitis (9 publications, 15.3%). Conclusion: The results of the current study showed the variable patient selection in different centres, the medical aspect criteria may be expanded under adequate pre-anaesthetic assessment and preparation and the surgical aspect criteria should include more laboratory or imaging parameters to ensure the surgical safety.
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ORIGINAL ARTICLES Top

Comparison of surgical outcome between conventional laparoscopic cystogastrostomy method and plication of the edge of anterior gastrotomy in patients with pancreatic pseudocyst: A retrospective study at two tertiary care centres p. 181
Prabhas Naik, Manash Ranjan Sahoo, Jyotirmay Nayak
DOI:10.4103/jmas.JMAS_201_20  PMID:33605931
Background: In retro-gastric Pancreatic pseudocyst (PP) Laparoscopic cystogastrostomy (LCG) is an established procedure of drainage. Aims and Objectives: To compare surgical outcome between laparoscopic cysto-gastrostomy conventional method and plication of the edge of anterior gastrotomy in patients of pancreatic pseudocyst. Materials and Methods: Twenty six patients were underwent LCG from 2010-2020 by a single surgeon. Both the conventional LCG group Group-1(Gr-1) and the plication group Group-2 (Gr-2) where plication of edge of anterior gastrostomy was performed, contained 13 patients each. Results: The numbers of male/female in Gr-1 was 9/4 and that in Gr-2 was 10/3 (P = 1). Mean ages of patients were 45.3 ± 10.4 years (range 23-60) in Gr-1 and 48.0 ± 12.3 years (range 27-65) in Gr-2. Etiological factors were alcohol (46.1% in Gr-1, 53.8% in Gr-2), gallstone disease (38.4% in Gr-1,15.3% in Gr-2), trauma (15.3% in each groups), idiopathic cause (15.3% in Gr-2). The cyst size was 9.0 ± 1.5 cm in Gr-1and 8.9 ± 2.1cm in Gr-2. The mean operative time in Gr-1 (107.6 ± 12.5 minutes) was longer than Gr-2 (97 ± 1 3.6 minutes) (P = 0.06). The size of cystogastric anastomosis in Gr-1 was 4.6 ± 0.7 cm and that in Gr-2 was 4 ± 0.8 cm (P = 0.04). The intra-operative blood loss in Gr-1 and Gr-2 were 101.9 ± 21.7ml and 78.4 ± 30.7 ml respectively. There was a significant change in intraoperative blood loss and stoma size in Gr-2. The postoperative complications were managed conservatively. No recurrence over a period of 18 months of follow-up. Conclusion: Plication of edges of anterior gastrostomy result in reduction in operative time, smaller anastomosis without complication and less intra-operative blood loss.
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Role of enhanced recovery after surgery in total laparoscopic hysterectomy p. 186
Mili Inania, Priyanka Sharma, Manoj Parikh
DOI:10.4103/jmas.JMAS_86_21  PMID:35046168
Introduction: Enhanced recovery after surgery (ERAS) principles is an evidence-based surgical management approach that requires cooperation across various medical specialties. In this study, we applied ERAS principles in total laparoscopic hysterectomy (TLH) and the post-operative outcomes like post-operative pain, nausea and vomiting, opioid requirement, day of discharge, and any other complaints were studied. Methods: The study was conducted in a private healthcare setup in Jodhpur, Rajasthan, India. In this non-randomised controlled study 103 patients who underwent TLH over a period of 1 year were alternatively allocated to the study group and the control group. There were 51 patients in the study group in whom ERAS principles were applied and 52 patients in control group in whom traditional post-operative care was given. Results: Post-operative nausea and vomiting and opioid requirement were significantly reduced in the study group (P < 0.05). The post-operative pain was similar in both groups. The majority of patients in study group were discharged within 24 h as compared to the routine discharge after 48 h. Conclusion: Following ERAS principles in TLH results in decrease in post-operative nausea and vomiting, post-operative opioid requirement and hospital stay. Hence, the ERAS principles should be the standard practice in TLH even in a developing country setup.
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Laparoscopic versus open surgical management of patients with chronic pancreatitis: Amatched case–control study p. 191
Hirdaya Hulas Nag, Phani Kumar Nekarakanti, PS Arvinda, Aditya Sharma
DOI:10.4103/jmas.JMAS_183_20  PMID:33885009
Background: The safety and feasibility of laparoscopic surgery in patients with chronic pancreatitis (CP) have been established, but its outcome has not been compared to that of open surgery. Patients and Methods: This retrospective study was conducted on patients with CP who were treated by a single surgical team from 2012 to 2018. The medical records of patients with surgical treatment of CP were reviewed. Patients were divided into laparoscopic group (LG) and open group (OG). Both the groups were matched for age and procedures. The matched groups were compared. Results: The total number of unmatched patients was 99 and post matching, there were 38 patients in each group. The demographic, aetiological, clinical and laboratory parameters were comparable. The number of each surgical procedure including bilio-enteric anastomosis was also similar. Lateral pancreaticojejunostomy was the most common surgical procedure in both the groups. An additional surgical procedure (bilio-enteric bypass) was required in 10.5% of the patients in LG and 21% of the patients in OG groups (P = 0.3). Significantly lower blood loss (100 vs. 120 ml) and higher operation time (300 vs. 210 min) were observed in LG. The post-operative complication rate was 7.9% in LG group versus 10.5% in OG group. More than 85% of the patients in both the groups had a significant relief from pain. The impact of exocrine and endocrine insufficiency was not remarkable in both the groups. The requirement of an additional surgical procedure was associated with a high conversion rate. Conclusions: The outcomes of laparoscopic surgery in patients with CP were similar to that of open surgery, and requirement of an additional surgical procedure is associated with a high conversion rate.
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Safety of peripheral gastric vessel coagulation during laparoscopic sleeve gastrectomy p. 197
Jian Hong, Jason Widjaja, Ponnie Robertlee Dolo, Libin Yao, Xiaocheng Zhu
DOI:10.4103/jmas.JMAS_1_21  PMID:33885018
Introduction: Staple-line bleeding (SLB) is a common issue during laparoscopic sleeve gastrectomy (SG). Identifying a method or technique intraoperatively to manage or reduce the prevalence of SLB is crucial. Materials and Methods: Patients' data who had undergone primary laparoscopic SG from January 2018 to December 2019 at our hospital were retrospectively analysed. The patients in this study received peripheral gastric vessel coagulation intervention in addition to the standard SG procedure. Preoperative parameters included age, gender, body mass index (BMI), the prevalence of diabetes and hypertension. Intra- and postoperative parameters were prevalence of SLB, operative time, total postoperative stay, the prevalence of leakage and bleeding. Intraoperative SLB was identified and analysed through video recordings. Results: 217 cases of laparoscopic SG were included in the study. The mean preoperative assessments were as follows: age, 34.2 ± 10.7 years; male/female, 98/119; BMI, 39.9 ± 7.6 kg/m2; prevalence of diabetes, 52 (24.0%) and hypertension, 90 (41.5%). Of 217 patients, 35 (16%) were found to have SLB following the new interventional procedure. The mean operative time was 93.2 ± 13.6 min. The mean total postoperative stay was 3.3 ± 1.3 days. The postoperative prevalence of leakage and bleeding were 0% and 0%, respectively. Conclusion: The technique of coagulating the peripheral gastric vessels to prevent SLB is safe and appears promising. A prospective study comparing with and without peripheral gastric vessel coagulation will be needed in the future.
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Can gastric botulinum toxin A injection be used as minimally invasive procedure in the short-term treatment of obesity? p. 201
Kamil Özdil, AK Çağatay, Süleyman Sayar, Hüseyin Aykut, Ebru Tarıkçı Kılıç
DOI:10.4103/jmas.JMAS_105_21  PMID:35046171
Background/Aim: Gastric botulinum toxin A (BTX-A) injection is a type of endoscopic obesity treatment option that delays gastric emptying. However, there is little and contradictory information concerning the treatment efficacy of BTX-A injection. This study evaluated the treatment efficacy of BTX-A injection in the treatment of obesity. Materials and Methods: This was an open-label, prospective study of obese individuals with a body mass index >30 kg/m2 admitted to our clinic. The sample consisted of 72 consecutive treatment-naive patients with obesity divided into age–sex-matched three groups: gastric BTX-A injection (study group), calorie-restricted (15–20 Kcal/kg) diet (control) and bariatric surgery (BS) (control) groups. İn the study group, 200 IU BTX-A was injected to the antrum and corpus endoscopically. The study and control groups were compared for their total body weight loss (TBWL) and excess body weight loss (EBWL) at the 6th month. Results: Gastric BTX-A injection therapy was applied to 24 patients. The mean age was 39.1 ± 9.1/years. 54.1% of the patients (n = 13) was female. At the 6th month, the mean TBWL and EBWL of patients were; 10% ±4.1 and 37.2% ±13.9 for gastric BTXA injection group, 5% ±2.3 and 20.2% ±9.3 for diet group, 30.7% ±5.3 and 66.9% ±14.4 for BS group. Patients who underwent gastric BTX-A injection lost weight more effectively than patients who were on diet alone, while BS patients lost weight more effectively than those who had gastric BTX-A injection (P < 0.001). In the gastric BXT-A injection group, the first 3-month delta EBWL and TBWL (change of EBWL and TBWL percentages) were found significantly higher than the 3–6th month and 6–12th month (P = 0.001 and P < 0.001). Conclusion: Gastric BTX-A injection is a minimally invasive and short-term effective method that can be used in the treatment of obesity.
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Conventional versus single-incision laparoscopy for the surgical treatment of ovarian torsion p. 207
Murat Gozukucuk, Yetkin Karasu, Sena Münire Kaya, Erhan Yangır, Yusuf Üstün
DOI:10.4103/jmas.JMAS_114_21  PMID:35046166
Aim: The aim of the study was to compare the effectiveness of single-incision laparoscopy with conventional laparoscopy in cases of ovarian torsion. Materials and Methods: Patients who were surgically treated for ovarian torsion in our clinic were retrospectively analysed. The demographic information and surgical records of the patients were obtained from the patient files. Patients treated with single-incision laparoscopy and conventional laparoscopy were compared in terms of demographic characteristics, surgical procedure performed, duration of surgery, amount of bleeding, laboratory results, post-operative pain scores and length of hospital stay. Results: There were 19 patients in the single-incision laparoscopy and 30 in the conventional laparoscopy groups. The two groups were similar in terms of age, obstetric history and body mass index (P > 0.05). The mean operation time was 56.26 ± 15.34 min in the single-incision laparoscopic surgery (SILS) group and 55.07 ± 10.78 min in the conventional laparoscopic surgery group (P > 0.05). There was no significant difference between the two groups in terms of complications, duration of hospital stay, pre- and post-operative haematocrit difference and visual analogue scale-pain scores at hours 0, 6, 12 and 24 (P > 0.05). Conclusion: SILS appears to be as feasible, effective and safe as conventional laparoscopy in the treatment of ovarian torsion cases.
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The outcome of transanal endoscopic microsurgery and adjuvant radiotherapy in patients with high-risk T1 rectal cancer p. 212
Wisam Khoury, Mai Dauod, Mohamed Khalefah, Simon D Duek, Nidal Issa
DOI:10.4103/jmas.JMAS_67_21  PMID:35313431
Introduction: Transanal endoscopic microsurgery (TEM) is considered the technique of choice for adenoma and low-risk T1 rectal cancer. The adequacy of such treatment for high-risk T1 tumours, however, is still controversial. The aim of the study is to evaluate our results with local excision of high-risk T1 cancers. Materials and Methods: Demographic, clinical data pertaining to patients undergoing TEM for T1 rectal cancer between 1999 and 2015 was retrospectively collected. Long-term outcomes were assessed for the entire cohort. Patients were classified into two groups: favourable and high-risk cancer features. Results: Three hundred and fifty-five TEM procedures were recorded in the study period. Forty-three patients were included in the present study. There were 20 females and 23 males, the median age was 69 ± 9. The median tumour distance from the anal verge was 6 cm (range 1–13 cm). Post-operative histopathology showed well/moderately differentiated T1 adenocarcinoma in 30 patients and poorly differentiated in 13. The overall survival for patients with favourable and high-risk features groups were 93.5% and 77%, respectively, while the local recurrence (LR) was 3.5% and 23.1%, respectively. Nine patients with high-risk features received adjuvant radiotherapy; one (11.1%) of them experienced LR. Conclusions: Local excision by TEM augmented by adjuvant radiotherapy may be a feasible alternative for selected patients with high-risk T1 rectal cancer. The addition of radiotherapy seems to decrease the rates of LR.
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Anatomical mapping of the biliary tree during laparoscopic cholecystectomy by using indocyanine green dye p. 218
Manisha Bandari, Manohar V Pai, Abhijith Acharya, Alfred J Augustine, BV Murlimanju
DOI:10.4103/jmas.JMAS_87_21  PMID:35313432
Background: Fluorescent cholangiography using intravenous indocyanine green (ICG) is a noninvasive technique that enables real-time intraoperative imaging of biliary anatomy. The objective of this study was to visualise the biliary anatomy in routine and complicated cases of laparoscopic cholecystectomy (LC). Methods: This was a prospective observational study of patients undergoing LC for various indications. After obtaining consent, 5 mg/1 ml of ICG dye was administered intravenously in each patient, 2 h before the incision time. LC was performed by standard critical view of the safety technique. The biliary tree was visualised using near-infrared (NIR) view before clipping any structure. Intra-operative findings, visibility of ducts in the NIR view, conversion, adverse reactions to ICG and post-operative outcomes in all patients were recorded. Results: Out of 43 patients undergoing LC, 24 had cholelithiasis, 10 had acute cholecystitis, 3 had chronic cholecystitis, 1 had mucocele of the gall bladder, 1 had gall bladder polyp and 4 cases had common bile duct (CBD) stone clearance with endoscopic retrograde cholangiopancreatography. Cystic duct (CD) and CBD were visualised in 100% of cases among all groups except for those with acute cholecystitis where CD and CBD were visualised in 90% and 80% of cases, respectively, and in chronic cholecystitis CD and CBD were visualised in 66.6% and 80% of patients, respectively. There was one elective conversion in the chronic cholecystitis group due to dense adhesions and non-progression. Only the CBD was visualised in this case. There were no cases of CBD injury or any allergic reactions to the dye. Conclusions: Fluorescent cholangiography during LC is a safe and non-invasive method, allowing superior anatomical visualisation of the biliary tree in comparison to simple laparoscopy. This method can correct misinterpretation errors and detect aberrant duct anatomy, thus increasing the confidence of the operating surgeon enabling safe dissection. This simple technique has the potential to become standard practice to avoid bile duct injury during LC.
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Proper surgical extent for clinical Stage I right colon cancer p. 224
Han Deok Kwak, Jun Seong Chung, Jae Kyun Ju, Soo Young Lee, Chang Hyun Kim, Hyeong Rok Kim
DOI:10.4103/jmas.JMAS_9_21  PMID:35046161
Purpose: Pre-operative evaluation identifying clinical-stage affects the decision regarding the extent of surgical resection in right colon cancer. This study was designed to predict a proper surgical resection through the prognosis of clinical Stage I right colon cancer. Patients and Methods: We included patients who were diagnosed with clinical and pathological Stage I right-sided colon cancer, including appendiceal, caecal, ascending, hepatic flexure and proximal transverse colon cancer, between August 2010 and December 2016 in two tertiary teaching hospitals. Patients who underwent open surgeries were excluded because laparoscopic surgery is the initial approach for colorectal cancer in our institutions. Results: Eighty patients with clinical Stage I and 104 patients with pathological Stage I were included in the study. The biopsy reports showed that the tumour size was larger in the clinical Stage I group than in the pathological Stage I group (3.4 vs. 2.3 cm, P < 0.001). Further, the clinical Stage I group had some pathological Stage III cases (positive lymph nodes, P = 0.023). The clinical Stage I group had a higher rate of distant metastases (P = 0.046) and a lower rate of overall (P = 0.031) and cancer-specific survival (P = 0.021) than the pathological Stage I group. Compared to pathological Stage II included in the period, some of the survival curves were located below the pathological Stage II, but there was no statistical difference. Conclusion: The study results show that even clinical Stage I cases, radical resection should be considered in accordance with T3 and T4 tumours.
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Video-assisted thoracoscopic surgery: The preferred method to manage pulmonary sequestration p. 230
Sukhram Bishnoi, Harsh Vardhan Puri, Belal Bin Asaf, Mohan Venkatesh Pulle, Manan Bharat Kumar Parikh, Mitul Vinodbhai Patel, Ajay Sirohi, Arvind Kumar
DOI:10.4103/jmas.JMAS_251_20  PMID:33605934
Background: This study aims at describing the feasibility and safety of video-assisted thoracic surgery (VATS) in benign diseases such as pulmonary sequestrations (PSs) and report the surgical outcomes. Materials and Methods: This is a retrospective analysis of prospectively maintained data of 25 patients who were operated for PS over 7 years at a dedicated thoracic surgery centre in India. Pre-operative details, operative technique and details, post-operative details and complications were recorded and analysed. Results: There were 15 (60%) males and 10 (40%) females, with a median age of 22.28 years (range, 16–28 years). All patients had intra-lobar type of sequestration. The most commonly involved was left lower lobe (n = 15 patients, 60%) followed by the right lower lobe (n = 10 patients, 40%). The origin of blood supply was from the descending thoracic aorta in 18 patients (72%), the abdominal aorta in 5 (20%) and the coeliac trunk and the inferior phrenic artery in one patient (4%) each. All patients underwent complete lobar resection. One patient was converted because of dense hilar adhesion. The average duration of surgery was 179 min and the average blood loss was 204 ml. The median hospital stay and chest tube duration were 4 and 3 days, respectively. One patient was re-explored because of post-operative bleeding. Only one patient had an air leak for >7 days. The median follow-up was 42 months (range, 6–90 months) without any recurrence. Conclusions: VATS is a safe, feasible and effective option for PS at experienced centres.
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Initial experience of laparoscopic complete mesocolic excision with D3 lymph node dissection for right colon cancer using Artisential®, a new laparoscopic articulating instrument p. 235
Hyeong Yong Jin, Abulfetouh M Ibahim, Jung Hoon Bae, Chul Seung Lee, Seung Rim Han, In Kyu Lee, Do Sang Lee, Yoon Suk Lee
DOI:10.4103/jmas.JMAS_88_21  PMID:35313433
Background: Laparoscopic complete mesocolic excision (CME) with D3 lymph node dissection for the right colon is becoming popular, but still technically challenging. Several articulating laparoscopic instruments had been introduced to reduce technical difficulties; however, those were not practical. This study aimed to report the first clinical experience of using ArtiSential®, a new laparoscopic articulating instrument in laparoscopic complete mesocolic with D3 lymph node dissection for right colon cancer. Patients and Methods: This was a retrospective, single-institution, consecutive case study. From October 2018 to March 2020, a total of 33 patients underwent laparoscopic right hemicolectomy using ArtiSential®, a new articulating instrument. We compared the short-term outcomes of patients who underwent surgery using ArtiSential® (AG) to the conventional instrument (CG). Results: In total, there were 33 cases in AG and 43 cases in CG. There were no significant differences in operation time (141.0 ± 22.5 vs. 156.0 ± 50.6 min, P = 0.09), mean estimated blood loss (46.8 ± 36.2 vs. 100.8 ± 300.6 ml, P = 0.31) and intra-operative and post-operative complications. However, the number of harvested lymph nodes was higher and the length of hospital stay was shorter in AG than in CG (32.6 ± 12.2 vs. 24.6 ± 7.4, P < 0.01 and 3.0 ± 1.2 vs. 4.1 ± 2.2 days, P = 0.01, respectively). Conclusions: Laparoscopic CME with D3 lymph node dissection for right colon cancer using ArtiSential®, the new articulating laparoscopic instrument is safe and technically feasible.
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A comparison of paravertebral block, erector spinae plane block and the combination of erector spinae plane block and paravertebral block for post-operative analgesia after video-assisted thoracoscopic surgery: A randomised controlled trial Highly accessed article p. 241
Ze Fu, Yi Zhang, Yongjian Zhou, Zhe Li, Kexin Wang, Hongqing Li, Wenwen Jiang, Zimeng Liu, Xuezhao Cao
DOI:10.4103/jmas.JMAS_277_20  PMID:33885016
Background: This study was to determine the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) and paravertebral block (PVB) as well as the combination of PVB and ESPB (P + E) after video-assisted thoracoscopic surgery (VATS). Patients and Methods: Patients were randomly assigned to receive ESPB, PVB or PVB combined with ESPB with 0.5% ropivacaine (20 ml). The primary outcomes were cumulative hydromorphone consumption and Visual Analogue Scale (VAS) scores at rest and while coughing at 0 h, 12 h, 24 h, 48 h and 72 h postoperatively. The secondary outcomes were effective PCA usage count and rescue analgesia requirement at the same time points. Results: The median (interquartile range) hydromorphone consumption, including converted oxycodone, was significantly different at 48 h postoperatively among the three groups (ESPB, 10.24 [9.53–11.71] mg; PVB, 9.94 [9.19–10.75] mg; P + E, 9.44 [8.96–9.97] mg; P = 0.011). Hydromorphone consumption in P + E group was lower compared with that in ESPB group at 12 h, 24 h and 48 h (P < 0.001, P = 0.004 and P = 0.003, respectively). VAS scores at rest were significantly higher for ESPB group compared to P + E group at 0 h postoperatively (P = 0.009). VAS scores while coughing were significantly higher for ESPB group compared to P + E group at 0 h and 12 h postoperatively (P = 0.015 and P < 0.001) and to the PVB group at 12 h postoperatively (P = 0.002). The effective PCA usage count in P + E group was lower than in ESPB group in 0–12 h (P < 0.001). More patients needed rescue analgesia in ESPB group compared to those in P + E group in 0–12 h, 0–24 h and 0–48 h (P = 0.022, 0.035 and 0.035, respectively). Conclusions: Ultrasound-guided PVB combined with ESPB provided superior analgesia to ESPB for VATS. The combination of PVB and ESPB had a similar analgesic effect compared with PVB alone.
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Laparoscopic giant hiatal hernia repair with absorbable mesh p. 248
Massimiliano Ardu, Damiano Bisogni, Alessandro Bruscino, Rosaria Tucci, Massimo Falchini, Andrea Valeri, Paolo Prosperi
DOI:10.4103/jmas.JMAS_26_21  PMID:35313434
Background: The best operative approach to large hiatal hernias still remains controversial between suture cruroplasty and prosthetic hiatal herniorrhaphy. This study aims at analysing results from a single institution in Italy in terms of subjective and objective outcomes. Methods: Retrospectively collected data of all patients that underwent laparoscopic hiatal hernia repair since 2011 were considered. Sixty-five patients were included overall; 17 of them fit the criteria of large hiatal hernia. Follow-up (FU) was assessed by visit, questionnaires and X-ray imaging. Results: No major complications occurred in the post-operative course. No patient was lost during the FU period. Out of all the patients included, 13 agreed to have an X-ray with water-soluble contrast. The questionnaires showed a 76.5% rate of satisfaction (13 patients), and the recurrence rate demonstrated by radiology was 29.4% (five patients). There were no major mesh-related complications. Conclusion: The best operative approach for large hiatal hernias remains far from standardised: There is a lack of evidence on the use of a mesh for this kind of surgery as well as substantial controversy over the definition of what a giant hiatal hernia is. Nevertheless, the results from this study and the main studies in the literature seem to be encouraging in improving giant hiatal hernia repair outcomes.
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Safety and feasibility of laparoscopic left hepatectomy for the treatment of hepatolithiasis in patients with previous abdominal surgery p. 254
Lingpeng Liu, Yong Huang, Zigang Ding, Bangran Xu, Dilai Luo, Hu Xiong, Hongliang Liu, Mingwen Huang
DOI:10.4103/jmas.JMAS_17_21  PMID:34259212
Background: The aim of the study was to compare the benefits and drawbacks of laparoscopic left hepatectomy (LLH) in patients with previous abdominal surgery (PAS) with those in patients without PAS and confirm the safety and feasibility of LLH as a treatment for patients with hepatolithiasis and PAS. Materials and Methods: This retrospective comparative study included 111 patients who underwent LLH for hepatolithiasis (with PAS, n = 41; without PAS, n = 70) from August 2017 to August 2019. Patients' general information, surgical outcomes, hospital stay duration, hospitalisation cost, post-operative laboratory data and post-operative complications were evaluated. Results: No statistically significant difference was noted in the post-operative laboratory data between patients with and without PAS (P > 0.05). Longer operative times were required for patients with PAS than for those without PAS (P = 0.025). Hospitalisation cost, hospital stay duration, blood loss, open conversion and post-operative complications were not significantly different between patients with and without PAS (P > 0.05). No cases of mortality were noted. Conclusions: LLH is a safe and feasible treatment for patients with hepatolithiasis and PAS.
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Effect of pre-operative weight loss on patients' outcomes undergoing laparoscopic sleeve gastrectomy p. 260
Ozan Sen, Ahmet Gökhan Türkçapar
DOI:10.4103/jmas.JMAS_297_20  PMID:35313435
Background: The study aims to demonstrate whether weight loss with a low-calorie diet before laparoscopic sleeve gastrectomy (LSG) may affect the outcomes. Materials and Methods: A total of 305 patients undergoing primary LSG were included in the study. Each patient adopted a low-calorie diet (1000 calories) before LSG. The patients were stratified into two groups. Group A: Those who lost 3% or more of their total body weight loss (TBWL), Group B: Those who lost <3% of their TBWL. Two groups were compared in terms of operative time, length of hospital stay, complications and weight loss outcomes. Results: One hundred and five patients (35%) were in Group A and 200 patients were in Group B. Median weight loss was 4 kg (3–20 kg). Pre-operative mean body mass index (BMI) was 40 ± 7.4 kg/m2 in Group A and 41 ± 5.9 kg/m2 in Group B (P = 0.06). At 1 year after the surgery, BMI regressed to 29.7 ± 4.9 kg/m2 in Group A and to 27 ± 4.2 kg/m2 in Group B (P < 0.001). One hundred and twenty-nine patients who completed 2 years of follow-up, mean BMI regressed to 29.4 ± 4.1 kg/m2 in Group A (n = 46) and to 27.2 ± 4.5 kg/m2 in Group B (n = 83) (P < 0.001). In Group B, one patient experienced post-operative bleeding. No other complications were observed in the study. There was no significant difference between the groups in terms of operative time (P = 0.53) and length of hospital stay (P = 0.9). Conclusion: Weight loss before LSG does not improve post-operative weight loss.
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Tailored one anastomosis gastric bypass – Subgroup analysis of a randomised control trial based on bilio-pancreatic limb length with long-term results of 101 patients p. 264
Mayank Jain, Om Tantia, Ghanshyam Goyal, Tamonas Chaudhuri, Shashi Khanna, Anshuman Poddar, Kajari Majumdar, Sonam Gupta
DOI:10.4103/jmas.JMAS_117_21  PMID:35313436
Background: Ideal bilio-pancreatic limb (BPL) length is a highly debatable issue in one anastomosis gastric bypass (OAGB). Whether to use a tailored BPL or a fixed-length BPL needs to be answered. Materials and Methods: One-hundred and one patients who have undergone tailored OAGB based on basal metabolic index (BMI) and type 2 diabetes mellitus (T2DM) were analysed. Sixty-three patients had BPL of 150 cm and 38 patients had BPL of 180 cm. Mean pre-operative BMI of BPL 150 and 180 cm groups were 39.73 and 51.92 kg/m2, respectively. Results: There was a significant drop in mean total body weight, BMI and excess body weight of both the groups at 1 year which persisted for 5 years post-operatively. The mean BMI of BPL 150 and BPL 180 cm group at 5 years was 29.17 and 32.88 kg/m2, respectively. Although mean percentage excess weight loss (%EWL) and percentage of excess BMI loss in the two groups was similar, the mean percentage total weight loss (%TWL) was significantly higher for the BPL 180 cm group. There was no difference between the two groups in the number of patients who had >50% EWL and >20% TWL. At 5 years of follow-up, the mean serum iron level was significantly low in BPL 180 cm group. There was a significant drop in mean haemoglobin A1c values postoperatively, with no difference between the two groups. Conclusions: Tailored BPL of 150 and 180 cm do not show any difference in the number of patients achieving >50% EWL or >20% TWL and so increasing limb length may not increase the number of good responders for weight loss. Although the resolution of T2DM and improvement of QoL score do not change significantly with increase in BPL length, mean serum iron levels may be lower with longer BPL.
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Readmissions after cholecystectomy in a tertiary UK centre: Incidence, causes and burden p. 273
Islam Omar, Ahmed Hafez
DOI:10.4103/jmas.JMAS_296_20  PMID:33885025
Context: Although cholecystectomy is a widely performed procedure, post-operative readmissions place a heavy burden on healthcare facilities. Aims: This study assesses the incidence, causes and burden of 30-day readmissions after cholecystectomy in a tertiary UK centre. Settings and Design: This study was conducted at a university hospital, and the study design involves retrospective cohort study. Materials and Methods: Information was obtained from our prospectively maintained database and hospital's computerised records. Statistical Analysis: The encounters are expressed in numbers and percentages. The hospital stay, body mass index and age are expressed in mean, standard deviation (SD), min-max and median. Microsoft Excel® was used to calculate the means, SD, min-max and median. Results: Out of the 1140 cholecystectomies performed over this time, there were 75 true readmissions and 29 revisits; thus, the actual readmission rate is 6.58%. Non-specific abdominal pain ± deranged liver function test (LFT) is the most common cause of readmissions/ revisits in (38; 36.54%) cases, followed by (18; 17.31%) wound infections and (12; 11.54%) collections/bile leaks/abscess. This cost the centre 93 scans, 30 procedures and 295 days of hospital stay. Conclusions: Non-specific abdominal pain ± deranged LFT is the most common cause of readmissions/revisits in the centre. Readmissions after a cholecystectomy are a significant encumbrance.
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Is it a myth to perform blind apical wedge resection in primary spontaneous pneumothorax surgery to improve recurrence rates? p. 279
Mustafa Vayvada, Yelda Tezel, Çağatay Tezel
DOI:10.4103/jmas.JMAS_269_20  PMID:33885029
Background: Video-assisted thoracoscopy surgery (VATS) is the first method for the surgical treatment of primary spontaneous pneumothorax (PSP). Many surgeons traditionally performed bullectomy or wedge resection (WR) in addition to mechanical or chemical pleurodesis. Our study aimed to determine whether WR was necessary without seeing bleb or bullae during the surgery. Methods: Patients with no bleb or bullae detected during surgery were included in the study. Apical pleurectomy was performed in all cases. The patients were divided into two groups as WR and non-WR. The minimum follow-up period was 24 months. Medical records of patients were evaluated retrospectively. Patients who could not be followed up were excluded from the study. Results: A total of 104 surgical treatments of PSP were performed, WR was not performed in 70 cases (67.3%). The surgical time was statistically significantly longer in the WR group than in the non-WR group. There was no statistically significant difference between the two groups in terms of drainage amount, drain removal time, length of hospital stay and bleeding requiring thoracotomy. Prolonged air leak was more common in the non-WR group than in the WR group (7.1% vs. 2.9%; P = 0.661). There was no difference in the rate of recurrence in either group. Recurrence was 2.9% (1/34) in the WR group and 2.9% (2/70) in the non-WR group. Conclusion: In VATS of PSP, blind apical WR without bleb or bullae reduced prolonged air leakage but did not contribute to lowering the rate of pneumothorax recurrence.
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Good to excellent Quality of Life in patients suffering from severe obesity post bariatric surgery - A single-center retrospective study report using BAROS Questionnaire p. 284
Manish Khaitan, Riddhish Gadani, Koshish Nandan Pokharel, Ankita Gupta
DOI:10.4103/jmas.JMAS_268_20  PMID:33885023
Context: Despite the positive outcomes reported in terms of weight loss and resolution of co-morbidities, the impact of bariatric surgery on patient-reported outcomes of quality of life (QoL) still remains scarce, particularly in the Indian population. The present study was conducted to evaluate the efficacy of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) procedures in patients with severe obesity over a period of 2 years in terms of weight loss, resolution of comorbidities, safety and changes in QoL using the Bariatric analysis and reporting outcome system (BAROS). Subjects and Methods: The data of 100 patients who underwent RYGB and LSG between March 2014 and December 2017 were analyzed. The study endpoints such as QoL, major and minor complication rates, co-morbidity resolutions and the percentage of excess weight loss (%EWL) were measured using the Moorehead-Ardelt BAROS questionnaire II. Results: At a follow-up point of 2 years, patients achieved a mean %EWL of 79.2 (±28.9) % and the mean postoperative body mass index decreased to 31.7 (±6.22) kg/m2. No major complications were reported to have occurred. Excellent global BAROS outcome was obtained in 20% of patients, very good in 47%, good in 29%, fair 2% and failure in 2% patients 24 months post-surgery. The mean BAROS score was 5.8 ± 1.73, and a 'good' to 'excellent' QoL outcome was observed in 96% of patients. Conclusion: RYGB and LSG are safe and effective bariatric procedures. These procedures provided substantial results in good to excellent health-related QoL, weight loss and medical conditions.
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Three-dimensional versus conventional two-dimensional laparoscopic colectomy for colon cancer: A 3-year follow-up study p. 289
Yi-Wen Yang, Sheng-Chieh Huang, Shih-Ching Chang, Huann-Sheng Wang, Shung-Haur Yang, Wei-Shone Chen, Yuan-Tzu Lan, Chun-Chi Lin, Hung-Hsin Lin, Jeng-Kai Jiang
DOI:10.4103/jmas.JMAS_31_21  PMID:35313437
Background: Three-dimensional (3D) laparoscopy was developed to overcome the drawbacks of two-dimensional (2D) laparoscopy, namely lack of depth perception. However, the benefit of 3D laparoscopy in colorectal surgery is inconclusive. Here, we compare the 3-year follow-up outcomes of 3D and 2D laparoscopic colectomy. Patients and Methods: A total of 91 consecutive patients who underwent either 3D or 2D laparoscopy colectomy from October 2015 to November 2017 by a single surgical team for colon cancer were enrolled. Data were collected from a prospectively constructed database, including clinico-pathological features and operative parameters. The pathological results, recurrence, survival and systemic treatment were collected from the Taiwan Cancer Database. Results: There were 47 patients in the 3D group and 44 in the 2D group. There were no significant differences in characteristics of patients, operation data, pathological results, complications, operative time, blood loss or the number of lymph node harvested between the two groups. In addition, disease-free survival and overall survival were equal between the two groups. Conclusions: This is the first long-term result of a 3D laparoscopic colectomy. In our 3-year follow-up, there was no difference in long-term outcomes between 2D and 3D laparoscopy for colorectal surgery in an experienced centre.
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Laparoscopic posterior rectopexy for complete rectal prolapse: Is it the ideal procedure for males? p. 295
Senthil Kumar Ganapathi, Rajapandian Subbiah, Sathiyamoorthy Rudramurthy, Harish Kakkilaya, Parthasarathi Ramakrishnan, Palanivelu Chinnusamy
DOI:10.4103/jmas.JMAS_323_20  PMID:35313438
Background: Rectal prolapse is more common in elderly women worldwide, but in India, it predominantly occurs in young- and middle-aged males. While ventral mesh rectopexy is proposed as the preferred procedure in females, the debate on the best procedure in men is still wide open. Methods: A retrospective review of all adult male patients operated for external rectal prolapse (ERP) between January 2005 and December 2019 was performed. Patients either underwent modified laparoscopic posterior mesh rectopexy (LPMR) or laparoscopic resection rectopexy (LRR). The outcome was analysed in terms of recurrence, post-operative constipation, sexual dysfunction and other complications. Results: A total of 118 male patients were included (LPMR: 106, LRR: 12). The mean age was 46.2 years (standard deviation [SD] 11.8, range: 21–88). The mean operating time was 108 min (SD: 24). The mean length of hospital stay was 4.8 days (SD: 1.4, range: 3–11 days). There was no anastomotic leak in the LRR group. Other complications included wound infection (n = 2), mesh infection with sigmoid colon perforation (n = 1), constipation (n = 4), sexual dysfunction (n = 2), urinary urgency (n = 3) and retention of urine (n = 4). There was no mortality in both the groups. During a mean follow-up of 5.2 years, recurrent ERP was noted in one patient and partial mucosal prolapse was seen in three patients. Conclusion: LPMR/LRR is a safe and effective treatment for ERP in men with very low recurrence rates. Randomised trials comparing modified LPMR with LVMR are needed to establish the better procedure in males.
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Risk factors for patient selection in ambulatory laparoscopic cholecystectomy: A Single-centre experience p. 302
Qiang Wu, Ning Fu, Weiwei Chen, Xueli Jin, Lei He, Chencheng Mo, Jiao Chen, Daoyun Luo, Minkun Ma, Hongqiang Yang, Jingcheng Hao
DOI:10.4103/jmas.JMAS_25_21  PMID:35313439
Backgrounds: Ambulatory laparoscopic cholecystectomy (LC) reduces healthcare cost and increases hospital bed capacity. Currently, there is no consensus on patient selection for ambulatory LC. Evaluation of risk factors for ambulatory discharge is essential. Materials and Methods: Consecutive patients who underwent LC in our centre throughout 2019 were collected. We evaluated the discharge fitness using the Post-Anaesthetic Discharge Scoring System at 8 h after the operation. The relations between pre-operative variables and dischargeable possibilities were analysed for screening risk factors. Furthermore, we performed a literature review to summarise all published information. Results: Six hundred and forty-one cases were included in this study. American Society of Anaesthesiologist (ASA) grading (odds ratio OR = 0.415, P = 0.001) and leucocytes (OR = 0.80, P < 0.001) significantly predicted the fitness of discharge. ASA contributed to lower activity (P = 0.002) and intake/output (P = 0.006) scores. Leucocytes influence the vital sign (P < 0.001) and pain or post-operative nausea and vomiting (PONV) (P < 0.001) scores. The prolonged operation could predict the inabilities of discharge with a cut-off value of 55 min by dropping vital signs (P = 0.011), activity (P < 0.001) and pain or PONV (P = 0.012) scores. Male sex (OR: 1.702, P = 0.010), body mass index (BMI) (OR: 1.087, P = 0.008), leucocytes (OR: 1.075, P = 0.017) and C-reactive protein (CRP) (OR: 1.018, P = 0.003) were predictors for prolonged operation (>55 min). Conclusions: We suggest that pre-operative ASA grading III and leucocytes are risk factors for the fitness of ambulatory discharge after LC and intraoperative time. Male, BMI and CRP predict complicated surgery, and they should be considered preoperatively.
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UNUSUAL CASES Top

Complexities in the management of a Richter's supraumbilical hernia with colocutaneous fistula in a patient with morbid obesity: A case report with a review of literature p. 308
Sarfaraz Jalil Baig, Pallawi Priya
DOI:10.4103/jmas.JMAS_99_21  PMID:35313440
Abdominal wall Richter's hernia is rare. The usual presentation is with irreducibility, obstruction and strangulation. Occasionally, enterocutaneous fistula containing small bowel has been reported. Management is frequently difficult due to emergency presentation and contamination. A 60-year-old male with a history of suture repair of umbilical hernia presented with faecal discharge from a long-standing recurrent hernia in the background of obesity and history of pulmonary embolism. There were no features of peritonitis or obstruction. After optimisation, we took the patient for a diagnostic laparoscopy with curative intent. Diagnostic laparoscopy revealed a Richter's hernia containing transverse colon. The patient was treated with resection of the involved colonic segment, anastomosis, complete excision of the fistula tract along with surrounding skin, negative pressure wound therapy and delayed skin closure. To our knowledge, this is the first report of a spontaneous umbilical Richter's hernia complicated with a colocutaneous fistula. Management was challenging due to emergency presentation, multiple comorbidities as well as faecal contamination. Minimal access approach may have helped by decreasing the contamination and surgical site infection in the postoperative period.
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Simultaneous robotic resection of pheochromocytoma and gastrointestinal stromal tumour in an adult neurofibromatosis type 1 patient: A single-docking procedure using da Vinci XI platform p. 311
Jan Grosek, Aleš Tomažič, Maja Frelih, Simon Hawlina
DOI:10.4103/jmas.jmas_171_21  PMID:35046164
The risk of tumours, including pheochromocytoma and gastrointestinal stromal tumour is higher in patients with neurofibromatosis Type 1 (NF1). The co-occurrence of these two tumours is rare, and most patients are symptomatic. In this case report we describe the case of an asymptomatic 42-year-old female patient with left adrenal mass and concurrent lesion in the jejunum, just distal to the ligament of Treitz. Both tumours were successfully simultaneously removed by totally robotic transperitoneal technique using da Vinci Robotic Surgical System Xi.
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Indocyanine green imaging to identify intralobar pulmonary sequestration for uniportal thoracoscopic resection p. 314
Kuan-Hsun Lian, Mong-Wei Lin
DOI:10.4103/jmas.jmas_142_21  PMID:35046169
Surgical excision of pulmonary sequestration is a definite treatment, but dissection of the arterial supply from systemic circulation and determination of the boundary are always challenging. We reported a case utilising pre-operative three-dimensional reconstruction and indocyanine green injection to make the procedure minimally invasive, precise and safe.
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HOW I DO IT DIFFERENTLY Top

Use of indocyanine green-aided real-time angiography in laparoscopic mesenteric cyst excision – A safer approach p. 317
Amol N Wagh, Nikhil Dhimole, Shirish R Bhagvat, Sachin S Sholapur, Samprati Doddamalappa
DOI:10.4103/jmas.JMAS_39_21  PMID:34259208
Mesenteric cysts are rare abdominal lesions in the mesentery of the intestine. Complete surgical excision is the only treatment which can be done by an open laparotomy or laparoscopic technique. Application of indocyanine green dye during the surgery helps in identification of the mesenteric vasculature, prevention and early repair of inadvertent iatrogenic vascular and bowel injury.
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TROUBLESHOOTING IN MINIMAL ACCESS SURGERY Top

Fluorescent ureterography with indocyanine green in laparoscopic colorectal surgery: A safe method to prevent intraoperative ureteric injury p. 320
VN V. R. Satish, Abhijith Acharya, Srinivasan Ramachandran, Mohan Narasimhan, Ramesh Ardhanari
DOI:10.4103/jmas.jmas_183_21  PMID:35046172
Intraoperative injuries to the ureter can occur in complicated colorectal and gynaecologic procedures in minimal access surgery. The majority of these go unrecognised at the time of the operation, which can be disastrous to the patient. The routine use of ureteric stents is controversial, with some studies showing that stents only enable detection of ureteric injury but do not prevent it. Fluorescent image-guided surgery with indocyanine green (ICG) to visualise the ureter is a relatively new technique. We report our method of visualisation of the ureter in two patients undergoing laparoscopic anterior resection and Hartmann procedure, respectively. After induction of anaesthesia, retrograde catheterisation of both ureters was performed by the urologist. 2.5 mg ICG was injected into each catheter at the start of the procedure. Both ureters were visualised very well throughout the procedure with no post-operative complications. This technique using ICG adds visual cues to make up for the loss of tactile feedback, making it a safe strategy to prevent intraoperative ureteric injury.
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LETTER TO THE EDITOR Top

Early laparoscopic cholecystectomy in acute gallbladder perforation – Single-centre experience p. 324
Hermilo Jeptef Angeles-Mar, Rodrigo Enrique Elizondo-Omaña, Santos Guzmán-López, Alejandro Quiroga-Garza
DOI:10.4103/jmas.JMAS_211_21  PMID:35046163
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04