Practical consensus recommendations for gestational breast cancer.

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to manage gestational breast cancer.

Two port laparoscopic ventral hernia mesh repair: an innovative technical advancement.

Ventral hernia is a common surgical problem. The traditional open surgical repair has the disadvantage of excessive morbidity, long hospital stay and high recurrence rates. Laparoscopic ventral hernia repair (LVHR) is gaining acceptance but there is no standardized technique for the repair of these hernias. We have introduced an innovative technique of 2-port laparoscopic mesh repair for ventral and incisional hernias. Between January 2002 and September 2008, 168 patients underwent the 2-port repair of ventral hernias at our institution, with Bard polypropylene mesh in 162 cases and Gore-tex expanded polytetrafloroethylene mesh in 6 patients. The average size of the defects was 10.2 cm (6.6-24.8 cm). Mean operating time was 61.4 min (48-102 min). The mean post-operative hospital stay was 1.2 days. Prolonged ileus over one day occurred in 22 patients while 6 patients had urinary retention in the post-operative period. There were 6 recurrences (3.94%) in the mean follow up period of 42 months (6-62 months). Seroma formation occurred in 5.3% cases but all of them subsided within 6 weeks without any active intervention. In conclusion we recommend that the 2-port LVHR is a technically sound procedure which is less invasive and with comparable complication rates to the 3 or 4 port hernia repair.

Inflammatory variant of a well-differentiated retroperitoneal liposarcoma: case report of a rare giant variety.

Inflammatory liposarcoma is a rare variant of a well-differentiated liposarcoma (WDLPS). We present a case of a 37 years old male who had a giant variety of this inflammatory WDLPS. CT scan revealed a large abdomino-pelvic mass abutting the left kidney and pushing the IVC, Aorta and the left ureter across the midline. CT guided FNAC did not reveal any malignant cells. A large 9-kg fibro-fatty mass, which appeared irregular, congested and bosillated was excised. Microscopic picture revealed foci of fibrosis with mature adipose tissue. Lymphocyte and plasma cell infiltrate was abundant along with multi-nucleate giant cells and few lipoblasts. There are no case reports of a giant inflammatory variant of WD-LPS in world literature and this is the first of its kind from the Indian sub-continent. We present a case report of this rare giant variant of inflammatory WDLPS and discuss the review of literature.

Giant pseudocyst of the anterior abdominal wall following mesh repair of incisional hernia: a rare complication managed laparoscopically.

UNLABELLED: Giant pseudocyst formation of the anterior abdominal wall, following on-lay polypropylene mesh repair for incisional hernia is an under reported complication. We report an unusual case of a 56-year-old female who underwent a polypropylene mesh repair of incisional hernia 2 years back. Subsequently she developed a giant pseudocyst of the anterior abdominal wall, which was occupying the whole of the abdomen from the xiphisternum to the pubic bone, and over both the flanks. Over a period of one year, the cyst had defied multiple attempts at aspiration. The patient underwent a laparoscopic drainage of the collection with piecemeal excision of the entire cyst wall. Histopathology of the cyst wall revealed necrotic material with intervening areas of hemorrhage. No epithelial lining was seen. There has been no recurrence in the two years of follow-up. CONCLUSION: giant pseudocyst of the anterior abdominal wall is a rare complication following mesh repair of an incisional hernia. Such pseudocysts can be managed successfully by laparoscopic procedures.

Laparoscopic management of gallstone presenting as obstructive gangrenous appendicitis.

We present an unusual case of a 55-year-old man with symptoms of recurrent appendicitis. Laparoscopy revealed a 1.5 cm gallstone impacted at the base of the appendix, leading to gangrenous appendicitis. This patient did not have any features of gallstone ileus. On imaging he had an inflammatory mass in the region of the right iliac fossa with a hyperintense shadow in the cecal area which was reported as an appendicolith. There was no demonstrable cholelithiasis or biliary-enteric fistula. There were dense omental adhesions in the pericholecystic area on laparoscopy. The case was successfully managed by laparoscopic appendectomy with retrieval of the gallstone. No surgery was undertaken for the gallbladder. Diagnosis was confirmed by biochemical analysis of the stone, which contained calcium bilirubinate and cholesterol. A gallstone obstructing the appendicular lumen is a very rare etiology of gangrenous perforation of the appendix peritonitis. This case was successfully managed laparoscopically.

Laparoscopic surgical management of perforative peritonitis in enteric fever: a preliminary study.

Early surgery in enteric perforation is the only accepted form of treatment in modem day medicine and gives excellent results. Exploratory laparotomy continues to be the mainstay of surgical treatment and several different procedures are recommended in literature. Between January 1998 and November 2001, we have successfully managed 6 consecutive cases of enteric perforation laparoscopically with complete resolution of the disease. There were 4 males and 2 females in our study. The mean time of presentation to us was 38 hours after the perforation (range 22 hours to 63 hours). The mean age was 32 years (range 28 years to 43 years). All patients presented with free air under the diaphragm. A laparoscopic approach was carried out through a 10 mm supraumbilical port and two 5 mm additional ports in the midline infraumbilical area and the left iliac fossa area. Simple one layer closure of the perforation was carried out with 2-0 silk intracorporeally and the peritoneal cavity was washed out and adequately drained. All perforations were localised to the terminal ileum and were single in number. The mean operating time was 54 minutes-(range 42 to 75 minutes). All patients received parenteral ofloxacin and metrogyl. Postoperative recovery was uneventful in all patients and there were no major complications. All patients were discharged from hospital by the 4th postoperative day. Follow up over a period of 12 to 16 months revealed all patients to be in normal health. We strongly recommend a first line laparoscopic approach in all patients with typhoid perforation; as it is a safe and effective method of managing such cases.

Gastroscopic-assisted laparoscopic cystogastrostomy in the management of pseudocysts of the pancreas.

Once pancreatic pseudocysts become persistent, unresolving, and symptomatic, surgical drainage is mandatory. Between January 1998 and December 2001, we performed five laparoscopic cystogastrostomies for such pseudocysts with the simultaneous use of the gastroendoscope. The mean cyst diameter was 20 cm (range, 18.5-24). In the first four cases, the anterior wall of the stomach was entered through two 10-mm balloon cannulae under gastroscopic guidance. By introducing the laparoscope through one port and a harmonic scalpel through the other, a wide cystogastrostomy was performed. In the fifth case, a modification of the above technique was carried out. A single 10-mm cannula was used to enter the stomach and, with the use of a side-viewing gastroduodenoscope as the camera source, the harmonic scalpel was used to create the cystogastrostomy. The punctures in the wall of the stomach were repaired with endosutures. The gallbladder was removed in all cases. The mean operating time was 110 minutes (range, 92-128) for the combined procedure. There were no postoperative complications, and the mean hospital stay was 4 days. Postoperative follow-up with ultrasonography over a period of 1 year in each case revealed complete resolution of the cyst. Laparoscopic cystogastrostomy using harmonic scalpel under gastroscopic control is an effective and rapid method of surgically managing such lesions.

Laparoscopic management of abdominal complications in ventriculoperitoneal shunt surgery.

Ventriculoperitoneal (VP) shunts are among the most frequently performed operations in the management of hydrocephalus. Abdominal complications, though rare, are reported to occur in 5-47%. VP shunt obstruction or malfunction leads to raised intracranial pressure, which requires immediate intervention. Recently we have used the laparoscope to manage abdominal complications of VP shunt in two patients. The first patient had hydrocephalus secondary to tubercular meningitis. She developed recurrent intraabdominal cerebrospinal fluid (CSF) pseudocysts, possibly due to subtle peritoneal infection. In the second patient, who developed hydrocephalus following subarachnoid haemorrhage, the lower end of the shunt was malfunctioning due to retraction into the extraperitoneal tissues. The distal end of the VP shunt was revised in both patients with the help of a laparoscopically assisted technique. Thus, a conventional laparotomy, along with its various associated postoperative problems, was avoided without compromising the quality of surgery.

Laparoscopic surgery in hepatic hydatid cysts: a technical improvement.

Hepatic hydatid cysts are a common surgical problem that is encountered in many tropical countries, including India. Open surgical exploration and excision had been the mainstay of treatment until the advent of laparoscopy. In 1998, we successfully managed six cases of large hepatic hydatid cysts using the videoendoscope, with excellent postoperative follow-up results. Four men and two women participated in this study, with patient ages ranging from 28 to 42 years. The duration of the disease ranged from 1.3 to 2.8 years. All patients had undergone preoperative albendazole therapy for more than 2 months. Complete evacuation of the cyst contents, including all daughter cysts and laminated membrane, along with a subtotal excision of the extrahepatic part of the cyst wall, was accomplished without any spillage into the peritoneal cavity. The saucerized cavity was drained. The drains were removed 6 to 9.4 days after a check ultrasound. Postoperative follow-up ranged from 3 to 9 months and revealed no evidence of a recurrence in the abdomen. It is possible with carefully planned placement of trocars to completely eliminate the risk of spillage, and therefore not compromise the standard principles of hydatid surgery.

Laparoscopic surgical management of giant post-traumatic lymphocele involving sacrum and the lower extremity.

Lymphocele (collection of lymphatic fluid) is not an uncommon occurrence after trauma, surgical or otherwise. It is commonly associated with kidney transplant surgery and trauma to soft tissues of an extensive nature. In this paper, we report the minimally invasive surgical management of an unusual case of a 30-year-old physician who was involved in a road traffic accident as a result of which he received extensive soft tissue injuries to the sacrum, the right buttock, and the right thigh. Over a period of 3 months, he developed a giant lymphocele that defied three attempts at excision and drainage. The patient underwent successful laparoscopic drainage of the collection with ablation of the lining. Video-assisted surgical drainage and ablation is a safe, effective, and minimally invasive procedure that should be put to wider use and can be used to treat very large lesions.

Laparoscopic transabdominal repair of hernia of Morgagni-Larrey.

A patient with symptomatic gall stones was found to have a hernia of Morgagni. The patient complained of upper abdominal symptoms along with heaviness in the chest and mild dyspnea. A complete diagnosis was possible with a chest X ray and a CT scan, which revealed a right-sided Morgagni hernia containing omentum and some bowel loops. It was decided to laparoscopically deal with both lesions at the same sitting. Initially, a laparoscopic cholecystectomy was accomplished. The hernial contents were then reduced and an 8 cm x 5 cm defect was closed with a tailored mesh sutured in place with a hernia stapler. Follow up after one month showed an asymptomatic patient confirmed by CT scan. Morgagni hernia is eminently treatable laparoscopically and must be considered as a first line approach to this problem. It can safely be combined with other laparoscopic procedures.

Umbilical hernial defects encountered before and after abdominal laparoscopic procedures.

UNLABELLED: Pre-existing fascial umbilical defects may compound problems faced during laparoscopic surgery. Detection helps in preventing bowel or omental injury and repair can be done at the same time. Postoperative port incisional hernias are not uncommon and require surgical repair. METHODS: The incidence, clinical features and management of such fascial defects were studied in 2100 patients undergoing abdominal laparoscopy. RESULTS: The incidence of fascial defects was 18%. The hernias were symptomatic in 56.5% cases, with an overwhelming female preponderance. A supra-umbilical incision above the upper limit of the hernia was used to establish the umbilical port and through this the hernias were repaired with nonabsorbable sutures. Postoperative incisional hernias occurred in 41 patients out of a total follow-up of 1892 cases (2.16%). The common predisposing factors were wound infection, postoperative chest infection and previous existing diseases, like diabetes and connective tissue disorders. Twenty-eight patients underwent mesh plasty and 3 cases had laparoscopic Gortex mesh repair. The remaining 10 cases refused surgery. CONCLUSIONS: Omental fascial defects should be dealt with at the same sitting through a supra-umbilical port incision avoiding direct entry into the hernia. Use of nonabsorbable sutures is recommended. Prevention of wound infection and postoperative chest infection greatly reduces the chances of an incisional hernia.

Two-port laparoscopic cholecystectomy: an innovative new method for gallbladder removal.

Laparoscopic cholecystectomy is the gold standard in gallbladder surgery all over the world today. The operation is routinely performed using four or three ports of entry into the abdomen. We have now modified this procedure and introduced a new innovative two-port method of gallbladder removal. Between September 1997 and November 1997, 50 consecutive patients (41 females and 9 males; mean age 41 years) with calculus cholecystitis underwent our new two-port procedure. In this operation, only the supraumbilical port (10 mm/5 mm) and the epigastric port (10 mm) were used for access. The gallbladder was manipulated through three strategically placed traction sutures, passed through the fundus, the body, and the neck area of the gallbladder, respectively. The operating time required was 35 to 125 minutes, with an average time of 56 minutes. None of the patients required conversion to the four-port technique. All patients were on liquids after 6 hours. The average hospital stay was 1.31 days. Postoperative pain was significantly reduced, and the procedure was cosmetically more acceptable to the patient.