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   Table of Contents - Current issue
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October-December 2021
Volume 17 | Issue 4
Page Nos. 423-585

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REVIEW ARTICLES  

Long-term and short-term outcomes after laparoscopic versus open surgery for advanced gastric cancer: An updated meta-analysis p. 423
Wei Zhang, Zhangkan Huang, Jianwei Zhang, Xu Che
DOI:10.4103/jmas.JMAS_219_20  
Background: The efficacy of laparoscopy for advanced gastric cancer (AGC) remains controversial. Materials and Methods: We conducted a literature search on the EMBASE, PubMed and Cochrane Library databases to identify relevant available articles published between the time of the databases' inception and July 2020. Results: A total of 14,689 patients were included in the 41 studies identified. A total of 6976 patients were in an laparoscopic approach group (LG) and 7713 patients were in an open approach group (OG). The meta-analysis showed that in randomized control trials (RCTs), LG were better than OG in terms of estimated blood loss, time to oral intake and time to first flatus while the operation time and proximal resection margin (PRM) were significantly worse in LG than in OG. In the non-RCTs, LG had shorter hospital stays, less blood loss, less intraoperative transfusion, less time to oral intake, time to first flatus, time to ambulation; less overall or serious complications; and better 3-year and 5-year overall or disease-free survival (DFS). Operation times and PRM were significantly worse for LGs. Conclusion: The safety and effectiveness of laparoscopic surgery for AGC is not inferior to that of traditional open surgery, and to a certain extent, can reduce trauma, facilitate recovery, and be validated in RCTs and non-RCTs. In the real-world cohort, laparoscopic surgery for gastric cancer achieved a better survival rate and DFS rate. However, to evaluate the efficacy of these two methods more comprehensively, high-quality randomized controlled trials and longer follow-up times are still needed.
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Quality of life after giant hiatus hernia repair: A systematic review p. 435
Akshay R Date, Yan Mei Goh, Yan Li Goh, Ilayaraja Rajendran, Ravindra S Date
DOI:10.4103/jmas.JMAS_233_20  PMID:33885030
Background: Elective surgery is the treatment of choice for symptomatic giant hiatus hernia (GHH), and quality of life (QoL) has become an important outcome measure following surgery. The aim of this study is to review the literature assessing QoL following repair of GHH. Methodology: A systematic literature search was performed by two reviewers independently to identify original studies evaluating QoL outcomes after GHH surgery. MeSH terms such as paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life were used in the initial search. Original studies in English language using validated questionnaires on humans were included. Review articles, conference abstracts and case reports and studies with duplicate data were excluded. Results: Two hundred and eight articles were identified on initial search, of which 38 studies (4404 patients) were included. Studies showed a significant heterogeneity in QoL assessment tools, surgical techniques and follow-up methods. All studies assessing both pre-operative and post-operative QoL (n = 31) reported improved QoL on follow-up after surgical repair of GHH. Improvement in QoL following GHH repair was not affected by patient age, surgical technique or the use of mesh. Recurrence of GHH after surgery may, however, adversely impact QoL. Conclusion: Surgical repair of GHH improved QoL scores in all the 38 studies. The impact of recurrence on QoL needs further assessment. The authors also recommend uniform reporting of surgical outcomes in future studies.
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Symptomatic pseudoaneurysms following laparoscopic cholecystectomy: Focus on an unusual and dangerous complication p. 450
Charalampos Lampropoulos, George Markopoulos, Stylianos Tsochatzis, Aggeliki Bellou, Theofilos Amanatidis, Dimitrios Kehagias, George Papadopoulos, Ioannis Kehagias
DOI:10.4103/jmas.JMAS_164_20  
Background: Laparoscopic cholecystectomy (LC) has been associated with an increase in the incidence of biliary and vascular injuries. Pseudoaneurysms (PAs) following LC are rare life-threatening events with limited available experience regarding diagnosis and treatment. Materials and Methods: An extensive review of literature during a 26-year period (1994–2020) using MEDLINE® database and Google Scholar® academic search engine revealed 134 patients with at least one symptomatic PA following LC. Results: Nearly 81% of patients with PAs become symptomatic during the first 8 weeks following LC. The most common symptoms were gastrointestinal bleeding (74%) and abdominal pain (61%). In 28% of cases, there was a concomitant bile duct injury or leak from the cystic duct stump, whereas in about one-third of cases, PAs presented following an uneventful LC. The most common involved arteries were the right hepatic artery (70%), the cystic artery (19%) or both of them (3%). Trans-arterial embolisation was the favoured first-line treatment with a success rate of 83%. During a median follow-up of 9 months, the mortality rate was 7%. Conclusion: Clinicians should be aware of the PA occurrence following LC. Prompt diagnosis and treatment are essential.
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ORIGINAL ARTICLES Top

Quantitative assessment of crural closure for laparoscopic anti-reflux surgeries: A novel technique to reduce post-operative dysphagia p. 458
Pranav Mandovra, Vishakha Kalikar, Roy V Patankar
DOI:10.4103/jmas.JMAS_85_20  PMID:32964875
Background: Long-term dysphagia is a known complication of laparoscopic anti-reflux surgery (LARS). Of the several factors, inadequate hiatal closure is one of the major reasons for its occurrence. The aim of this study is to develop a technique for the quantitative assessment of crural closure during LARS to reduce dysphagia. Materials and Methods: It is an analysis of prospectively collected data of 109 patients who underwent LARS at a tertiary healthcare centre in India. To identify the adequacy of hiatal closure intraoperatively, a 7 French Fogarty catheter was used, and its balloon was inflated with 1 cc air at the repaired hiatus. This inflated balloon in the repaired hiatus following cruroplasty gives an accurate quantitative assessment of the adequate closure and adequate space for food bolus to pass without causing mechanical obstruction after hiatus repair. Pre- and post-operative 12 months' DeMeester scores and lower oesophageal sphincter (LES) pressures were calculated. Results: The patients had a significant reduction in DeMeester scores postoperatively from a mean of 68.5–12.3 (P < 0.0001). None of the patients had long-term dysphagia or the need for long-term proton-pump inhibitors. The mean LES pressures on post-operative manometry showed increase to 15.1 mmHg from a mean of 6.4 mmHg, which was statistically significant (P = 0.0001). None of the patients had a recurrence of hiatus hernia. Conclusion: Quantitative assessment of adequacy for crural closure during LARS using a 7 French Fogarty catheter balloon is a novel technique which may decrease the incidence of post-operative dysphagia or intrathoracic wrap migration or recurrence of hiatus hernia.
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Impact of bariatric surgery on type 2 diabetes in morbidly obese patients and its correlation with pre-operative prediction scores p. 462
Mehul Gupta, Sandeep Aggarwal, Amit Bhambri, Vitish Singla, Rachna Chaudhary
DOI:10.4103/jmas.JMAS_19_20  PMID:32964893
Background: Bariatric surgery, besides causing significant weight reduction, leads to improvement in type 2 diabetes mellitus (T2DM). However, there is a scarcity of data on the prediction of diabetes resolution in non-Western population. Objective: To evaluate the impact of bariatric surgery on T2DM and to assess the accuracy of pre-operative scoring systems in predicting remission. Study Setting: A tertiary care academic centre, India. Methodology: We used a retrospective cohort of all diabetic patients (n = 244) who underwent bariatric surgery at our centre in the past 10 years. The cohort was followed up for diabetes remission, and pre-operative scoring systems were analysed against the observed results. Results: Of 244 patients, we were able to contact 156 patients. The median period of follow-up was 38 months. The mean body mass index (BMI) of the study group decreased from 45.4 to 33.4 kg/m2 (%excess BMI loss = 61.2%). The number of patients dependent on oral anti-diabetic pharmacotherapy and on insulin decreased from 133 (85.3%) to 40 (25.6%) and from 31 (19.9%) to 7 (4.5%), respectively. Remission was analysed for 96 patients, who submitted complete biochemical investigations. The median follow-up period for this sub-cohort was 36 months. 38 (39.6%) patients were in complete remission, 15 (15.6%) patients in partial remission and 34 (38.5%) patients showed an improved glycaemic control. The three pre-operative scores, Advanced-DiaRem, DiaRem and ABCD, showed predictive accuracies of 81.1%, 75.6% and 77.8%, respectively. Conclusions: Besides leading to excess BMI loss of 61.2%, bariatric surgery also resulted in diabetes remission in 55.2% of the patients. Amongst various pre-operative scores, Advanced-DiaRem has the highest predictive accuracy for T2DM remission.
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Video-assisted thoracoscopic surgery versus open thoracotomy in the management of empyema: A comparative study p. 470
Rohit Jindal, Amandeep Singh Nar, Atul Mishra, Ravinder Pal Singh, Aayushi Aggarwal, Namita Bansal
DOI:10.4103/jmas.JMAS_249_19  PMID:33047681
Introduction: With a rise in the incidence of thoracic empyema, surgical interventions also have evolved from the traditional open decortication to the current minimally invasive video-assisted thoracoscopic surgery (VATS). In this study, we determine the feasibility of VATS and also put the superiority of VATS over open thoracotomy (OT) to test. Subjects and Methods: Prospective single-centre comparative analysis of clinical outcome in 60 patients undergoing either VATS or OT for thoracic empyema was done between 1st September, 2014, and 1st November, 2018. Furthermore, another group of patients, who were converted intraoperatively from VATS to OT, was studied descriptively. Results: Nearly 75% of the patients were male with a mean age of 45.16 years. Every second patient had associated tuberculosis (TB), attributed to the endemicity of TB in India. When compared with OT, VATS had a shorter duration of surgery (268.15 vs. 178.33 min), chest tube drainage (11.70 vs. 6.13 days), post-operative hospital stay (13.56 vs. 7.42 days) and time to return to work (26.96 vs. 12.57 days). Post-operative pain and analgesic requirement were also significantly reduced in the VATS group (P < 0.0001). Conversion rate observed was 14.2%, the most common reason being the presence of dense adhesions. Conclusion: We conclude that VATS, a minimally invasive procedure with its substantial advantages over thoracotomy and better functional outcome, should be preferred whenever feasible to do so. Also if needed, conversion of VATS to the conventional open procedure, rather than a failure, is a wise surgical judgement.
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Sentinel node mapping using indocyanine green and near-infrared fluorescence imaging technology for endometrial cancer: A prospective study using a surgical algorithm in Indian patients p. 479
SP Somashekhar, R Arvind, C Rohit Kumar, Vijay Ahuja, KR Ashwin
DOI:10.4103/jmas.JMAS_154_20  PMID:33605932
Background: Indocyanine green (ICG) fluorescence with high-definition, three-dimensional imaging systems is emerging as the latest strategy to reduce trauma and improve surgical outcomes during oncosurgery. Materials and Methods: This is a prospective study involving 100 patients with carcinoma endometrium who underwent robotic-assisted Type 1 pan-hysterectomy, with ICG-directed sentinel lymph node (SLN) biopsy from November 2017 to December 2019. The aim was to assess the feasibility and diagnostic accuracy of SLN algorithm and to evaluate the location and distribution of SLN in pelvic, para-aortic and unusual areas and the role of frozen section. Results: The overall SLN detection rate was 98%. Bilateral detection was possible in 92% of the cases. Right side was detected in 98% of the cases and left side was visualised in 92% of the cases. Complete node dissection was done where SLN mapping failed. The most common location for SLN in our series was obturator on the right hemipelvis and internal iliac on the left hemipelvis. SLN in the para-aortic area was detected in 14% of cases. In six cases, SLN was found in atypical locations, that is pre-sacral area. Eight patients had SLN positivity for metastasis and underwent complete retroperitoneal lymphadenectomy. Comparison of final histopathological report with frozen section reports showed no false negatives. Conclusions: SLN mapping holds a great promise as a modern staging strategy for endometrial cancer. In our experience, cervical injection was an optimal method of mapping the pelvis. ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer. The ICG fluorescence imaging system is simple and safe and may become a standard in oncosurgery in view of its staging and anatomical imaging capabilities. This approach can reduce the morbidity, operative times and costs associated with complete lymphadenectomy while maintaining prognostic and predictive information.
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A novel two-port single-site laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis p. 486
Chaoxiang Lu, Zhongwen Li, Weike Xie, Qi Wang, Yongkang Pan
DOI:10.4103/jmas.JMAS_169_20  PMID:33885012
Objective: The objective of the study is to explore a less invasive laparoscopic pyloromyotomy for treating infantile hypertrophic pyloric stenosis. Patients and Methods: A series of 154 cases from January 2014 to January 2020 were retrospectively analysed. Seventy patients were treated with the method of transumbilical single-site laparoscopic pyloromyotomy (SSLP), and 84 patients were treated with two-site laparoscopic pyloromyotomy. There was no difference in the body weight, sex ratio or age between the two groups. The operation time, blood loss, post-operative feeding time and complications between the two groups were compared. Results: The novel single-site method had better cosmetic effect than the two-site approach. There was no difference in the operation time, blood loss, post-operative feeding time or complications between the two groups. Conclusion: The novel SSLP method requires only two incisions through the umbilicus to complete the procedure, with barely visible scars and similar surgical complications to that of the two-site approach; thus, the novel method is worth promoting.
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Transanal endoscopic microsurgery under spinal anaesthesia p. 490
Yael Berger, Rachel Gingold-Belfer, Muhammad Khatib, Mostafa Yassin, Wisam Khoury, Hemda Schmilovitz-Weiss, Nidal Issa
DOI:10.4103/jmas.JMAS_144_20  
Background: Transanal endoscopic microsurgery (TEM) is considered the procedure of choice for rectal adenomas non-amendable for endoscopic excision and for early rectal cancer. TEM may gain more importance in patients who are considered unfit for major surgery. The option of spinal anaesthesia may offer many advantages for patients undergoing TEM while maintaining the principles of complete tumour excision. The aim of this study is to report the outcome of patients undergoing TEM under spinal anaesthesia. Methods: Demographic and clinical data pertaining patients undergoing TEM under spinal anaesthesia between 2004 and 2015 were retrospectively collected. Results: A total of 158 TEM procedures were recorded in the study period. Twenty-three patients (15%) underwent the procedure under spinal anaesthesia and were included in the study; 13 of them were male and ten were female. The mean age of the patients was 69.1 ± 10.6 years. Seventeen (74%) rectal lesions were adenomas, two (9%) were adenocarcinoma and four (17%) had involved margins after polypectomy. The mean tumour size was 2.1 cm (range, 0.5–3). Distance from the anal verge was 7.7 ± 2.2 cm. Seventeen (74%) lesions were in the posterior wall. The operative time was 73 min (range, 46–108) No adverse anaesthesia-related events were recorded, and the post-operative pain was reduced. The median time of hospitalisation was 2 days (range, 1–4). No major complications were noted, and the minor complications were treated conservatively. The surgical margins were free of tumour in all cases. Conclusion: TEM under spinal anaesthesia had short duration of surgery, no increase in operative and post-operative complications or hospital length of stay. Avoiding the use of general anaesthesia, in such challenging procedure, may open new opportunities for patients determined to be unfit for general anaesthesia.
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Advanced training in laparoscopic gastrointestinal surgical procedures using Genelyn®-embalmed human cadavers: A novel model p. 495
S. S. S. N. Rajasekhar, V Dinesh Kumar, V Raveendranath, Raja Kalayarasan, Senthil Gnanasekaran, Biju Pottakkat, M Sivakumar
DOI:10.4103/jmas.JMAS_152_20  PMID:33605926
Background: Human cadaver is ideal for learning and acquiring new surgical skills. While cadavers preserved using Thiel's embalming method are commonly used for training in laparoscopic surgery, it is a cumbersome technique. We report our experience of using Genelyn®-embalmed cadavers for training in advanced laparoscopic gastrointestinal procedures. Materials and Methods: A cross-sectional satisfaction survey corresponding to level 1 of the Kirkpatrick model for training evaluation was performed among 19 participants of advanced laparoscopy surgical skills training workshop, in December 2019, using Genelyn®-embalmed cadavers. Visual, haptic and tactile characteristics of the organs and tissues were assessed along with overall satisfaction of the workshop using Likert scale. Results: Five Genelyn®-embalmed cadavers were used for the workshop. All the 19 participants perceived that the cadavers were odourless and allowed adequate insufflation for laparoscopic procedures. Most of the participants(n=16, 84%) agreed that the appearance and tactile fidelity of the solid organs, luminal structures and tissues in Genelyn®-embalmed cadavers were similar to that of a live patient. There was a strong agreement among participants that the workshop will help improve the laparoscopic skills(median Likert score–4). Conclusion: The participants of the surgical skill training workshop felt that the Genelyn®-embalmed cadavers were ideal for use in practicing advanced laparoscopic procedures.
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Difficult biliary stones in the elderly: Endoscopic retrograde cholangiography – A single surgical tertiary centre experience with follow-up p. 502
Pavlos Antypas, Fabrizio Cereatti, Fausto Fiocca, Annalisa Cappello, Chiara Eberspacher, Gianfranco Fanello, Domenico Mascagni, Gianfranco Donatelli
DOI:10.4103/jmas.JMAS_162_20  PMID:33605927
Background: Pancreaticobiliary diseases and choledocholithiasis are common in elderly patients. Endoscopic treatment of biliary stones represents a well-established mini-invasive technique. However, limited data are available regarding the treatment of 'difficult' biliary stones, especially in the elderly population. The aim of our study is to evaluate the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients ≥85 years of age with complex biliary stones. Materials and Methods: From January 2015 to January 2017, data from ERCP procedures performed for complex biliary stones were retrospectively collected. The patients were divided into two groups based on their age: Group A – aged 85 years or older (n = 110) and Group B – aged 65 years or younger (n = 62). Demographic data, success, complications and recurrence rates for both groups were reported. Results: Chronic comorbidities (86.3% vs. 24.2%; P < 0.001) and use of antithrombotic drugs (48.2% vs. 19.3%; P < 0.001) were more frequent in the elderly. The technical success rate (95.4% vs. 96.7%; P > 0.6) and complication rate (8.2% vs. 13%; P > 0.2) were not statistically different among the two groups. Periampullary diverticula (PAD) were observed more frequently in Group A (38.1% vs. 17.7%; P < 0.006). More patients from Group B underwent cholecystectomy during the same admission (8.2% vs. 42.3%; P < 0.001). The recurrence rate was not different among the groups (7.6% vs. 5%; P > 0.5). PAD was identified as the risk factor for recurrence (P < 0.02). Conclusion: ERCP in the elderly was found to be a safe procedure, carrying a high degree of success for the treatment of difficult biliary stones.
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Changing paradigms in endoscopic thyroid surgery: A comparison between scarless-in-the-neck axillo-breast approach and totally scarless transoral approach p. 509
Gyan Chand, Nitish Gupta, Goonj Johri, Anjali Mishra, Saroj Kant Mishra
DOI:10.4103/jmas.JMAS_11_20  
Background: To avoid cervical scar in thyroid surgery, various approaches have been proposed. The commonly used approach is combined axillo-breast approach (ABA). However, trans-orovestibular approach (TOVA) is getting popular. The aim of this study is to compare surgical outcomes of patients who underwent endoscopic hemithyroidectomy (EHT) by either ABA or TOVA. Patients and Methods: This was a retrospective analysis of clinical data of patients who underwent EHT from January 2013 to December 2018. Patients were divided into two groups: Group A – through ABA and Group B – through TOVA. Results: A total of eighty patients underwent EHT in Group A and 25 in Group B. In both groups, most patients were female (male: female = 1:4.7 in Group A and 1:7.33 in Group B, P = 0.515). In both groups, there was no difference in age (the mean age was 33.44 ± 10.44 years in Group A and 33.04 ± 14.01 years in Group B, P = 0.391) and in size of the nodule (Group A – 3.91 ± 1.17 cm and Group B – 3.6 ± 1.39 cm, P = 0.228). The operating time was significantly less in Group B (Group A – 152.25 ± 30.19 mins and Group B – 126.80 ± 22.94 mins, P ≤ 0.01). The post-operative hospital stay was significantly less in Group B (mean 3.17 ± 0.97 days in Group A and 2.24 ± 0.60 days in Group B, P ≤ 0.01). Conclusion: TOVA is associated with shorter operating time and hospital stay with comparable outcomes. Cosmetic outcome is excellent in TOVA, however requires further subjective evaluation.
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Endoscopic ultrasound-guided drainage of intra-abdominal diverticular abscess. A case series p. 513
Gianfranco Donatelli, Fabrizio Cereatti, Maurizio Fazi, Vincenzo Ceci, Parag Dhumane
DOI:10.4103/jmas.JMAS_184_20  
Aim: Diverticular disease is widespread worldwide. Mainstay approach is non-operative treatment with bowel rest and broad-spectrum intravenous antibiotics. However, extra-colic abscess larger than 4 cm may require percutaneous trans-abdominal drainage. We report a single centre case series of patients underwent to trans-luminal endoscopic ultrasound (EUS)-guided drainage of pelvic abscess in diverticular disease with temporary placement of lumen apposing metal stent (LAMS). Methods: All patients referred to our tertiary centre from January 2019 to July 2020 were enrolled in a prospective data base that was retrospectively analysed. Procedural steps were as follows: pre-operative computed tomography scan, broad-spectrum antibiotic therapy, EUS-guided deployment of LAMS for 15 days, LAMS removal and deployment of pigtail stent in case of pseudo-cavity persistence. Results: Ten patients (6F) with an average of 59.6 years were enrolled with deployment of 10 LAMS. One patient was excluded after EUS evaluation and 1 patient had 2 LAMS for 2 separate abscesses. Technical and clinical success was achieved in 88.8% (8/9). Conclusions: Management of diverticulitis has shifted from primary surgical intervention towards a non-operative approach of bowel rest and broad-spectrum intravenous antibiotics in conjunction with interventional procedures to drain abscesses whenever necessary. EUS-guided drainage with LAMS for the management of diverticular abscesses seems an efficient treatment modality for encapsulated abscesses more than 4 cm in size and close to colonic wall. In expert centres, it may avoid radiologic intervention and/or surgery in a relevant percentage of cases.
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Comparison of efficacy and safety of the enhanced-view totally extraperitoneal (eTEP) and transabdominal (TARM) minimal access techniques for retromuscular placement of prosthesis in the treatment of irreducible midline ventral hernia p. 519
Sameer Ashok Rege, Jayati Jagdish Churiwala, Abdeali Saif A. Kaderi, Ketan Fakira Kshirsagar, Abhay N Dalvi
DOI:10.4103/jmas.JMAS_145_20  PMID:33885011
Background: Retromuscular plane for mesh placement is preferred for ventral hernia repair. With the evolution of minimal access surgeries, newer techniques to deploy a mesh in the sublay plane have evolved. We compared two such minimally invasive approaches for repair of irreducible ventral midline hernia with respect to the efficacy and safety of the procedures. Patients and Methods: This is a retrospective study of a prospectively maintained database of 73 patients operated with retromuscular placement of mesh for irreducible ventral midline hernia by enhanced-view totally extraperitoneal (eTEP) or transabdominal retromuscular (TARM) repair. We recorded and compared the intraoperative and post-operative complications, post-operative pain score, recovery, recurrence, subjective technical ease of procedure and patient satisfaction after 3 months and 12 months of the surgery. Results and Conclusion: Thirty-eight patients were operated by eTEP technique and the subsequent 35 were operated by TARM repair. There was no significant difference in the outcome of surgery and complications by the two techniques. However, there was a significant subjective technical ease in the TARM group due to ergonomic triangulated port placement and adhesiolysis and reduction of hernia contents under vision. The number of ports used and post-operative pain were, however, higher in the TARM group as compared to that of the eTEP group. Nearly 96% of the patients belonging to both groups were satisfied with their surgery after a year on telephonic follow-up. However, further studies and follow-up of patients would be required to establish the advantage of one technique over the other.
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Minimally invasive surgery for adult oesophageal duplication cysts: Clinical profile and outcomes of treatment from a tertiary care centre and a review of literature p. 525
Suraj Surendran, Ashish Sam Samuel, Myla Yacob, Vijay Abraham, Birla Roy Gnanamuthu, Inian Samarasam
DOI:10.4103/jmas.JMAS_137_20  
Background: Oesophageal duplication cysts (ODC) are rare in adults. Complete surgical excision is the ideal treatment. Conventionally, it is performed through a thoracotomy. We aimed to study the feasibility and safety of minimally invasive surgery (MIS) in the management of ODC and briefly reviewed the available literature. Materials and Methods: A retrospective study of all adult patients with ODC diagnosed and treated at our tertiary care centre, from 2015 to 2019, was done. All patients were operated on by MIS. Their demographic, clinicopathological, radiological and surgical details and outcomes were analysed. Results: A total of six patients (four females and two males) were diagnosed to have ODC by contrast-enhanced computed tomography. The mean age was 38 ± 4.4 years. The most common presenting complaint was chest pain (50%). Upper gastrointestinal endoscopy was normal in four patients. Endoscopic ultrasound was performed in five patients. In four patients, the cyst was located in the distal third of the oesophagus. The mean size of the cysts was 5.7 ± 2.02 cm. All the patients were operated upon by video-assisted thoracoscopic surgery (VATS). There was no conversion to open surgery. The resection was complete in all but one patient. The mean duration of surgery was 143.3 ± 35 min, and the average blood loss was 58.33 ± 20.4 mL. One patient had an oesophageal staple line leak on the 9th post-operative day. There was no mortality. The median duration of hospital stay was 7.5 days (range: 3–25 days). Conclusion: MIS is feasible and safe in the management of adult ODC.
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Thoracoscopic bilateral dorsal sympathectomy for primary palmo-axillary hyperhidrosis short- and mid-term results p. 532
Harsh Vardhan Puri, Belal Bin Asaf, Sukhram Bishnoi, Mohan Venkatesh Pulle, Shikha Sharma, Arvind Kumar
DOI:10.4103/jmas.JMAS_174_20  PMID:33885020
Background: Thoracoscopic bilateral dorsal sympathectomy is the standard of care for primary palmo-axillary hyperhidrosis. This study aims at studying the surgical outcomes with special emphasis on the incidence of compensatory hyperhidrosis (CH) after thoracoscopic dorsal sympathectomy. Post-procedural patient satisfaction as well as quality of life was measured and analysed. Materials and Methods: This is a retrospective analysis of sixty thoracoscopic dorsal sympathectomy surgeries in thirty patients in a tertiary level thoracic surgery centre over 2 years. Various peri-operative variables were recorded and assessed. Incidence of CH was noted and analysed in relation to patient satisfaction and record was made of quality of life at the time of discharge, at 3 months and 1-year follow-up following surgery. Results: We performed sixty video-assisted thoracoscopic sympathectomies in 30 patients. The mean operative time was 44.93 ± 10 min. The mean hospital stay was 1 day. There were no immediate post-procedural complications. All the patients had complete resolution of palmar and axillary hyperhidrosis. Fifty per cent of our patients (15/30) had some degree of CH after surgery. Quality-of-life measurement showed very good satisfaction by 100% at discharge, by 93.3% at 3 months and at 1 year. Those 6.66% of patients were partially satisfied/not satisfied because of the presence of moderate-to-severe CH. Conclusion: A significant percentage of the patients with primary palmo-axillary hyperhidrosis will be very satisfied with the procedure at 1 year after surgery despite 50% of them developing CH. Detailed counselling regarding CH in the pre-operative period would minimise the dissatisfaction rate after surgery.
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Measurement of hiatal surface area and other hiatus oesophageal diameters at computed tomography imaging in patients with gastroesophageal reflux disease and its relationship with hiatal hernia p. 537
Emrah Karatay, Mehmet Ali Gok, Mirkhalig Javadov
DOI:10.4103/jmas.JMAS_175_20  PMID:34259213
Background: The oesophageal hiatus is a long and oblique opening in the diaphragm where the thoracic section of the oesophagus passes into the abdomen. Enlarged hiatal surface and insufficiency are considered to be associated with gastroesophageal reflux disease (GERD) and hiatal hernia (HH). In this study, we aimed to retrospectively evaluate the relationship and the presence of GERD with HH by performing hiatal surface area (HSA) and other hiatal measurements at the thorax and abdominal computed tomography (CT) images in cases without any intra-abdominal or oesophageal surgery history. Patients and Methods: A total of 192 patients of GERD+ and 173 cases with GERD− as a control group were included in the study. In CT examinations of 365 patients included in the study, measurements and comments were made by an experienced radiologist in abdominal radiology. In CT scans, the following were evaluated for each case; HSA, hiatus anterior–posterior (A-P) diameter, hiatus transverse diameter, and HH types. The HSA measurement was made with the freehand region of interest in the picture archiving and communication system. Results: A total of 365 cases were included in this study; there was a significant difference between the median HSA, A-P diameter, and transverse diameter measurements between GERD− and GERD+ groups (P < 0.001). A statistically significant difference was found between the presence of GERD and HH types (P < 0.001). Conclusions: CT imaging helps investigate the presence of HH at GERD+ patients. In addition, pre-operative valuable data can be obtained from the detection of HH types and HSA measurements in cases with HH.
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Impact of COVID-19 pandemic on bariatric surgery in India: An obesity and metabolic surgery society of India survey of 1307 patients p. 542
Aparna Govil Bhasker, Manish Khaitan, Vivek Bindal, Amardeep Kumar, Anirudh Rajkumar, Anshuman Kaushal, Arun Prasad, Chirag Parikh, Daksh Sethi, Deep Goel, Deepak Thampi Hareendran, Digvijay Bedi, Gurvinder Singh Jammu, Jayanth Leo, Kuldeepak Kular, Mahendra Narwaria, Mahesh Chikkachanappa, Manish Motwani, Manoj Bharucha, Mohamed Ismail, Nandkishore Dukkipati, Neha Shah, Om Tantia, Parag Patel, R Padmakumar, Rahul Singh, Raj Palaniappan, Rajesh Shrivastava, Ram Raksha Pal Rajput, Ramen Goel, Randeep Wadhawan, Rohit Garg, Sandeep Aggarwal, Sanjay Patolia, Sarfaraz J Baig, Shashank Shah, HV Shivaram, Shrihari Dhorepatil, Sukhvinder Singh Saggu, Surendra Ugale, T Perungo, Vandana Soni
DOI:10.4103/jmas.JMAS_2_21  
Background: Although safe practice guidelines were issued by the Obesity and Metabolic Surgery Society of India (OSSI) in the end of May 2020, surgeons have been in a dilemma about risk of subjecting patients to hospitalisation and bariatric surgery. This survey was conducted with the objective to evaluate the risk of coronavirus disease-19 (COVID-19) infection in peri- and post-operative period after bariatric and metabolic surgery (BMS). Methods: A survey with OSSI members was conducted from 20 July 2020 to 31 August 2020 in accordance with EQUATOR guidelines. Google Form was circulated to all surgeon members through E-mail and WhatsAppTM. In the second phase, clinical details were captured from surgeons who reported positive cases. Results: One thousand three hundred and seven BMS were reported from 1 January 2020 to 15 July 2020. Seventy-eight per cent were performed prior to 31 March 2020 and 276 were performed after 1 April 2020. Of these, 13 (0.99%) patients were reported positive for COVID-19 in the post-operative period. All suffered from a mild disease and there was no mortality. Eighty-seven positive cases were reported from patients who underwent BMS prior to 31 December 2019. Of these, 82.7% of patients had mild disease, 13.7% of patients had moderate symptoms and four patients succumbed to COVID-19. Conclusion: BMS may be considered as a safe treatment option for patients suffering from clinically severe obesity during the COVID-19 pandemic. Due care must be taken to protect patients and healthcare workers and all procedures must be conducted in line with the safe practice guidelines.
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UNUSUAL CASES Top

Non-Hodgkin's lymphoma of the appendix and distal ileum. A rare case report p. 548
Aparna Govil Bhasker, Jay D Kotecha, Rahul Pandey, Sachin Wani
DOI:10.4103/jmas.JMAS_3_21  PMID:34259206
Primary gastrointestinal (GI) tract lymphomas constitute 1%–4% of all GI malignancies. Primary lymphomas of appendix are even more rare and are seen in 0.015% of all appendicectomy specimens. Here, we report a rare case of non-Hodgkin's lymphoma tumours in the appendix and distal ileum in a non-immune compromised young male patient who presented with intermittent intussusception and pain in the right iliac fossa. A laparoscopic right hemicolectomy was performed and the patient recovered uneventfully. Adjuvant chemotherapy (CHOP) in the form of CHOP regimen has been further advised.
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Gastric glomus tumour: A case report p. 551
Mridul Tantia, Pravin R Suryawanshi, Akshi Gupta, Praveen Rachakatla
DOI:10.4103/jmas.JMAS_299_20  
Glomus tumours (GTs) are rare, mesenchymal neoplasms arising from the glomus body. Atypical sites, like the stomach, have been reported with extreme rarity since the usual location lies under the nail beds. We report a rare case of gastric GT in a 28-year-old female presenting with upper abdominal pain, intermittent haematemesis and melena. Contrast-enhanced computed tomography indicated a well-defined, heterogeneously enhancing lesion in the antral region of the stomach and a possibility of gastrointestinal (GI) stromal tumour (GIST). Upper GI endoscopy showed a wide-based lesion in the sub-mucosal plane with ulcerated mucosa. Laparoscopic excision of the tumour with primary closure of the defect was performed, with an uneventful post-operative course. Histopathological and immunohistochemical findings confirmed a gastric GT. Follow-up clinical and endoscopic examinations were normal. Gastric GTs should be a rare differential in patients with suspected GIST and upper GI bleed.
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Minimally invasive approach for retrieval of retropharyngeal foreign body p. 554
K Devaraja, Suresh Pillai, Kailesh Pujary
DOI:10.4103/jmas.JMAS_243_20  
Ingested fish bone at times can migrate extraluminally into the surrounding soft tissue, leading to complications. Conventionally, these migrated fish bones are retrieved by open procedures, which could add to the morbidity. We successfully retrieved one such foreign body by a minimally invasive transcervical approach in a 64-year-old female patient. The method offered an easy identification of the foreign body with minimal soft-tissue dissection, which ultimately aided in the early post-operative recovery. This is the first report of a minimally invasive approach to explore the retropharyngeal space, and we propose the technique even for sampling retropharyngeal lymph node.
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Thoracoscopic excision of double-pulmonary sequestration in left haemithorax, without anomalous blood supply (supply from pulmonary artery) in a neonate: First case p. 556
Sunita Ojha, Prabhar Srivastava, Anil Poonia, Rajiv Bansal
DOI:10.4103/jmas.JMAS_218_20  
Pulmonary sequestration (PS) is a rare anomaly. PS is a mass of abnormal pulmonary tissue that does not communicate with the tracheobronchial tree and is supplied by an anomalous systemic artery. Although aberrant systemic arterial supply is considered the key element to diagnose PS, rarely it can have arterial supply from the pulmonary artery as a spectrum of sequestration. Here, we present an unusual case of double (upper and lower) extralobar sequestration, present unilaterally (left haemithorax) in a neonate, without anomalous blood supply (supply from the left pulmonary artery and drainage into the superior and inferior pulmonary veins), not reported in literature earlier, to the best of our knowledge. In the present case, a child presented with respiratory discomfort at birth, requiring surgery due to inability to wean off respiratory support. It is important to be aware of this variant of sequestration spectrum. In a 18 days old child, both pulmonary sequestrations were resected thoracoscopically, making it a rare case, not described earlier in literature.
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A case of unusual evisceration through laparoscopic port site p. 559
Mathews James, G Senthil, R Kalayarasan, Biju Pottakkat
DOI:10.4103/jmas.JMAS_221_20  
Drain site eviscerations have been reported as a rare complication following abdominal surgery. An 82-year-old women was diagnosed with carcinoma stomach and underwent laparoscopic subtotal gastrectomy. A few hours following removal of the duodenal stump drain, she developed small bowel evisceration through the drain site. It was successfully managed with immediate bedside release of fascial constriction followed by definitive repair later. Although herniations and eviscerations via larger drain sites have been reported, eviscerations from small laparoscopic port sites used for drains are rare. Here, we report the first case of small bowel evisceration with strangulation through a 5-mm port site.
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Ultrasound-guided thoracal paravertebral block for awake thoracoscopic lobectomy in a high-risk patient: The first reported case p. 562
Volkan Ozen, Onur Derdiyok, Serap Karacalar
DOI:10.4103/jmas.JMAS_106_21  
One-lung ventilation provided by double-lumen tube intubation under general anaesthesia has conventionally been considered necessary for thoracoscopic major pulmonary resections. Recently, regional anaesthesia techniques have been used to avoid complications of tracheal intubation and general anaesthesia. Although paravertebral block (PVB) comes to the fore as a safe and useful regional anaesthesia technique for intra-operative and post-operative analgesia for a wide variety of surgeries involving the thoracic and lumbar regions, it is sometimes used for anaesthesia. Here, we aimed to demonstrate that biportal video-assisted thoracoscopic surgery can be performed in a right upper lobectomy while maintaining spontaneous ventilation in a 55-year-old, awake patient who was not intubated under ultrasound-guided PVB.
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HOW I DO IT Top

Robotic infrahepatic vena cava clamping and Pringle manoeuvre for major hepatectomy: A safe and bloodless procedure – First technical report p. 566
Francesco Marchegiani, Antonio Pesce, Isacco Damoli, Cristiano Huscher
DOI:10.4103/jmas.JMAS_275_20  PMID:34259205
Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks.
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HOW I DO IT DIFFERENTLY Top

Laparoscopic radical hysterectomy with enclosed colpotomy without the use of uterine manipulator for early-stage cervical cancer p. 570
Bo Ding, Xiaoming Guan, Kristina Duan, Yang Shen
DOI:10.4103/jmas.JMAS_146_20  
Background: We report the application of transuterine suspension sutures (TUSSs) for manipulation and vaginal closure before colpotomy in laparoscopic radical hysterectomy for early-stage cervical cancer. Methodology: Eight patients with clinical stage IB1 cervical squamous cell cancer were treated with laparoscopic radical hysterectomy between October 2019 and May 2020. The procedure was performed without a traditional uterine manipulator, and the vaginal cuff was closed with a stapler before colpotomy to prevent tumour spillage. Results: All patients successfully underwent the surgery, with a median hospitalisation of 8 days (range 6–14). All drains and urethral catheters were removed after a median of 7 days (range 5–11) and 16 days (range 12–21), respectively. A median of 26 (range 20–32) pelvic lymph nodes were resected and no lymph-related complications were encountered post-operatively. With an enclosed colpotomy, no visible tumour tissues were exposed to the pelvic cavity, and all vaginal stumps healed well without complications. All pathological examinations of the vaginal margin were negative, and there were no residual lesions. At a median follow-up of 6 months, all patients were alive with no recurrence of disease. Conclusion: We found that laparoscopic radical hysterectomy with TUSS and vaginal closure before colpotomy is a useful and effective procedure to prevent tumour spillage for the treatment of cervical cancer.
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“Misra's appendicular hitch” stich – Innovative technique for simplifying endo-suturing during laparoscopic appendectomy p. 573
Krishna Asuri, Mayank Jain
DOI:10.4103/jmas.JMAS_248_20  
Laparoscopic suture transfixation and free tie ligation are the most commonly used cost-effective technique of managing the base of the appendix during laparoscopic appendectomy in low resource settings such as India. This becomes technically cumbersome especially in the presence of the long friable appendix and for novice surgeons. We hereby describe an innovative technique of suspending the appendix using a transfacial suture to ease the placement of suture at the base of the appendix during laparoscopic appendectomy.
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Laparoscopic real-time vessel navigation using indocyanine green fluorescence during laparoscopy-assisted gastric tube reconstruction: First experience p. 576
Yuma Ebihara, Toshiaki Shichinohe, Yo Kurashima, Soichi Murakami, Satoshi Hirano
DOI:10.4103/jmas.JMAS_210_20  
A considerable percentage of morbidity and mortality after oesophagectomy is due to leakage of oesophagogastrostomy, which is mainly caused by ischaemia of the gastric tube. Therefore, we performed laparoscopic real-time vessel navigation (LRTVN) using indocyanine green fluorescence (ICG) during laparoscopy-assisted gastric tube reconstruction (LAGR) to evaluate gastric tube blood flow and avoid vascular injury. This study included five oesophageal cancer patients who underwent video-assisted thoracoscopic oesophagectomy and LAGR. We confirmed the presence of the left gastroepiploic artery (LGEA) in all cases, and no findings such as post-operative gastric tube ischaemia were observed. In all cases, no vascular injury was observed, and the vascularization of LGEA was confirmed. This report is the first to consider the usefulness of LRTVN using ICG during LAGR. LRTVN using ICG during LAGR was considered to be useful for evaluating gastric tube blood flow and avoiding vascular injury around the splenic hiatus.
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Trocar insertion in enhanced-view totally extra-peritoneal (eTEP) repair of inguinal hernias Highly accessed article p. 580
Rahul Mahadar, Eham Arora
DOI:10.4103/jmas.JMAS_312_20  
Background: The enhanced view totally extra-peritoneal (eTEP) repair is a useful modification of the classic TEP operation which offers a more panoramic view of the operative field with greater flexibility in port positioning. It can offer greater ease of surgery in large, irreducible or bilateral inguinal hernias due to its improved ergonomics. Misunderstanding the myo-fascial anatomy, incorrect positioning or sequence of trocar insertion can lead to inadvertent peritoneal injury with pneumoperitoneum, impeding the operating surgeon. Methods: We describe our method for the surface marking of the semilunar and arcuate lines which guides the site of initial optic access. After blunt/balloon dissection of the pelvic extra-peritoneal space, the lateral trocar is inserted first to clear the peritoneum off the posterior aspect of arcuate line, allowing us to divide it near its medial attachment. The second working trocar is inserted at the umbilicus after visually confirming the extent of dissection. Additional trocars are inserted depending on bilaterality or size of the hernia. Results: We have operated 124 cases of bilateral inguinal hernia between April 2017 and February 2020, where we suffered peritoneal injury in only four cases, without leading to the conversion of the procedure. The widely dissected space with the division of the arcuate line further increased the ease of laying down a large prosthetic mesh. Conclusion: The exact sequence of trocar insertion and their positioning described by us improves ergonomics and ensures a safe division of the arcuate line with minimal risk of damage to underlying peritoneum.
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TROUBLESHOOTING IN MINIMAL ACCESS SURGERY Top

Iatrogenic bladder perforation post laparoscopic totally extraperitoneal inguinal hernia repair: Troubleshooting with laparoscopic approach p. 584
Rafique Umer Harvitkar, Abhijit Joshi
DOI:10.4103/jmas.JMAS_43_21  
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04