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The ease of the anterior component separation technique (ACST) makes it an attractive surgical option for ventral hernia repairs (VHR). Incorporation of indocyanine green-fluorescence angiography (ICG-FA) to map soft tissue perfusion during open ACST is an effective way to minimize the wound complications. This study aims to evaluate the impact of adoption of ICG-FA on wound-related complications following open ACST in VHR. We performed a retrospective review of patients who underwent VHR with the open ACST at a single centre between March 2018 and July 2020. The study comprised of consecutive cases of open ACST with onlay meshplasty done before (March 2018–April 2019) and after (May 2019 to July 2020) implementation of ICG-FA for intra-operative perfusion mapping of subcutaneous tissue and skin. The pre-ICG group and post-ICG group were similar in terms of baseline patient demographics and peri-operative details. The rate of surgical site occurrence’s was higher in the pre-ICG group, but this result was not statistically significant (46% vs. 26%; p value 0.189). Skin necrosis, however, was observed in significantly less patients of the post-ICG cohort (29% vs. 5%; p value 0.045). This study demonstrates the effectiveness of perfusion mapping by the use of ICG angiography to determine potential areas of decreased perfusion and thereby minimize wound complications. Using ICG-FA to guide removal of at-risk tissue to minimize wound complications may substantially improve the patients outcome.

Background Laparoscopic cholecystectomy (LC) is increasingly being used as a first-line treatment for acute cholecystitis. Bile duct injury (BDI) remains the most feared complication of the minimally invasive approach specially in cases with an inflamed calots triangle. While use of indocyanine dye (ICG) to delineate biliary anatomy serves to reduce BDI, the high cost of the technology prohibits its use in the developing world. We propose a novel use of common bile duct (CBD) stenting preoperatively in cases of cholecystitis secondary to choledocholithiasis as a means of identification and safeguarding the CBD. Methods A retrospective review was conducted on 22 patients of Grade 2 or Grade 3 cholecystitis who underwent an early LC at our institution. All patients were stented preoperatively and the stent was used for a much-needed tactile feedback during dissection. A c-arm with intraoperative fluoroscopy was used to identify the CBD prior to clipping of the cystic duct. Results The gall bladder was gangrenous in all the cases while two cases had evidence of end organ damage. This innovative use of CBD stenting allowed us to correctly delineate biliary anatomy in all of the cases and we report no instances of BDI despite a severely inflamed local environment. Conclusion This technique can become a standard of care in all teaching institutions in developing countries further enhancing the safety of cholecystectomy in gangrenous cholecystitis with a distorted biliary anatomy.

Background Any fracture to the rib cage, particularly the left sided ribs, implies a high impact trauma and higher predisposition to splenic injury. Our hypothesis is that injuries causing fractures to the left sided ribs may indicate a high-grade splenic injury which may require splenectomy. This would help the surgeon working in rural and limited resource settings, to plan splenectomy in hemodynamically stable patients with an undetermined grade of splenic injury. With this hypothesis in mind, we aimed to determine how fractures to the left sided ribs, in cases of splenic injury, are associated with splenectomy. Methods We performed a subgroup analysis of patients with splenic injury from a prospective trauma registry study named ‘Towards Improved Trauma Care Outcomes’ in India. Categorical variables were analyzed using the chi square test and a binary logistic regression was developed to assess the significance of continuous variables. Results During the study period, a total of 16047 patients were included. Of these, 267 patients suffered from splenic injury and 70 patients required splenectomy. Fractures of the left sided ribs was not associated with splenectomy. Injury severity score (ISS), a lower systolic blood pressure and oxygen saturation at arrival, requirement of blood transfusions within 24 hours of admission and a higher grade of splenic injury (grade 4 and grade 5) were associated with splenectomy. Conclusion In contradiction to our initial hypothesis, we found that left sided rib fractures were not significantly associated with splenectomy. Grade of splenic injury was an important determinant of splenectomy.

Purpose Since mesh-related long-term morbidity like chronic groin pain and vas entrapment in patients with an inguinal hernia is a concern, tissue-based repairs should be revaluated. There have been few prospective studies comparing the outcomes of Lichtenstein's technique and Desarda's technique for the repair of uncomplicated inguinal hernias. So, we conducted this prospective study comparing the two techniques. Methods This is a single-center prospective observational study conducted for a period of one year (2019). The patients who underwent surgery for uncomplicated inguinal hernia either by Lichtenstein's technique or Desarda's technique were included in the study. The two techniques were compared with respect to recurrence rates, immediate postoperative pain, chronic groin pain, wound infection, and the time taken to return to activities of daily living (ADL). Results There was no significant difference in the recurrence rates, chronic groin pain, wound infection, or return to ADL between Lichtenstein's technique and Desarda's technique of inguinal hernia repair. The mean duration to return to ADL was lesser when patients underwent Desarda's repair though this difference was not significant. Conclusion Desarda's tissue repair was found comparable to Lichtenstein's mesh repair in terms of recurrence and postoperative morbidity, immediate postoperative pain, chronic groin pain, wound infection, and the time taken to return to ADL. Desarda's technique may be considered as an alternative to mesh-based repairs to avoid long-term mesh-related morbidity for uncomplicated indirect hernias in the younger population.

Background: Pancreatic trauma occurs in 0.2-2% of patients with blunt trauma and 1–12% of patients with penetrating trauma. The mortality and morbidity rates range from 9-34% and 30-60% respectively. We aimed to review the management of pancreatic trauma in a multicenter database from India.Methods: We analyzed all patients who suffered a pancreatic injury and who were included in the multicenter prospective observational study ‘Towards Improved Trauma Care Outcomes (TITCO)’.Results: Of the 16047 trauma cases, 1134 (7.1%) patients suffered abdominal trauma. Of all those with abdominal trauma 55 patients (4.9%) had injury to the pancreas. 28 patients (50.9%) with pancreatic trauma were managed conservatively. 27 patients (49.1%) underwent surgical exploration in the form of laparotomies. 11 procedures were undertaken for pancreas. A total of 45 (82%) patients had associated injuries along with pancreatic injury. Thorax (19) (including injuries to lung, pleura and ribs), liver (17), bowel (14) and spleen (13) were the most common associated injuries.Conclusion: Conservative management was as common as operative management in patients with pancreatic injuries. Most (80%) grade III/IV underwent operative treatment. Many patients (82%) had associated injuries. Level of evidence: III

Background The spleen is protected by the ribs anteriorly, the vertebral column posteriorly and the pelvis inferiorly. Fractures to this bony cage may indicate a high-grade splenic injury necessitating splenectomy. We aim to determine whether fractures to the bony cage protecting the abdomen are associated with splenectomy. Methods We performed a subgroup analysis of patients with splenic injury from a prospective trauma registry study named ‘Towards Improved Trauma Care Outcomes’ (TITCO) in India. Out of the 16047 patients enrolled in the TITCO study, 267 patients with splenic injury were included. Categorical variables were analyzed using the chi square test and logistic regression was used to assess the significance of continuous variables. A multivariate analysis was performed on the factors deemed clinically most significant. Results Patients with a higher grade of splenic injury were more likely to require splenectomy when adjusted for other variables (p value

Background Posterior component separation (PCS) via transversus abdominis release (TAR) technique overcomes the pitfalls of traditionally described repairs. We evaluate the safety and efficacy of this approach and present the lessons we have learnt in our experience with a large series of complex ventral hernias. We also evaluate the importance of pre-operative optimisation and the value of a dedicated abdominal wall reconstruction (AWR) team in improving the surgical outcomes. Study Design A retrospective review of all patients undergoing TAR at a specialised hernia centre in the 2016-2019 period was performed. Pertinent data collected included patient demographics, peri-operative details and post-operative complications. Primary outcome variables were surgical site occurrences (SSO) and hernia recurrence. A multivariate regression model was developed to determine significant predictors of SSO. Results In 92 consecutive patients, the mean age was 52 years with a mean body mass index of 27.9%. Major comorbidities included diabetes (41%), hypertension (23%), and chronic obstructive pulmonary disease (15%). The mean hernia defect was 13.2 cm and the average operative time was 232 minutes. Complete posterior sheath closure was achieved in 95.6% cases. There were 18 (19.5%) cases of SSO which were managed conservatively and no cases required mesh explanation. There were 2 (2.1%) recurrences which required a redo surgery. On multivariate analysis operative time (p value 0.047) was a significant predictor of SSO. Conclusions AWR using the TAR approach offers a robust repair with low overall morbidity. A holistic pre-operative optimisation strategy and a dedicated AWR team can further improve surgical outcomes.

Incisional hernia is one of the most common surgical complications after surgery with an incidence of 10–20%. A total of 33–78% of patients with ventral and incisional hernias are symptomatic for their condition while 5 to 14% develop complications such as incarceration, obstruction, and strangulation. Minimally invasive techniques have gained preference over open techniques in view of decreased morbidity and lower recurrence rates. In this article, we describe our experience of endoscopic pre-aponeurotic repair—a minimally invasive technique for ventral and incisional hernia repair at a tertiary care centre in India. Patients presenting with primary ventral or incisional hernia with concomitant rectus abdominis diastasis were included in the study. This study was conducted between July 2016 and July 2018 and included 38 patients. These patients were operated by endoscopic pre-aponeurotic repair technique. The mean operative time was 85 min with no intra-operative complications and zero conversion rate to open surgery. Seroma and umbilical dermal ischaemia were the only complications, which were managed conservatively. The endoscopic pre-aponeurotic repair technique is a safe and effective alternative for treating patients diagnosed to have ventral hernia with rectus abdominis diastasis.