A comparative study to evaluate abdominal wall dynamics in patients with incisional hernia compared to healthy controls.

BACKGROUND: Incisional hernia is a common complication following abdominal surgery. It causes change in function of core abdominal muscles leading to change in abdominal wall dynamics. This study aims to objectively measure and compare preoperative abdominal wall dynamics with surface electromyography (sEMG) in incisional hernia patients with healthy individuals. MATERIALS AND METHODS: In this prospective comparative study, two groups of participants as cases and controls were evaluated for their abdominal wall dynamics by using sEMG. Both cases and controls were evenly matched in terms of age and gender. Statistical analysis was done with STATA 14.1 and p value of < 0.05 was considered significant. RESULTS: Demographic profile was comparable between the two groups. Mean BMI of cases was higher than controls. The most common index procedure was lower segment cesarean section. The strength and power of all three abdominal wall muscles (rectus abdominis, external oblique, internal oblique) were significantly diminished among cases compared to controls. CONCLUSIONS: Abdominal wall dynamics can be objectively and correctly interpreted from sEMG of abdominal wall core muscles in patients with incisional hernia. This study shows that there is a decrease in abdominal wall strength and power in patients suffering from incisional hernia in comparison with healthy controls.

Use of Critical View of Safety and Proctored Preceptorship in Preventing Bile Duct Injury During Laparoscopic Cholecystectomy-Experience of 3726 Cases From a Tertiary Care Teaching Institute.

INTRODUCTION: Bile duct injury (BDI) continues to occur despite technological advances and improvements in surgical training over the past 2 decades. This study was conducted to audit our data on laparoscopic cholecystectomies performed over the past 2 decades to determine the role of Critical View of Safety (CVS) and proctored preceptorship in preventing BDI and postoperative complications. MATERIALS AND METHODS: All patients undergoing elective laparoscopic cholecystectomy were analyzed retrospectively. The data were obtained from a prospectively maintained database from January 2004 to December 2019. Proctored preceptorship was used in all cases. Intraoperative details included the number of patients where CVS was defined, number of BDI and conversions. Postoperative outcomes, including hospital stay, morbidity, and bile duct stricture, were noted. RESULTS: Three thousand seven hundred twenty-six patients were included in the final analysis. Trainee surgeons performed 31.6% of surgeries and 9.5% of these surgeries were taken over by the senior surgeon. A CVS could be delineated in 96.6% of patients. The major BDI rate was only 0.05%. CONCLUSION: This study reiterates the fact that following the basic tenets of safe laparoscopic cholecystectomy, defining and confirming CVS, and following proctored preceptorship are critical in preventing major BDI.

Endoscopic totally extraperitoneal repair for groin hernia: Experience from a tertiary care centre.

Background: Totally extra-peritoneal (TEP) and transabdominal preperitoneal (TAPP) repair are two established minimal access techniques of groin hernia surgery. TEP offers the advantage of avoiding violation of the peritoneal cavity. Aim: This study aims to describe the decade-long experience of TEP in groin hernia repair in a tertiary care teaching institute and the feasibility of the same in difficult scenarios. Materials and Methods: Retrospective analysis of the database of patients undergoing TEP repair for inguinal hernia in a single surgical unit at a tertiary teaching hospital between January 2008 and December 2019 was performed. Detailed pre-operative clinical details, operative duration, intraoperative and post-operative complications, including pain, length of post-operative hospital stay and hernia recurrence data were analysed. Results: Over 12 years' duration, 511 patients underwent endoscopic TEP mesh repair and the total number of hernias repaired was 614. Majority (97.45%) of patients were male. The mean age of the patient population was 51.3 years. Primary hernia was seen in 490 patients. The mean operating time for unilateral inguinal hernia repair was 56.8 ± 16 min and for bilateral repair 80.9 ± 25.2 min. TEP in previous lower abdominal/suprapubic surgical scars was attempted in 17 (3.3%) patients, with only one requiring conversion. The intraoperative peritoneal breach was the most common documented complication (34.8%). Seroma was seen in 9.4% of patients. Seventeen patients required conversion (14 TAPP and 3 open). Recurrence was seen in 4 (0.7) patients. Conclusion: TEP repair is an effective method of groin hernia repair and can be attempted in the majority of patients groin hernia, including patients with previous lower abdominal incisions.

Smartphone applications (apps) in general surgical practice: An insight into their reliability and usefulness.

Objectives: In today's day and age with the advent of smartphones along with the handy apps available for download, there is increasing opportunities for surgeons to integrate such technology into clinical practice with great ease. This study aims to provide a systematic classification of apps in order to provide dependable data for choosing the right app by both surgeons and trainees. Material and Methods: A series of methodical searches were carried out on "Google Play Store" and "Apple's App Store" with pre-decided keywords. The results were then sorted and segregated into relevant categories like core surgery, apps related to surgical practice, patient utility apps and other surgical branches. Thereafter, the apps that met with our cut-offs, were assessed for their credibility and utility, based on predefined parameters. Results: There were a lot of variations in between the categories we segregated the apps into. Using predefined cutoff criteria, (rating >3 and reviews >30), 48 of the apps were assessed finally for their utility and credibility. Out of these 48 apps, 42 were on android platform while the remaining 6 were on iOS. Ten apps were found to be having high credibility and 15 apps have high utility. Conclusion: The role of smartphone apps in surgery and surgical training appears highly promising and using apps with high credibility and utility will provide dependable and updated information for the surgeons and trainees.

Effect of structured training in improving the ergonomic stress in laparoscopic surgery among general surgery residents.

BACKGROUND: Minimal access surgery has fast become the standard of care for many operative procedures, but is associated with lot of ergonomic stress to the surgeons performing these procedures, which may result in reduction in surgeon's performance and work capacity. In this study, we evaluated the impact of structured training program in improving the ergonomic stress in trainee laparoscopic surgeons. METHODS: Laparoscopic surgeons were divided in 2 groups: trainee surgeons (ten) and expert surgeons (three). Baseline surface electromyography (sEMG) data were collected from bilateral deltoid, biceps brachii, forearm extensors, and pronator teres during a predefined suturing task on Tuebingen trainer with integrated porcine organs in both the groups. Trainee surgeons underwent 20 h of laparoscopic intra-corporeal suturing training and surface electromyography data were recorded at the end of training again and compared with baseline. RESULTS: Experts were found to have lower muscle activation (p < 0.05) and muscle work (p < 0.05) and better bimanual dexterity than the trainee surgeons at baseline. After training, the trainee surgeons showed significant improvement (p = 0.01), but still did not reach the values of the expert surgeons (p = 0.01). Right deltoid and pronator teres muscles were found to have maximal activity while performing intra-corporeal suturing. CONCLUSION: Structured and focused training outside operation theater can significantly reduce unnecessary muscle activation of trainee laparoscopic surgeons and better dexterity leading on to lesser ergonomic stress and thus possibly may reduce the risk of development of future musculo-skeletal disorders.

Outcome of bariatric surgery on hypothyroidism: experience from a tertiary care center in India.

BACKGROUND: Hypothyroidism is frequently found to be associated with morbid obesity. Effect of bariatric surgery on type 2 diabetes, hypertension, and sleep apnea has been studied extensively but there is a dearth of literature on its impact on thyroid function. We had published our experience of laparoscopic sleeve gastrectomy and its effect on hypothyroidism in morbidly obese patients previously. In this study, we have tried to evaluate the impact of bariatric surgery on the whole cohort of hypothyroid patients and compare the effect of various bariatric procedures on thyroid hormone replacement dose. OBJECTIVE: To assess outcome of bariatric surgery on the hypothyroid patients and to compare the outcomes of laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass, and one-anastomosis gastric bypass in terms of reduction of thyroid hormone replacement dosage. SETTING: Tertiary care University Hospital, India; Government Practice. METHODS: This is a retrospective analysis of a database of all bariatric procedures done in a single unit at a tertiary care teaching hospital in India. Morbidly obese patients with hypothyroidism on thyroxine replacement were identified and their preoperative and postoperative thyroid hormone replacement dosage (THR) and thyroid stimulating hormone levels were compared. RESULTS: Of 883 patients undergoing bariatric surgery, 180 patients were hypothyroid (on thyroxine replacement). Ninety-three patients were included in the final analysis. The mean age of the study population was 42.2 ± 10.4 years and the mean preoperative body mass index was 47.8 ± 8.3 kg/m2. Mean follow-up duration was 29.8 ± 19.6 months. The excess weight loss was 58.9%. Fifty-two (55.8%) patients had a decrease in the in THR dosage, 37 (39.8%) had no change in THR dosage, and 4 patients required an increase in THR dosage. Decrease of THR dose was observed in 61.7% patients in laparoscopic sleeve gastrectomy in comparison to 45.4% in bypass group. CONCLUSION: Bariatric surgery might cause reduction of thyroid replacement dosage in hypothyroid, morbidly obese patients.

Incidental Carcinoma Gallbladder: Incidence, Risk Factors, and Factors Affecting Survival-5-Year Experience from a Tertiary Care Institute.

INTRODUCTION: Carcinoma gallbladder is a very lethal disease. It can get detected incidentally after laparoscopic cholecystectomy. The overall outcome of incidentally detected carcinoma gallbladder is a matter of debate in literature. AIM: To estimate the overall incidence of the incidental gallbladder carcinoma, the various risk factors associated with it and factors affecting overall survival in patients who underwent laparoscopic cholecystectomy with eventual histology turning out to be carcinoma gallbladder. METHODS: Data of all the patients undergoing laparoscopic cholecystectomies in one surgical unit under the Department of Surgery at All India Institute of Medical Sciences, New Delhi, India, between January 2014 and December 2018 was retrospectively analyzed. All patients with incidental carcinoma gallbladder were followed up and completion radical cholecystectomy was performed. The demographic profile, preoperative imaging, intra-operative finding, histopathology of primary surgery, and median interval between two surgeries were analyzed to look for various risk factors associated with incidental carcinoma gallbladder and factors affecting overall survival. RESULTS: Incidence of the incidental carcinoma gallbladder was 0.51% with a female/male ratio of 4:1 and mean age of 47.2 years. Preoperative imaging of most of them was suggestive of chronic cholecystitis; however, one patient had multiple gallbladder polyps. Six patients had uneventful laparoscopic cholecystectomy, while four had bile spillages intraoperatively. All the patients had adenocarcinoma on histopathology. Pathological staging of four patients was pT1b and six patients had pT2 tumor. The median interval between cholecystectomy and completion radical cholecystectomy in this series was 8 weeks. At the end of 19-month median follow-up, overall survival was 55.5%. CONCLUSION: Incidence of incidental carcinoma gallbladder is 0.51%, most commonly affecting middle-aged females. Risk factors associated with incidental carcinoma gallbladder were found to be multiple gallbladder calculi, single large stone, and gallbladder polyps. Survival is better in males, young patients with uneventful primary surgery and better-differentiated pathology.

Lipoleiomyosarcoma of spermatic cord: an unusual presentation.

Spermatic cord malignancies are very rare tumours. Less than 100 cases of cord liposarcoma have been reported in the literature. Divergent differentiation into leiomyosarcoma and liposarcoma is a rare phenomenon but can occur. Lipoleiomyosarcoma usually represents the well-differentiated subtype of this entity. We report such a rare case in spermatic cord with an unusual presentation as a recurrent inguinal hernia in a 62-year-old man.