A randomized trial comparing the use of endobiliary stent and T-tube for biliary decompression after laparoscopic common bile duct exploration.

PURPOSE: To compare the use of a biliary stent with T-tube for biliary decompression after laparoscopic common bile duct (CBD) exploration. METHODS: Between September 2004 and March 2008, 60 patients undergoing laparoscopic CBD exploration for CBD stones were randomized to choledochotomy closure over either a biliary stent or a T-tube after CBD clearance. Patients at high risk for surgery and unremitting cholangitis requiring preoperative endoscopic biliary drainage were excluded. RESULTS: There were 29 and 31 patients in the T-tube and stenting groups, respectively. The 2 groups were comparable with respect to their demographic profile and disease characteristics. Patients in the stent group had a significantly shorter operative time and postoperative stay with an earlier return to normal activity (P<0.0001). CONCLUSIONS: Choledochotomy closure over a stent results in a shorter postoperative stay and an earlier return to normal activity compared with closure over a T-tube without any increase in morbidity.

A prospective nonrandomized comparison of laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication in Indian population using detailed objective and subjective criteria.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) is a commonly performed procedure for the treatment of gastro esophageal reflux disease (GERD) worldwide. However, unfavourable postoperative sequel, including gas bloat and dysphagia, has encouraged surgeons to perform alternative procedures such as laparoscopic Toupet fundoplication (LTF). This prospective nonrandomized study was designed to compare LNF with LTF in patients with GERD. MATERIALS AND METHODS: Hundred and ten patients symptomatic for GERD were included in the study after having received intensive acid suppression therapy for a minimum of 8 weeks. A 24-hour pH metry was done on all patients. Fifty patients having reflux on 24-hour pH metry were taken up for the surgery. Patients were further divided into group-A (LNF) and group-B (LTF). RESULTS: The median percentage time with esophageal pH < 4 decreased from 10.18% and 12.31% preoperatively to 0.85% and 1.94% postoperatively in LNF and LTF-groups, respectively. There was a significant and comparable increase in length of lower esophageal sphincter (LES), length of intraabdominal part of LES and LES pressure at respiratory inversion point in both the groups. In LNF-group, five patients had early dysphagia that improved afterwards. There were no significant postoperative complications. CONCLUSION: LNF and LTF are highly effective in the management of GERD with significant improvement in symptoms and objective parameters. LNF may be associated with significantly higher incidence of short onset transient dysphagia that improves with time. Patients in both the groups showed excellent symptom and objective control on 24-hour pH metry on short term follow-up.

Laparoscopic choledochoduodenostomy for biliary stone disease: a single-center 10-year experience.

BACKGROUND AND AIMS: Patients with a dilated common bile duct (CBD) and multiple, primary, or recurrent stones are candidates for choledochoduodenostomy. This article reviews our technique and results of laparoscopic choledochoduodenostomy (LCDD) in patients with CBD stones. SUBJECTS AND METHODS: Prospectively maintained data of patients with a dilated CBD and multiple, primary, or recurrent CBD stones who underwent LCDD after laparoscopic CBD exploration (LCBDE) at a tertiary-care teaching hospital in New Delhi, India, during a 10-year period from April 2001 to March 2011 were analyzed. RESULTS: During this period, of 195 patients who underwent LCBDE for CBD stones, 27 patients underwent LCDD. The mean age of patients was 45.7±13.5 years. There were 6 male and 21 female patients. Sixteen (59.2%) patients had jaundice at presentation. Average CBD diameter was 19.6±4.4 mm. On average, 11.5±15.7 stones were removed from the CBD. Mean operative time was 156.3±25.4 minutes. Mean operative blood loss was 143.3±85.5 mL. Average postoperative hospital stay was 6.4±3.8 days. CBD clearance was obtained in all cases. One patient had a bile leak that resolved with conservative treatment. There was no mortality. No patient has had recurrence of symptoms or cholangitis after a follow-up of up to 9 years. CONCLUSION: LCDD can be safely performed in patients with a large stone burden and recurrent or primary CBD stones. Although it requires advanced laparoscopic skills, the benefits of a single-stage laparoscopic procedure can be extended to these patients safely with good results.

Retroperitoneal laparoscopic pyelolithotomy versus extra corporeal shock-wave lithotripsy for management of renal stones.

AIM: The purpose of this study was to evaluate the role of retroperitoneal laparoscopic pyelolithotomy (RPPL) and its comparison with extra corporeal shock wave lithotripsy in the management of renal calculi. MATERIALS AND METHODS: The study was carried out in the Department of surgery, Maulana Azad Medical College, New Delhi, India. The study included 86 cases of solitary renal calculi in the retroperitoneoscopic (RPPL) group and 82 cases in the shock wave lithotripsy (SWL) group. The parameters compared were stone clearance, hospital stay, number of postoperative visits, mean time to resume normal activities, number of man days lost, and analgesic requirement. RESULTS: The RPPL group showed better stone clearance, fewer hospital visits, low analgesic requirement, fewer number of man days lost, and early resumption of normal activities, as compared to the SWL group. CONCLUSIONS: Shock wave lithotripsy, being a noninvasive modality, is an established procedure all over the world. However RPPL achieves comparable or better results in high volume centers.

Is unilateral laparoscopic TEP inguinal hernia repair a job half done? The case for bilateral repair.

INTRODUCTION: Bilateral laparoscopic totally extraperitoneal (TEP) repair of unilateral hernia is conspicuous in published literature by its absence. There are no studies or data on the feasibility, advantages or disadvantages of bilateral repair in all cases or in any subset of patients with unilateral primary inguinal hernia. The objective of this study is to investigate the feasibility of bilateral laparoscopic exploration for all unilateral cases followed by laparoscopic TEP in all cases and to compare complications, recurrence rates, postoperative pain, patient satisfaction, and return to work retrospectively with a similar number of age-matched retrospective controls. METHOD: One hundred fifty TEP operations were performed in 75 patients (group A) prospectively and were compared with 75 unilateral TEP operations (group B) in age-matched controls done previously by the same surgeon. All cases were performed under general anesthesia, and TEP repair was performed using three midline ports. All uncomplicated patients were discharged at 24 h, in keeping with departmental policy. RESULTS: Of 75 patients (group A), 25 (33.3%) were clinically diagnosed with bilateral hernia and the rest (50, 66.66%) with unilateral hernia. The distribution of the 25 bilateral cases was 11 bilateral direct and 14 bilateral indirect inguinal hernias. The distribution of the 75 age-matched controls (group B) was all unilateral hernia, of which 47 were right-sided and 28 were left-sided. There were 23 direct hernias and 52 indirect hernias among the control group. The mean operative time for all 150 cases was 76.66 +/- 15.92 min. The operative time in the control group (unilateral hernias) was 66.16 +/- 12.44 min, whereas the operative time in the test group (bilateral repair) was 87.2 +/- 11.32 min. The operative time in the bilateral group was significantly higher, by 21.04 min or 31.88% (p = 0.000). The operative time in the true unilateral group was 82.45 +/- 9.38 min, whereas the operative time in the former group [occult contralateral hernias (OCHs) + bilateral hernias] was 91.35 +/- 11.95 min, which is a statistically significant difference (p = 0.0015). Occult hernia was seen in a total of 15 cases, of which 13 were OCHs (26%) and 2 were occult ipsilateral hernias (OIH). The mean operative time in the OCH cases was 81.46 +/- 7.9 min, whereas in those without OCH it was 82.45 +/- 9.38 min, which is not a statistically significant difference (p = 0.46). Regarding complications, there were no cases of seroma, hematoma, wound infection, visceral injury or postoperative neuralgia in either group A or B. On statistical analysis, visual analog score (VAS)-measured pain score, at 12 h only, was significantly higher in the unilateral repair group as compared with the bilateral TEP group; VAS scores at all other times were not statistically significantly different between the two groups. The average time of return to light routine or activities of daily living was 1 day in group A, whereas in group B it was 1.91 days (range 1-3 days), which is a statistically significant difference (p = 0.000). There was one case of recurrence in this study, in a left-sided hernia in group A, over a follow-up period of 60-72 (mean 66) months; all patients reported for follow-up by office visit or correspondence until 2 years, and two patients were lost to follow-up after 2 years. In group B, there was no recurrence over a follow-up period of 72-84 months, with three patients lost to follow-up after 3 years. CONCLUSION: In the present study bilateral TEP was performed in three types of patients: those with clinically bilateral hernias, those with clinically unilateral hernia but with an OCH, and in truly unilateral hernias. All of these were compared with unilateral TEPs in clinically unilateral hernias, and we found no significant increase in morbidity, pain, recurrence or complications in bilateral repairs. Convalescence from surgery, as determined by return to activities of daily living and return to work parameters, was also comparable. Surgeons experienced in laparoscopic TEP, in high-volume centers, can provide bilateral repairs in patients with inguinal hernia, bearing in mind its advantages and comparable morbidity. We also feel that, in elective repair of inguinal hernia, the patient should be given the option of bilateral repair. Bilateral repair does not add to the risk of surgery in experienced hands and we strongly feel that unilateral TEP is actually a job half done.

Stapled hemorrhoidopexy: a technique for applying the crucial purse string suture (MAMC Technique).

BACKGROUND: Stapled hemorrhoidopexy for prolapsing hemorrhoids has been found to be associated with lesser postoperative pain and consequently earlier mobilization and return to work, in comparison to conventional hemorrhoidectomy. Purse string application remains a crucial step to ensure adequate lifting of the anal mucosa and this step is technically tedious in the presence of large hemorrhoids obscuring the vision using the standard purse string applicator. The proposed method in our technique makes this crucial step more reliable, easier, and safe in the hands of the beginner and the experienced surgeon alike. METHODS: Thirty healthy adults (21 males and 9 females) with grade 3 or 4 hemorrhoids underwent stapled hemorrhoidopexy at a large university referral hospital in New Delhi. Purse string application was the first step in the entire procedure even before the application of the circular anal dilator. The purse string was applied using authors' method herein after referred to as Maulana Azad Medical College "(MAMC) technique" after the name of the institution. Rest of the procedure was completed as described by Longo et al. RESULTS: The mean operative time was 26 minutes (range 16 to 40 min). The mean visual analog scale (VAS) pain score on day 1 was 1.6 (range 0 to 3). The mean hospital stay was 1.1 days (range 1 to 2 d). There was no major intraoperative complication and one case each of postoperative urinary retention and residual hemorrhoid, there was no recurrence, anal stenosis, or anal incontinence after a mean follow up of 15 months (range 3 to 24 mo). CONCLUSIONS: The procedure described is safe, easy to learn, and technically sound, enabling the application of the crucial purse string at the desired distance from the dentate line, in the correct submucosal plane with closely placed bites and at the same transverse level.

Rectus abdominis muscle flap for high-output duodenal fistula: novel technique.

Duodenal fistula after closure of peptic ulcer perforation, though rare, is difficult to manage and carries a high mortality. The high mortality is associated with the poor nutritional status of the patient, high output from the fistula, and late development of peritonitis and septicemia. The various techniques described in the literature for the closure of the postsurgical external duodenal fistulas range from conservative management with total parenteral nutrition (TPN), serosal patch repair, and Roux-en- Y procedures to radical surgery like Billroth II gastrectomy. Total parenteral nutrition achieves spontaneous closure in 70% to 80% of cases, but it is very expensive and requires prolonged hospitalization. In addition, some surgical procedures have yielded poor results in our setting, so we sought a new modality of treatment. We describe a novel technique for repair of postsurgical external fistula of the duodenum with a rectus abdominis muscle flap. The rectus abdominis muscle is detached from its superior attachment and mobilized from the rectus sheath. The flap, based on the deep inferior epigastric artery, is raised and sutured to the duodenal fistula with thick silk sutures. We treated six patients with post-surgical duodenal fistulas with this technique between 1995 and 2002. The leak was completely sealed in all patients. One patient died of septicemia. We recommend this technique for the management of postsurgical external duodenal fistula as an alternative to other surgical techniques.