Laparoscopy during the COVID-19 Pandemic: Absence of Evidence is not Evidence of Absence.

From a local outbreak to a global pandemic, the severe acute respiratory syndrome-coronavirus-2 infection has spread across 210 borders to infect 2.5 million humans. There is an organized disruption in the routine hospital functioning to divert the available resources for effective crisis management; most of the departments have been split to carve out a "COVID task force." The recommended indications for treatment of various medical conditions, medical procedures, and protocols have regressed on the evolutionary timeline. Newer recommendations are being released and updated regularly based on emerging evidence and experts' opinions. In view of exponential spread of the virus through routes already identified or those still elusive, the shedding of the virus during the incubation period, and lack of scientific evidence, the questions of "laparoscopy" or "no laparoscopy" assume importance. Herein, the evidence in literature pertaining to patient safety, efficient and effective utilization of hospital resources, and safety of health-care workers (HCWs) during the pandemic have been reviewed from the perspective of laparoscopy. The pathobiology of the virus including its survival properties and the different modes of transmission has been highlighted, and the relative risk to the HCWs between open and laparoscopic surgery dwelt upon. The recommendations from various international bodies have been discussed. Notwithstanding the absence of concrete evidence to exclude the possibility of bioaerosol-based transmission of the disease to the operating room staff, there is a multitude of other concerns which are addressed by avoiding the use of the laparoscope in the current scenario. Moreover, the absence of evidence is not evidence of absence; considering the high contagion and a long latent period associated with this virus, the onus is upon each individual surgeon to decide if one needs evidence of bioaerosol-based transmission or evidence in favor of safety before taking up 'laparoscopy' against 'open surgery'.

Migration and maturation pattern of fetal enteric ganglia: a study of 16 cases.

AIMS: To study the migration and developmental pattern of ganglion cells in fetuses aged 9-21 weeks, and to document whether the migration was occurring circumferentially equally in the entire axis or if there were discrepancies in different portions at the same level. SETTINGS AND DESIGN: The hypothesis regarding the pathogenesis of Hirschsprung's disease mainly revolves around two schools. One is the single gradient migration of ganglia and the other is a dual gradient migration theory. Understanding the embryological development of enteric ganglia is necessary to study the pathogenesis of intestinal innervation disorders. MATERIALS AND METHODS: We studied the development of intestinal ganglia in fetuses aged 9-21 weeks. Serial longitudinal sections from the colon were studied, the first one including the squamo-columnar junction, for the presence and the nature of ganglion cells with Hematoxylin and Eosin, and neurone-specific enolase immunostaining. Transverse sections from proximal gut were studied in a similar fashion. Thus, we evaluated the migration pattern as well as the nature of ganglia in the fetuses. We also measured the length of distal aganglionic segment in these growing fetuses. RESULTS: We noted that ganglion cells appear first in the myenteric plexus followed by deep and superficial submucous plexus. We also found evidences in favor of dual migration theory, and the distal aganglionic segment varies around the circumference of the rectal wall. CONCLUSIONS: We got evidences in support of a dual migration pattern of intestinal ganglion cells. The level of distal aganglionic segments when measured from squamo-columnar junction varied with the age of gestation and the length was incongruous. The description of distal aganglionic segment may help surgeons while taking biopsies or during operative procedures.

Rectourinary perineal fistula--a unique anomaly.

Two patients who presented with a unique anorectal malformation are described. They had what we have named rectourinary perineal fistula. The first patient had a more severe malformation, rectovesicoperineal fistula, and has been followed up for 28 years. The second, with a lesser malformation, rectourethroperineal fistula, has been followed up for 19 years.