Assessment of Risk Factors for Conversion from Difficult Laparoscopic to Open Cholecystectomy - A Hospital Based Prospective Study

Background: Laparoscopic cholecystectomy is the gold standard in the treatment of gallstones. It has proved to be an effective and safe procedure both in elective and emergency conditions; however, conversion to open surgery is inevitable in some cases. Hence the present study was carried out to identify various factors which can predict the difficult laparoscopic cholecystectomy so that an early conversion to open cholecystectomy can be considered. Material and Methods: A prospective st st study was conducted from 1 February 2011 to 31 January 2012 that included 63 patients of all age groups and both sexes who were found to have symptomatic gallstones and were scheduled for laparoscopic cholecystectomy at Nepalgunj Medical College and Teaching Hospital, Nepal. Age, sex, body mass index, previous abdominal surgery and past history of acute attack of cholecystitis of the patients were recorded. A pre-operative ultrasound was performed just prior to surgery, and three ultrasonographic parameters were analyzed, namely gall bladder wall thickness, number of stones and stone impacted in Hartmann's pouch. Intra-operative causes for difficult laparoscopic cholecystectomy like adhesions in Calot's triangle and gall bladder perforation with bile leak were also evaluated. Results: Total number of patients in this study was 63; out of which difficult laparoscopic cholecystectomy was seen in 25(39.7) patients and 7(11.1) patients required conversion to open cholecystectomy. Ultrasonography was good at predicting difficulty in each component with exception of gall bladder wall thickness which was not statistically significant. Conclusion: BMI, ultrasonographic finding of presence of multiple stone or stones impacted in Hartmann's pouch, adhesion in Calot's triangle and gall bladder perforations are predictors of difficult laparoscopic cholecystectomy

e-TEP Retromuscular Repair for Recurrent Incisional Hernias: Report of Three Cases

Introduction. Recurrent incisional hernias are difficult to treat. There are many factors involved in the recurrence, and due to extensive dissections, the planes are fused with adhesions, and we may need a new plane for dissection and placement of meshes. Case Report. We report here three cases of recurrent incisional hernias which were dealt by a relatively new method to laparoscopy: the enhanced view totally extraperitoneal repair (e-TEP) retromuscular technique. There were three patients: one after an open onlay repair of lower midline incision, another after an onlay mesh repair of a subcostal incision for open cholecystectomy followed by an intraperitoneal onlay mesh hernioplasty (IPOM) repair, and another after IPOM repair of epigastric hernia. They were treated with the abovementioned technique with satisfying short-term results. Conclusion. The e-TEP technique is a relatively new method of providing minimal access surgery to these patients utilizing the previously unaccessed retromuscular (Rives and/or preperitoneal) space for the repair of these recurrent incisional hernias

Challenges and Results of Laparoscopic Splenectomy for Hematological Diseases in a Developing Country

Introduction. Though, in developed countries, laparoscopy is now a gold standard for splenectomy, we are lacking in this aspect in the eastern world. Splenectomy has mostly been performed by open surgery in our region. This is our effort to introduce laparoscopic splenectomy in our country. Methods. This is a retrospective cohort study done in patients presenting to hematology and surgery department of our hospital who underwent laparoscopic splenectomy for hematological diseases from January 2013 to December 2016. Results. There were 50 patients (38 females, 12 males). The diagnoses were idiopathic thrombocytopenic purpura in 31, (steroid/azathioprine-resistant, steroid dependent), hereditary spherocytosis in 9, alpha-thalassemia in 3, beta-thalassemia in 2, autoimmune hemolytic anemia in 4, and isolated splenic tuberculosis in 1. Average platelet counts preoperatively were 62000±11000/mm3 (range 52000-325000/mm3). The mean operative time was 130±49 minutes (range 108-224 min). The mean postoperative stay was 4±2.11 days (range 3-9 days). Laparoscopic splenectomy could be completed in 45 (90%) patients. Conclusion. Laparoscopic splenectomy could be successfully contemplated in patients with hematological diseases, especially if spleen is normal or only mildly enlarged, and is an advantageous alternative to open splenectomy. Absence of ideal resources has not limited our progress in minimal access approach

Endoreplication and polyploidy: insights into development and disease

Polyploid cells have genomes that contain multiples of the typical diploid chromosome number and are found in many different organisms. Studies in a variety of animal and plant developmental systems have revealed evolutionarily conserved mechanisms that control the generation of polyploidy and have recently begun to provide clues to its physiological function. These studies demonstrate that cellular polyploidy plays important roles during normal development and also contributes to human disease, particularly cancer