Total (Transthoracic and Transabdominal) Robotic Radical Three-Stage Esophagectomy-Initial Indian Experience.

This study aims to evaluate the safety and technical feasibility of total robot-assisted three-stage esophagectomy. From July 2011 to June 2014, 35 histologically proven resectable carcinoma esophagus patients underwent robot-assisted transthoracic and transperitoneal three-stage esophagectomy. In the initial ten cases, total docking time, thoracic docking time, total operative time, thoracic-phase operative time, and blood loss were 67.9 ± 13.24, 32.2 ± 9.74, 429.2 ± 57.65, and 96.6 ± 20.33 min and 433.20 ± 48.72 ml, respectively. In the subsequent 25 cases, all parameters decreased significantly (33.20 ± 4.16, 13.76 ± 3.43, 321.13 ± 13.75, and 57.04 ± 9.15 min and 256.32 ± 17.52 ml, respectively). Median numbers of lymph node dissected were 32. One case was converted to open method, and there was no in-hospital or 30-day mortality. Two cases required ventilator support for 1 day, with ICU stay for 1 day in 15 patients and 2 days in five patients. Two patients had major complications. Median hospital stay was 8 days. All had microscopic negative resection margins. Robot-assisted three-stage esophagectomy has the benefits of minimally invasive surgery and immediate oncological outcomes are comparable to conventional open surgery. Therefore, it is a safe and feasible technique for the treatment of esophageal cancer in selected patients.

Prospective randomized study comparing robotic-assisted hysterectomy and regional lymphadenectomy with traditional laparotomy for staging of endometrial carcinoma -initial Indian experience.

Robotic assisted hysterectomy with regional lymphadenectomy is increasingly used for the treatment of endometrial carcinoma. In the present study we evaluated the feasibility and technique of robotic assisted hysterectomy and lymphadenectomy in patients with endometrial carcinoma. A prospective randomized study was undertaken from July 2011 to June 2012, in 50 consecutive patients with carcinoma endometrium. Demographic (age, BMI) and perioperative data (operating time, estimated blood loss, total number of lymph nodes retrieved, hospital stay, conversion to open procedure, intraoperative and postoperative complications) of robotic assisted surgery were compared with open staging procedure. Mean age of the patient and BMI in both groups were comparable with no significant difference. Estimated blood loss (81.28 ml), hospital stay (1.94 days) and perioperative complications were significantly less in robotic assisted group in comparison to open method. Mean number of lymph nodes removed were 30.56 versus 27.6 which is suggestive of significant difference statistically. Operative time decreased as the experience of the surgeon increased but still significantly remained higher than the open procedure after 25 robotic assisted surgeries. All robotic surgeries were completed successfully without converting to open method. Robotic assisted staging procedure for endometrial carcinoma is feasible without converting to open method, with the advantages of decreased blood loss, short duration of hospital stay and less postoperative minor complications. Operative time will decrease further as the experience of surgeon increases. Para-aortic lymph node dissection is easily done and with a better ergonomics for surgeon.

Intraperitoneal chemotherapy for epithelial ovarian cancer - single center experience.

Majority of intraperitoneal (IP) chemotherapy complications were related to the chemoport. Aim of our study was to find the means of reducing complications of IP chemoport, to increase the benefits of IP chemotherapy. During January 2007 to December 2010, hundred consecutive patients of stage III epithelial ovarian cancer who had optimal cytoreduction underwent chemoport insertion during laparotomy. Initial 20 cases had 14.3F Bard IP chemoport, and later cases had 9.6Fr single lumen venous port inserted intraperitoneally. Entry point into the peritoneum was single, 6 cm lateral to the umbilicus and double purse-string suture taken around the catheter to prevent peri-catheter backflow of ascitic fluid or drug. Modified IP chemotherapy regimen (SWOG-9912 trial) was used. Age of the patient ranged from 34 years to 76 years. In total 600 cycles, 516 cycles (86 %) were completed. Seventy patients (70 %) received all the 6 cycles by IP route. Two in the initial 10 patients had vaginal leak, for whom first 2 cycles were given by IV route and then shifted to IP route. Subsequently all cases had double layer closure of vaginal vault. Nine patients (9 %) had port related complications, in which 8 were transient. Catheter block was seen in 5 cases, of which 4 salvaged by heparin injection lock for 2 h and in subsequent cases IV port access catheter with valve replaced the fenestrated IP catheter. None of the IV catheters had the block. Four cases had backflow of fluid around catheter collecting around the port chamber site. Two patients had severe abdominal pain due to dense adhesions and further cycles were completed by IV route. Cisplatin was replaced with carboplatin in 5 cases with severe toxicity. Longest follow-up is 4 years with median follow up of 1.8 years.70 % are disease free on follow up. Local recurrence rate was 18 and systemic in 8 cases. Mortality rate is 4 %. Complications of IP ports are low when insertion is done meticulously with a dedicated team. With modified IP dose and drug regimen, side effects are less and most patients can complete all the desired cycles.

Value of frozen section and primary tumor factors in determining sentinel lymph node spread in early breast carcinoma.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) is the standard of care to assess the metastasis in breast carcinoma. Accuracy of intraoperative frozen section examination to evaluate SLN in detecting metastasis is important as it determines the further management of axilla. Primary tumor characteristics determining the metastasis to the lymph node will help in predicting the probability of spread and to determine the nature of disease. It also helps in refining selection of patients for SLNB. We evaluated all these criteria on Indian patients for the better management. MATERIALS AND METHODS: Between January 2005 and April 2009, 114 consecutive patients of all age group of both sex, with cytology or biopsy proven carcinoma breast, clinical stage T1/T2 N0 M0 at Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore were subjected to SLNB and introperative frozen examination. First 75 cases had complete axillary clearance irrespective of SLNB result and subsequently, positive cases underwent axillary lymph node dissection (ALND). Age of the patient and primary tumor characteristics like size, grade, lymphovascular invasion (LVI), perineural invasion, ER/PR status, Her2-neu status and histological sub-types were evaluated for predicting the SLN metastasis. Feasibility of SLNB in previously treated patient is also evaluated. RESULTS: The age of the patient ranged from 23 to 87 years and its association with SLN spread is not significant. Frozen section examination had accuracy of 97.37% in determining metastatic sentinel node with sensitivity of 96.15% and specificity of 100% with value P < 0.001. SLN remained significant indicator of the status of rest of axilla with value P < 0.001. Primary tumor characteristics like histological subtypes, grade (P = 0.353), ER/PR status (P = 0.839), Her2-neu status (P =0.296) were not significantly associated with SLN metastasis. Size of the primary tumor (P = 0.002), LVI (P < 0.001), perineural invasion (P = 0.084+) were significant factors determining the SLN metastasis. SLNB evaluation had no false negative values in previously treated breast. CONCLUSION: SLNB is a valuable method of determining the axillary nodal metastasis. Intraoperative frozen section examination is highly ac-curate in detecting nodal metastasis. Primary tumor characteristics like size, LVI and perineural invasion are significant in predicting SLN metastasis. SLNB remains an important method of predicting axillary metastasis even in previously treated breast carcinomas.

Hernia uterine inguinale with transverse testicular ectopia and mixed germ cell tumor.

Persistent mullerian duct syndrome is a rare disorder characterized by the presence of uterus and fallopian tube in 46XY phenotypic males and is ascribed to defects in the synthesis or action of anti-mullerian hormone. We report a rare case of hernia uterine inguinale, transverse testicular ectopia associated with mixed germ cell tumor of the testis with metastasis. Transverse testicular ectopia should be suspected preoperatively in patients who have unilateral inguinal hernia associated with contralateral nonpalpable testis. In such cases ultrasonography should be done prior to repair of hernia to evaluate the possible presence of mullerian structures and testicular malignancy, for better management.