Search

BACKGROUND Intra-Operative Cholangiogram (IOC) is a procedure carried out during cholecystectomy with the primary objective of clearly delineating the biliary anatomy. Over decades, routine IOC became selective IOC and now it is being overtaken by less invasive investigations like MRCP and EUS. Role of IOC remains only to intraoperatively confirm or rule out bile duct injury in difficult cases. Laparoscopic IOC is a skilful procedure which requires training and extra added time during laparoscopic cholecystectomy. Once mastered it can be used in many situations for either anatomical reasons or to detect CBD pathology. METHODS All patients getting admitted for laparoscopic cholecystectomy with intermediate risk for choledocholithiasis were enrolled in the study from 2016 to 2019. Procedure was carried out with all necessary consents and precautions. All cases were performed by an experienced GI surgeon and followed up with proper protocol. RESULTS Fifty patients with known intermediate risk for choledocholithiasis underwent laparoscopic cholecystectomy with laparoscopic IOC. Procedure was successfully done in all patients except two, where cystic duct was very thin and cannulation was not possible. Forty-one (82%) patients had deranged liver function test and 9 patients (18%) had history of acute pancreatitis in the past as indications for the procedure. Two patients had dilated CBD (>6 mm) on ultrasound along with deranged liver function tests. An average of 12 minutes was taken to perform the procedure (range: 8 - 15 min). In cases where IOC took longer time was mainly due to technical issues (operability of C-arm). No IOC related complications occurred in any of the patients. Hospital stay was not prolonged in any of the patients due to IOC. None of the patients had any filling defect in CBD. All cases followed till date are asymptomatic. CONCLUSIONS It is a technically feasible procedure that can be performed with limited addition to OT time, minimal failure rate, and complications. All patients with limited criteria for intermediate risk of choledocholithiasis had a normal IOC with no evidence of biliary obstruction in follow up. KEYWORDS Laparoscopic Intraoperative Cholangiogram, Intermediate Risk, CBD Stones

The development of a cholecystoenteric fistula (CEF) is an uncommon complication of cholelithiasis and it is usually seen to develop in patients with long-standing disease. An incidence of 3–5% has been reported in patients with cholelithiasis and 0.15–4.8% of patients undergoing biliary surgeries may have a CEF (Chowbey et al. J Laparoendosc Adv Surg Tech 16:467–472, 2006). The most common cholecystoenteric fistulae are of the cholecystoduodenal variety (70%), followed by cholecystocolic (8 to 26.5%) and cholecystogastric fistulae (Safaie-Shirazi et al. Surg Gynecol Obstet 137:769–772, 1973; Balent et al. Hawaii J Med Public Health 71:155–157, 2012). In this report, we share our experience of cholecystoenteric fistulae to highlight the presentation, intraoperative findings, and management. Retrospective review of patients with CEF encountered in our experience between 2003 and 2016. Patients admitted for laparoscopic cholecystectomy during this period were involved in the series and patients having cholecystoenteric fistulae were analyzed in detail and their picture is discussed. Among 2450 cholecystectomies encountered, a total of 35 patients had cholecystoenteric fistulae. There were 15 males and 20 females in the age range of 33–76 and with a mean of 55 years. Twenty-eight of the 32 (80%) patients were over 50 years of age. The most common type of fistula was cholecystoduodenal fistula (CDF) and was detected in 32 (91.4%) patients. Other types encountered were cholecystocolic fistula in two patients (5.71%) and cholecystogastric fistula in one (2.857%) patient. Ultrasound was the basic investigation. All cases were diagnosed intraoperatively. Overall 23 patients (65.71%) required a laparotomy. The remaining 12 (34.28%) cases were managed completely by the laparoscopic approach. Earlier in the cases, feeding jejunostomy was regularly used which became occasional in the later part of series. Cholecystoenteric fistulae are rare complication of long-standing gall stone disease. In the era of laparoscopy, many of these cases can be dealt laparoscopically. Low tolerance should be kept for conversion so that patient gets the best possibility of dealing with the condition in the same sitting without added complications.

Pancreaticoduodenectemy(PD) is the treatment of choice for malignant and some benign diseases of the pancreas and periampullary region. Common complications after PD include delayed gastric emptying, pancreatic fistula, anastomotic leak and intra abdominal collection. Postoperative medical complications include arrhythmia, renal failure, pulmonary complications, UTI and Deep vein thrombosis. Superior mesenteric artery (SMA) thrombosis is rarely been reported after PD. There is theoretical possibility of arterial thrombosis in patient with history of vascular disease, which may precipitate after postoperative hypovolemia. SMA thrombosis is difficult to diagnose in postoperative period due to nonspecific symptoms and associated with high mortality rate up to 80-90%. Our patient was a 68 years old female with lower end cholangiocarcinoma without any other co-morbidity. She underwent PD without any intraoperative complications. Post operatively she developed SMA thrombosis. Unfortunately patient could not be salvaged and she succumbs to death.

Parahiatal hernias are rare and distinct subtype of diaphragmatic hernia, which is very difficult to diagnose clinically. Laparoscopic repair has been reported in the literature. We report a case of parahiatal hernia with gastric volvulus, which was repaired successfully by robotic surgery along with gastropexy. We present the case of a 50-year-old male who presented with vomiting and epigastric pain. His CT scan showed a giant parahiatal hernia with intrathoracic gastric volvulus. Intraoperatively, a diaphragmatic muscular defect was found lateral to an attenuated left crus of the diaphragm, distinct from the normal esophageal hiatus. The defect ring was fibrotic and large, making a tension-free primary repair difficult. A prolene mesh repair was done and two point gastropexy to the anterior abdominal wall was performed robotically. Recovery was uneventful and the patient was discharged on the 5th postoperative day. He remained asymptomatic at subsequent follow-up. Robotic repair of parahiatal hernia can be safely performed with advantage of robotic surgery in this difficult access area. In circumstances where a large defect prevents a tension-free primary repair, the use of a mesh can provide effective repair of the hernia defect.

Pancreatic inflammation limited to the area between the wall of the duodenum and common bile duct is referred to as groove pancreatitis. The condition is often associated with cystic dystrophy in the medial wall of the duodenum. These patients can present with features of either pancreatitis or pancreatic malignancy. CA19.9 levels are usually normal and serum amylase and lipase may be slightly elevated. Diagnosis is confirmed with either computerized tomography abdomen or endoscopic ultrasound. Management consists of conservative management and endoscopic shincterotomy. Pancreatico-duodenectomy may be required in some cases. In our case, a pancreatico-duodenectomy was required as the patient was suffering from gastric outlet obstruction and severe episodes of recurrent acute pancreatitis.

Colorectal cancer is a major cause of morbidity and mortality worldwide. The Indian scenario also shows a similar trend, and this has been attributed to the changing dietary patterns. Recurrence in colorectal cancer is associated with many factors, some related to the tumor itself and some to the surgical principles applied. Understanding these factors and application of sound surgical principles can go a long way in decreasing the incidence of colorectal cancer. Here, we highlight the main biological and technical factors implicated in the recurrence of colorectal cancer.

We present a case of 87-year-old overweight male who presented to us with intestinal obstruction. He was found to have the classical sings of gall stone ileus (pneumobilia, intestinal obstruction & gall stones in the distal ileum). He was managed with a single stage procedure. Here we also describe the available literature and the various treatment options available for the same.

The use of robotics in colorectal surgery is gaining momentum of late. Technical advances, such as three-dimensional imaging, a stable camera platform, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling and instruments with multiple degrees of freedom, have helped many surgeons adapt to it easily. There is a shorter learning curve compared to the standard laparoscopic surgery. This article helps to give an outline as to how robotic colorectal surgery can go a long way in the future of colorectal surgery.

Studies reporting on the recurrence rate after laparoscopic repair of large hiatal hernias (HH), including anatomical asymptomatic recurrence, are scarce. So far, the impact of telematic surgical approach in Gastroesophageal Reflux Disease (GERD) is still obscure. In this prospective study, we analyzed the da Vinci Intuitive Surgical robotic system for antireflux surgery. In August 2012, we set up a pilot study to evaluate the efficacy of laparoscopic telerobotic surgery using the three-arm da Vinci system. Optimal trocar positions, operating and setup times, conversion rate, intraoperative complications, and perioperative morbidity, as well as mortality rate, were analyzed.

An epiphrenic oesophageal diverticulum is most commonly a pulsion diverticulum which develops consequent to protrusion of mucosa through the muscular wall of the distal oesophagus. Most of them are associated with underlying oesophageal motility disorders. The predominant symptoms are dysphagia with regurgitation, and sometimes retrosternal pain, if accompanied by spasm of the oesophagus. Surgical management is recommended for symptomatic patients. Traditional procedures include thoracotomy or laparotomy with excision of the diverticula, but these are associated with high morbidity. Laparoscopic approach is a safe treatment option associated with lesser morbidity. Here, we present a case of epiphrenic diverticulum which was treated by the robotic approach without any complication. There was also no associated motility abnormality in our case so fundoplication was not done. Robotic surgery is a useful tool while operating near the hiatus and gastro-oesophageal junction. We consider transhiatal robotic approach as a safe and easy approach for surgery of epiphrenic diverticulum.