Pediatric Idiopathic Chylopericardium: A Case Managed with Thoracoscopic Window Pericardiotomy.

Idiopathic chylopericardium (CP) in the pediatric population is a rare entity with very few reported cases and is characterized by the accumulation of chyle in the pericardial cavity. There are no guidelines for the management of this rare entity. The present study reports a case of idiopathic CP in an infant and our experience of managing it by pericardial window creation using VATS and a multidisciplinary approach providing the optimum care for the child.

Personal financial literacy among Indian postgraduate residents.

Background Postgraduate residents' ability to understand and effectively manage their finances is variable. We conducted this study to assess the awareness of personal financial literacy among Indian residents. Methods We circulated a web-based cross-sectional Google Forms multiple-choice questionnaire having questions in three categories including financial awareness, current financial status and plans among 400 Indian residents. Results A total of 215 Indian residents (53.75%) responded to the survey (men 80.9%, unmarried 74.4% and pursuing broad specialties 83.3%). The majority were unaware of stocks, special student/doctor loans, tax planning, life insurance, professional indemnity and tax/financial planning. The majority opined that personal finance and investing should be taught at medical school/residency. A financial pyramid based on the hierarchy of needs is proposed. Conclusion Lack of financial literacy and planning was seen among the majority of Indian residents. Our study highlights this gap in the medical curriculum and the need for formal structured financial education during training.

Laparoscopic-Assisted Modified Posterior Sagittal Anorectoplasty for Rectobulbar Urethral Fistula of Anorectal Malformation: A Prospective Study.

Introduction: Laparoscopic anorectoplasty (LAARP) is useful for the management of rectoprostatic urethral fistula (RPUF), due to easier rectal mobilization, avoidance of posterior sagittal muscular incision, and shorter hospital stay. However, its role in rectobulbar urethral fistula (RBUF) is still debated as there is a chance of urethral diverticulum (UD), due to incomplete dissection. Laparoscopy-assisted modified posterior sagittal anorectoplasty (LAMPSARP) utilizes advantages of LAARP combined with fistula dissection using small sagittal incision preserving puborectalis. The present study compares the results of LAMPSARP with LAARP for correction of RBUF associated with anorectal malformations (ARMs). Materials and Methods: All male ARM with RBUF presenting in a tertiary center in Central India (January 2014-January 2016) were included. Low male ARM, RPUF, rectovesical fistula, and congenital pouch colon were excluded. They were randomized into LAARP and LAMPSARP groups. Complications were assessed in terms of anal stenosis, mucosal prolapse, and UD. Kelly's scoring and Krickenbeck scoring were used to assess continence, and visible anal cosmesis scale (VACS) was used to assess wanal cosmesis. Results were statistically analyzed using a comparison of means and 2 × 2 contingency tables. Results: Fifty-six colostomized patients with RBUF (26 LAARP, 30 LAMPSARP) were included. Mean operative duration in the LAARP group and LAMPSARP group was 42 ± 10 min and 56 ± 12 min, respectively (P < 0.0001). On mean follow-up of 4.5 years, mucosal prolapse (53.9%) and UD (15.38%) were significantly higher in LAARP group, while anal stenosis was similar. All three, Kelly's score, Krickenbeck score, and VACS, were better (P < 0.05) in the LAMPSARP group. Conclusion: Laparoscopy-assisted modified posterior sagittal approach is better for RBUF and offers better surgical outcome.

A 10-Year Study of the Outcome of Wilms' Tumor in Central India and Identifying Practice Gaps.

Introduction: Despite remarkable improvement in Wilms' tumor (WT) survival in Western world, sub-optimal outcome in resource-constrained settings is influenced by late presentation, larger size, and poor access to treatment. This prompted us to study the outcome at a tertiary care center and to identify the global and local practice gaps. Materials and Methods: A retrospective, observational study of WT was conducted from October 2009 to September 2019 at a tertiary care setting. Following the National Wilms' Tumor Study Group protocol, an upfront nephrectomy (unilateral resectable tumors) and preoperative chemotherapy (large/unresectable Stage I-III) were followed. The records were reviewed for demographics, stage, preoperative chemotherapy, predictive factors, and outcome. Survival curves were plotted by the Kaplan-Meier method, and analysis was performed using the SPSS software version 16. Results: One hundred and fifty-six children were included, median age was 4.1 years, with a male predominance. The most common stages of the presentation were II (40.4%) and III (34.6%). An upfront surgery was done in 27.6%, while remaining received preoperative chemotherapy. The median follow-up was 22 months, and the events included relapse in 46 (29.48%) and death in 54 (34.61%). The mean survival time was 45.7 (95% confidence interval [CI], 41.08-50.30). The 2-year overall survival was 65.38% (95% CI, 59-73), and the 2-year event-free survival was 36% (95% CI, 32-41). On comparison of the impact of preoperative chemotherapy, the survival estimates in Stages I-III and relapse rate were statistically similar, tumor size reduced significantly, and tumor spill was significantly lower (P < 0.05). Conclusion: WT is associated with late presentation, sub-optimal survival, and higher relapse in our setting associated with practice gaps related to the management including practice violations.

Impact of "Lateralizing" the Sigmoid Colostomy on Port Ergonomics in Laparoscopic Anorectoplasty for High Anorectal Malformations.

INTRODUCTION: The high-type anorectal malformations (ARM) are conventionally managed by an initial left iliac fossa sigmoid colostomy, followed by laparoscopic anorectoplasty (LARP). Such a stoma occupies left half of the infraumbilical region and hinders the LARP ergonomics, leading to the surgeon's discomfort. We studied the outcome and impact of "lateralizing" (shifting laterally in the abdominal wall) the colostomy on port ergonomics. MATERIALS AND METHODS: This prospective study was conducted in the pediatric surgery unit of a medical college in central India between March 2014 and June 2017 in two parts. In the first part of the study, neonates with high ARM were block randomized in two groups: conventional colostomy (CC) in left iliac fossa and lateral colostomy (LC, laterally placed abdominal colostomy). Outcomes of colostomy were compared among these two groups. In the second part of the study, 40 consecutive infants from both types of colostomy groups underwent ergonomic comparison and assessment of the surgeon's discomfort during LARP (CC-LARP and LC-LARP). Standard statistical tests were used for comparison. RESULTS: In the first part of the study, 203 ARM cases were included in this study; 100 underwent CC and 103 underwent LC. Colostomy prolapse, excoriation, reversed stoma, and short distal limb were significantly higher in the CC group. In the second part of the study, the LC-LARP group showed many significant advantages over the CC-LARP group, including less peri-stomal adhesions, better vision, shorter operative time, and better ergonomics (better manipulation, elevation, and azimuth angles). The LC-LARP also significantly reduced the surgeon's discomfort. CONCLUSION: Lateralization of high-sigmoid colostomy should be preferred over left iliac fossa sigmoid colostomy for ARM, as it improves the port ergonomics and reduces the surgeon's discomfort for second stage LARP.

Surgical innovation in LMICs-The perspective from India.

Surgical Innovations are central to surgical progress, and have led to exponential growth in various fields of Surgery. Surgical Innovations in Lower and Middle Income Countries are the result of creativity of frontline health workers in search of simple, safe and ethical solutions for their unique challenges. The key lies in: 'simplifying the idea/technique/device' to find patients' needs-driven low-cost innovative surgical solutions; which can be used on a wider scale to achieve health equity for underserved populations. Local surgeons understand the difficulties and nuances of various problems and can provide local-evidence-based customized solutions for their patients' health problems. We developed a Surgical Innovation Ecosystem allowing us to see difficulties as opportunities, learn from everyone and conduct research on what is 'important' rather than what is 'interesting'. Barriers to Surgical Innovations in Lower and Middle Income Countries are well known; however, a roadmap to overcome these barriers is now available. The right balance has to be found between encouraging creativity and innovation while maintaining ethical awareness and responsibility to patients. Introduction and adoption of Surgical Innovations are governed by evidence-based principles and have to undergo a rigorous and scientific evaluation. Science of Surgical Innovations has finally come of age and is getting its due recognition and the pioneering innovators are receiving the much needed appreciation and support.

Erratum to: Double Rectangle Fascia Lata Frontalis Sling: A Rationale Approach for Ptosis.

[This corrects the article DOI: 10.1055/s-0041-1723909.].

Double Rectangle Fascia Lata Frontalis Sling: A Rationale Approach for Ptosis.

Background The purpose of this study was to evaluate the functional outcomes of a modified technique of double rectangle pattern for correction of severe ptosis. Methods This is a retrospective study over a period of 8 years including patients who underwent correction of ptosis by double rectangle using autologous fascia lata sling. Surgical outcomes were assessed postoperatively by distance from the corneal light reflex to the upper eyelid margin (MRD1) and levator function. Results Twenty-six eyelids were operated in 20 patients. There were 9 males and 11 females, with age ranging from 4 to 35 years. Preoperatively, all patients had poor MRD1 and poor levator function. Postoperative MRD1 was good in 13 patients (17 eyelids), fair in 5 (7eyelids), and poor in 2 patients (2 eyelids). Postoperative levator function was excellent in 12 patients (15 eyelids), good in 6 (9 eyelids), and fair in 2 patients (2 eyelids). At a mean follow-up of 12 months, adequate correction was achieved in 24 eyelids, and 2 eyelids had undercorrection. Conclusion Frontalis sling with a double rectangle is simple and more efficient, as it provides a straight line of pull to the eyelid for correction of severe ptosis.

Workplace violence towards resident doctors in Indian teaching hospitals: A quantitative survey.

Violence at work is becoming an alarming phenomenon worldwide affecting the millions of health care workers. This study was conducted to assess the violence towards Resident doctors in Indian teaching hospitals. Google forms questionnaire was developed and circulated electronically to resident doctors working in India. Data were collected and managed using the Google forms electronic tool. Vast majority (86%) of respondents reported having experienced violence with no difference among two genders. Prevalence of violence was maximum (35.5%) in general surgery. Verbal threat and abuse was the commonest (∼94%) form of violence. Mostly these acts of violence happened in Emergency/Trauma room. The most common reasons for violence in hospital were patient's death. Over 94% residents accepted that they had never received any training to deal with work place violence. Majority (80%) of the respondents favoured better communication, strict Laws and strengthening of security measures in hospital to prevent WPV. Workplace violence prevention should be addressed aggressively and comprehensively in health care. A workplace violence prevention program should be a required component of all health care organizations.

Strategies for Optimizing the Use of PPE During Surgery in COVID-19 Pandemic: Rapid Scoping Review of Guidelines.

Personal protective equipment (PPE) plays a fundamental role in the prevention of spread to Health Care Professionals (HCP) ; especially in a surgical setting. This scoping review of surgery guidelines was performed to appraise the quality of appropriate PPE recommendations and propose a strategy to optimize the PPE usage. This rapid scoping review of guidelines on surgery during COVID-19 was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol. Important databases were searched from January 1, 2020 to July 31, 2020, for relevant studies produced by a national/international academic association/organization, in English literature, using relevant keywords. Quality of evidence was graded according to GRADE guidelines. The searches yielded a total of 1725 studies, out of these 41 guidelines on surgery during COVID-19 matching with pre-defined criteria were evaluated. The level of evidence was uniformly rated "low," as assessed by GRADE guidelines and recommendations provided by them were mostly non-specific covering a narrow range of items. The crucial issue of optimization of PPE was not addressed at all. Economic implications demand optimization of PPE and conservation of resources. A simple decision-making algorithm addressing all the limitations of guidelines can be constructed, which allows HCPs to safeguard themselves and at the same time optimize/ conserving resources.

Etiology-Based Decision-Making Protocol for Pediatric Cholelithiasis.

OBJECTIVES: We reviewed hospital records of pediatric cholelithiasis to develop an etiology-based decision-making protocol. METHODS: This retrospective study was conducted on consecutive pediatric cholelithiasis patients from July, 2014 to June, 2019 in a tertiary care center. Pediatric cholelithiasis was classified according to etiology, and the outcome of medical/surgical treatment was noted. RESULTS: Data of 354 pediatric patients were analyzed. Commonest (56.2%) etiology was idiopathic; followed by ceftriaxone pseudo-lithiasis (26.8%). Pigment stones were associated with the highest rate of complications. Non-hemolytic stones had a lower complication rate and a high rate of resolution with medical therapy. CONCLUSIONS: Hemolytic and symptomatic stones warrant an early cholecystectomy, whereas asymptomatic idiopathic stones, ceftriaxone stones, and TPN-induced stones are candidates for medical therapy under close observation.

Laparoscopic management of choledochal cyst in children: Lessons learnt from low-middle income countries.

Choledochal cyst (CC) is a disease with a strong Asian preponderance. As laparoscopic surgery has become mainstay in its treatment, the experience in these countries has been phenomenal. However, there are many contentious issues related with the laparoscopic management of CC. In this review article, we will try to answer the contentious questions related to the laparoscopic management of CC. The issues related to aetiology, classification, surgical technique, type of biliary anastomosis, intrahepatic stones and malignancy are discussed. We also discuss the current and future considerations of laparoscopic management with reference to it becoming a gold standard. This article describes the standard surgical approach and will discuss its technical nuances. This article will also discuss the outcome of treatment in different settings of low- and middle-income countries based on lessons learnt by the authors from their experience and research.

Comparison of 3D vs 2D laparoscopic-assisted anorectal pull-through (LAARP) for high anorectal malformations in children.

INTRODUCTION: The limitation of two-dimensional (2D) laparoscopic techniques includes lack of stereoscopic vision and depth perception which can affect surgical performance, physical and mental comfort of the operating surgeon. 3D laparoscopic surgery is popular in adults; however, its application and experience in the pediatric age group have been limited. We did a comparison of 2D and 3D laparoscopic-assisted anorectal pull-through (LAARP) in male high anorectal malformations (ARM). MATERIAL AND METHOD: This prospective cohort study included male children diagnosed with high anorectal malformation (recto-prostatic urethral fistula) who underwent LAARP in infancy after a neonatal colostomy between November 2019 to March 2020. The patients were randomized into a 2D group or 3D group at a 1:1 ratio. Patient demographics and operative/postoperative parameters were recorded. The effect of 3D laparoscopy was assessed in terms of laparoscopy visual parameters (image quality, depth perception, hand-eye coordination, and precision), physical discomfort (5-point Likert scale), and mental strain (State-Trait Anxiety Inventory scale). The statistical tests were performed on SPSS version 16. RESULTS: The demographics of both groups, 20 (patients in each), were similar. There was a significant reduction of laparoscopy execution time, physical discomfort (for eye, hand and wrist strain), and overall mental strain in the 3D group. There were similar complications, blood loss, and hospital stay, and no open conversion in two groups. CONCLUSION: 3D LAARP is feasible and safe in the surgical treatment of ARM in children. Further studies with assessment by more than one observer are needed to investigate the wider application of 3D in pediatric surgery.

"GRASP" Module of Self-assessment with Virtual Mentoring for Uninterrupted Surgical Training During COVID-19 Pandemic.

Disruption in surgical training during the COVID-19 pandemic has prompted many innovative "virtual" modules to address the loss of learning exposure during these difficult times. We suggest "GRASP" (Gain, Recognize, Analyze, Simulate, and Perform) module of self-assessment with virtual mentoring for uninterrupted surgical training. This idea merges the advantages of self-assessment and mentoring for the benefit of surgical trainees. Its embedded continuous close individualized mentoring can change the surgical training culture by initiating an assessment of surgical learning and skills right from the beginning of surgical training.