Minimal access surgery of corrosive and thermal strictures of the foregut.

Background and Aim: : Conventional surgery for caustic/thermal strictures (CS/TS) entails considerable trauma, which may be mitigated by minimal access surgery (MAS). Experience with its use in CS/TS is both heterogeneous and limited, hence, warrants a comprehensive review. Methods: : Medical literature/indexing databases were systematically searched for pertinent articles published in English, from 1990 to 2021, and analysed. Results: : Fifty relevant articles, pertaining to over 200 patients, were found. They showed that MAS is feasible in CS/TS management. It reduces the access damage in chest and abdomen whilst facilitating resection or bypass of the affected gut segment through different combination of operations, sequence of steps, conduits and routes. The procedures range from completely minimal access to hybrid ones, with reduced complications and faster recovery. Hybrid procedures prove as expeditious as open ones. Conclusions: : MAS proves efficacious in restoring alimentary continuity in corrosive/thermal strictures of the foregut.

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy.

BACKGROUND AND PURPOSE: Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy. METHODS: Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed. RESULTS: The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy. CONCLUSIONS: Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

Evidence-based adoption of purse-string skin closure for stoma wounds.

BACKGROUND: Opinion is divided on the optimal technique of skin closure after stoma reversal as most conventional techniques compromise either on speed/neatness of wound apposition or on the incidence of surgical site infection (SSI). Evidence suggests that purse-string skin closure (PSSC) may achieve both objectives. This study aims to compare conventional primary closure (PC) with PSSC to determine the efficacious technique for stoma wound closure. METHODS: Patients undergoing stoma reversal between April 2015 and September 2017 were prospectively studied. Patients were divided into two groups based on the technique of skin closure (PC or PSSC). The following parameters were assessed: SSI, hospital stay, additional outpatient visit, wound healing time and patient satisfaction based on a standardised questionnaire. RESULTS: Forty one patients underwent stoma reversal (20 PSSC vs 21 PC). Wound infection, need for wound care, length of hospital stay, healing time and scar size were significantly less, whereas average patient wound satisfaction scores were significantly more in the PSSC group. CONCLUSION: Purse-string skin closure (PSSC) proves efficacious and hence merits adoption as the technique of choice for closure of stoma wounds.

Modified Makuuchi incision for major upper abdominal surgeries.

ackground: Numerous incisions are described for abdominal operations. However, opinion is divided regarding the correct choice of incision for major upper abdominal surgeries. MATERIALS AND METHODS: Experience of 3 surgical centres with the use of modified Makuuchi incision, for major upper abdominal surgeries, from Mar 2014-Dec 2018, was audited. RESULTS: 144 patients (76 Males, 68 Females) with an average age of 48.25 years underwent surgery using modified Makuuchi incision. 'J' and 'L' incisions were used in 96 and 48 patients, respectively. Further extension of the incision was necessary in 2 patients. Adequate exposure and enhanced surgical ergonomics was observed in all cases. Surgical site infection was seen in 19 patients (13.2%). Incisional hernias was observed in 6 patients (4.2%), on an average follow up of 27.78 months. CONCLUSIONS: Modified Makuuchi incision proves efficacious for major upper abdominal surgeries.

Minimally Invasive Repair of Acquired Benign Thoracic Tracheo-Esophageal Fistula.

BACKGROUND: Repair of large, upper thoracic, cuff-induced, tracheo-esophageal fistula (TEF) is technically demanding and is conventionally performed by open surgery. Minimal access approach is, hitherto, unreported. T echnique & Case: Minimally invasive repair of TEF involving fistula isolation - by thoracoscopic oesophageal exclusion, and simultaneous establishment of alimentary continuity - by laparoscopy-assisted sub-sternal colonic transposition, is described. The technique was successfully employed in repairing a large (4.5 centimetres), cuff-induced, upper thoracic TEF, in a 25-year-old woman. The rationale behind the technique, its pros and cons are analysed and contrasted against conventional techniques of TEF repair. CONCLUSION: Large upper thoracic, cuff-induced TEF can be successfully repaired employing minimal access.

Buttressing hepaticojejunostomy's with hepatic round ligament flap may be beneficial.

BACKGROUND: Bile leaks and anastomotic strictures are important complications of hepaticojejunostomy (HJ). Evidence suggests that the use of hepatic round ligament (HRL) to buttress HJ may be beneficial. This study evaluates the feasibility of this approach. METHODS: HJs performed over 2 years (Jun 2014- May 2016), with HRL reinforcement, were analyzed. Operative outcomes measured included technical difficulty, blood loss, time necessary for flap harvest, and reinforcement of HJ. The postoperative outcomes measured were the presence of bile leak and anastomotic stricture. RESULTS: Forty-one patients (27 M: 14 F), aged 2-79 years, median age of61 years, underwent HJ with HRL buttress; 27 for periampullary/ head of the pancreas carcinoma; 4 for choledochal cysts; 4 for chronic pancreatitis; 3 for gallbladder carcinoma; 3 for benign biliary stricture. The time for harvesting HRL flaps and buttressing HJ was <10 minutes. No blood was lost during harvesting the flaps. One patient (2.5 %) had grade A leak following radical cholecystectomy, and structures were not observed during a median follow-up of 18 months (6 months to 2years). CONCLUSION: HRL-based buttressing of HJ can reduce the bile leak and/or stricture rate.