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Wg Cdr Ameet Kumar , Brig C.K. Jakhmola , Maj Gen N.C. Arora, VSM**, Col S.S. Chauhan d a Assistant Professor (Surgery), Army College of Medical Sciences and Classified Specialist (Surgery) and GI Surgeon, Base Hospital, New Delhi 10, India b Professor and Head (Surgery), Army College of Medical Sciences and Consultant (Surgery) and GI Surgery, Base Hospital, New Delhi 10, India c Consultant (Surgery and Orthopaedic Surgery) and Commandant, Base Hospital, New Delhi 10, India d Professor (Surgery), Army College of Medical Sciences and Classified Specialist (Surgery) and GI Surgeon, Base Hospital, New Delhi 10, India

A laparoscopic approach to repair of inguinal hernia has become popular. The reduction of an indirect sac can be challenging especially if it is long standing or is large. In such situations, the established practice is to divide the sac at the neck and ligate it. Ligation of the sac has been shown to cause increased postoperative pain. Hence we postulated that we could possibly avoid ligation of this divided sac without causing increased intraoperative difficulty or postoperative complications.This was a retrospective review of a prospectively maintained database of all patients who underwent laparoscopic totally extraperitoneal repair (TEP) during a 7-year period at our center with a minimum of 1 year of follow-up. We compared the outcomes of the patients who underwent only a division (group I) versus those who underwent division followed by ligation (group II) of the indirect sac.There were 189 and 126 patients in groups I and II, respectively. Group I patients fared better in terms of operative times and postoperative pain scores. The postoperative complication and short-term outcomes were not significantly different between the two groups.Non-ligation of a divided indirect sac during TEP is feasible and has the advantages of reduced operative times and postoperative pain and does not lead to increased complications.

Highlights • Gastrointestinal stromal tumors (GIST) are solid tumors. • Atypical presentations in form a cystic lesion have been rarely reported. • A duodenal GIST masquerading as a cystic lesion has never been reported. • First report a case of a large duodenal cyst that finally, turned out to be a GIST. • Successfully managed by local resection avoiding a pancreaticoduodenectomy., Introduction Gastrointestinal stromal tumors (GIST) are solid tumors. A duodenal GIST masquerading as a cystic lesion has never been reported. We report a large duodenal cyst that finally turned out to be a GIST and was managed without a pancreaticoduodenectomy (PD). Presentation of case A 55 year old lady presented with painful lump in epigastrium. A CT scan revealed a large exophytic cystic lesion from the duodenum with a small solid component. An endoscopy showed a polypoid lesion in the second part of the duodenum adjacent to what looked like a diverticulum. A sleeve duodenal resection, duodeno-duodenostomy and pyloric exclusion was done. The histopathology was duodenal GIST. Discussion This case posed diagnostic difficulty as it was thought to be either a duplication cyst or a diverticulum of duodenum. The odd point was the small solid component in it. We considered the possibility of a malignancy arising in these settings, which is has been occasionally reported. To our surprise, it turned out to be a GIST. An extensive literature search yielded only four reports that have reported cystic GISTS, all arising from the stomach or pancreas where they have been mistaken for pseudocysts or even a mucinous cystadenocarcinoma of the pancreas. This is the first report of a cystic GIST arising from the duodenum. Conclusion GISTS can present as a predominantly cystic lesion and needs to be considered in the differential diagnosis of cystic lesions of the duodenum. Local resection is an attractive option in select cases and avoids a PD.

Pancreaticoduodenectomy is a formidable surgery and was associated with high morbidity and mortality. Though the mortality rates have steadily improved, morbidity continues to be high. There is lack of published data on outcomes following pancreaticoduodenectomy in Armed Forces hospitals. The aim of this study was to analyze the short term outcomes at our center and to compare it with the published literature.A retrospective review of prospectively maintained data base was done. Preoperative, intraoperative and postoperative data was analyzed with emphasis on the morbidity and mortality rates. Follow up data was analyzed to look at disease recurrence.Between Jan 2008 and March 2014, 69 patients underwent Whipple's pancreaticoduodenectomy with a median age of 64 years. All had a malignant etiology with periampullary carcinoma being the commonest (42%). Overall, intra-abdominal complications occurred in 46% of patients which included postoperative pancreatic fistula (20%) and delayed gastric emptying (24%). The mortality rate for the whole was 11% which reduced to 8% in the second half of the study.The short term outcomes at our center were comparable to those in published literature. The mortality rates showed a decreasing trend with time.

Acute pancreatitis (AP) in the early postlaparoscopic cholecystectomy (LC) period is a rare complication. The cause is often a missed common bile duct stone. Having been reported only once before, we present a second case of AP after LC caused by hemobilia secondary to hepatic artery pseudoaneurysm. The management of this complication is distinctly different from the treatment for AP caused by a stone and must be done on an emergency basis.

Background: Minimally invasive esophagectomy (MIE) has shown an increasing trend, especially in the last decade, in the management of esophageal malignancy. The aim of the present study was to present a cohort of patients who underwent MIE between June 2008 to June 2016 at a single tertiary care centre.Methods: A total of 103 esophagectomies were performed for esophageal malignancy which included 69 patients by minimally invasive technique. The procedure was performed by thoracoscopic mobilization of esophagus initially followed by reconstruction part done by either by minilaparotomy or by laparoscopic approach i.e. total thoracolaparoscopic esophagectomy (TLE).Results: The MIE was successfully completed in 65 (94.2%) patients. Operative time ranged from 275 to 420 min (average 356 min). The number of dissected lymph nodes were 5–15 (9 on average). The postoperative period was uneventful - without any complications in 36 (52.17%) patients. The most common postoperative complications were respiratory complications which were observed in 22 (31.88%) patients. Other complications included post-operative bowel obstruction (1 patient), anastomotic leak (4 patients), and necrosis of the gastroplasty (1 patient). One patient had chyle leak while cardiac complication was seen in three cases. The overall morbidity of patients underwent MIE was 47.8%. Thirty-day mortality was 5.79%.Conclusions: Esophagectomy performed by minimally invasive technique is a widely accepted surgical procedure for patients with middle and lower esophageal malignancy. The biggest benefit of MIE is avoidance of thoracotomy / laparotomy associated pain with resultant decrease in morbidity. The success of MIE requires a dedicated surgical team well trained in both MIE as well as in open surgical procedure.

Background Surgery for inguinal hernia continues to evolve. The most recent development in the field of surgery for inguinal hernia is the emergence of laparoscopic inguinal hernia surgery (LIHS) which is challenging the gold standard Lichtenstein's tension free mesh repair. Our centre has the largest series of LIHS from any Armed Forces hospital. The aim of this study was to analyze the short and long term outcomes at our center since its inception. Methods Retrospective review of prospectively maintained data base of 501 LIHS done in 434 patients by a single surgeon between April 2008 and October 2013. Preoperative, intraoperative, postoperative and follow-up data was analyzed with emphasis on the recurrence rates and the incidence of inguinodynia. Results 402 (92.6%) patients had primary hernias and 367 (84.6%) patients had unilateral hernias. Of the 501 repairs, 453 (90.4 %) were done totally extraperitoneal approach and 48 (9.6 %) were done by the transabdominal preperitoneal approach. The mean operative time for unilateral and bilateral repairs was 40.9 ± 11.2 and 76.2 ± 15.0 minutes, respectively. The conversion rate to open surgery was 0.6%. The intraoperative, and early and late postoperative complication rates were 1.7%, 6.2% and 3%, respectively. The incidence of chronic groin pain was 0.7% and the recurrence rate was 1.6%. The median hospital stay was 1 day (1–5 days). Conclusion We, in this series of over 500 repairs have demonstrated that feasibility as well as safety of LIHS at our centre with good short and long term outcomes.

Autoiommune pancreatitis (AIP) is a rare disease that has distinct histological, immunological, serological and radiological findings. It is characterised histologically by lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phelibitis and presence of IgG4 positive plasma cells and lymphocytes. Elevated serum levels of IgG4 are also noted. It is usually misdiagnosed preoperatively as pancreatic cancer. It may involve extrapancreatic sites also and responds well to steroid therapy. Here, we share our experience of AIP in a 52-year-old male.

Spontaneous rupture of the rectum is a rare occurrence. A total laparoscopic approach to rectal perforation has only occasionally been reported. We report an unusual case of a young boy who developed a spontaneous rupture of the rectum following a trivial fall. A magnetic resonance imaging revealed a tear in the rectum at the peritoneal reflection with the omentum plugging it. He denied any history of rectal instrumentation or abnormal sexual activity. He had no history of constipation or rectal prolapse. The tear was repaired laparoscopically and a covering loop sigmoid colostomy was added. He made an uneventful post-operative recovery. Spontaneous rupture of the rectum can occur in younger age groups and even in the absence of significant trauma. One needs to diligently bring out a history of rectal trauma. Equally important is to rule out any underlying pathological condition. A laparoscopic approach is feasible, especially in early cases.

Altered bowels habits along with rectal mass in an elderly would point toward a rectal cancer. We report an unusual case of a post-menopausal lady who presented with these complaints. We had difficulties in establishing a pre-operative diagnosis. With a tentative diagnosis of a rectal cancer/gastrointestinal stromal tumor, she underwent a laparoscopic anterior resection. On histopathology, this turned out to be endometriosis. Bowel endometriosis is an uncommon occurrence. That it occurred in a post-menopausal lady was a very unusual finding. We discuss the case, its management, and the relevant literature.

The estimated incidence of congenital diaphragmatic hernia (CDH) is 1 in 2000–5000 live births. They are the rarest of CDH, making up 2–3% of all the diaphragmatic hernia cases.1 The aetiology of CDH is unknown, however, 2% of cases have been noted to be familial and another 15% of patients have associated chromosomal abnormalities. Presentation may vary from non-specific gastrointestinal symptoms to bowel obstruction and strangulation.2 More than half of patients can be diagnosed incidentally while investigating unrelated problems and most symptomatic cases tend to present acutely.3 We are reporting an eighty years old male patient with Morgagni hernia, who presented with features of GOO and underwent successful laparoscopic reduction of hernia followed by mesh and intracorporeal suture repair of the diaphragmatic defect Figs. 1 and 2. Fig. 1 (a) Radiograph chest – blunting of right CP angle (yellow arrow); obscuration of cardiac silhouette on right side; right dome of diaphragm is poorly delineated with areas of increased density and multiple air lucencies (red arrow head). (b) Post ... Fig. 2 Intra op (a) 10 × 8 cm sized defect clearly visible after reduction of the hernial contents. (b) Anchoring of dual mesh (PTFE side towards the abdomen); intracorporeal suturing with silk 2-O in progress, tackers already in place ... Case report An eighty-years-old patient was admitted under gastroenterology medicine (GE) with chief complaints of heart burn (10 days), post meal vomiting (2 days) and pain upper central abdomen (2 days). There was no history of lump abdomen, hemetemesis, malaena or jaundice. In the past history patient was a known case of coronary artery disease (CAD) and cerebro-vascular disease and was on regular follow up. General physical examination was normal. On abdominal examination there was fullness and deep tenderness in the epigastrium; but no signs of peritoneal irritation were present. The rest of abdominal examination was essentially normal. The respiratory system examination revealed reduced air entry in the right basal area and occasional crepts bilaterally. Routine blood tests; including liver function tests were within normal range. In the chest radiograph there was blunting of right cardio-phrenic (CP) angle and areas of increased density with multiple air lucencies were seen along right hemidiaphragm outline (Fig. 1a). Ultrasonography (USG) abdomen showed dilated stomach and pylorus with abrupt cut off at the junction of pylorus with first part of duodenum (D1). Contrast enhanced computed tomography (CECT) abdomen revealed distended stomach and a large defect in right hemidiaphragm. The body of stomach, pylorus and transverse colon along with omentum were found herniating into right hemithorax (Fig. 1b–d). Evaluation with upper gastrointestinal endoscopy showed stasis oesophagitis, food residue in the stomach, scope could not be negotiated beyond pylorus. A surgical review was requested and he was planned for surgery on next day. In the pre anaesthetic checkup there was mild restriction of pulmonary function and echocardiography was suggestive of early diastolic dysfunction. Considering the advanced age of patient, multiple comorbidities and morbidity of large sub costal incision; patient was considered for laparoscopic reduction and mesh repair. Intra operatively there was large Morgagni hernia anterior to right lobe of liver and the defect measuring 10 × 8 cm in size was present (Fig. 2a). Distal part of stomach, transverse colon and the omentum were found herniating through the defect. Laparoscopic reduction of the contents was done. The margins of hernia sac were dissected and defined; the sac was not removed. As primary closure was not possible, 15 × 12 cm dual mesh (Prolene+PTFE) was placed over the hernia defect and secured to the margins with 5 mm and 10 mm tackers. Intracorporeal silk 2-0 sutures on medial side were taken because of close proximity to the pericardium and heart; tackers were avoided on this side (Fig. 2b). Post operative recovery was uneventful. Patient was started on oral diet on first post operative day (POD) and was discharged on second POD. Patient is asymptomatic and there is no evidence of recurrence after six months of follow up.