ABSTRACT:Subcutaneous emphysema (SE) is a rare and usually self-limiting complication of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. We report a 74-year-old man who developed massive SE after a short, technically uncomplicated 32-min TEP repair, despite the absence of major modifiable technical risk factors - working pressure ≤12 mmHg, open (Hasson) entry, single absorbable tack and no peritoneal breach. An abrupt rise in end-tidal carbon dioxide (EtCO 2 ) from a stable baseline (34-36 mmHg) to 60 mmHg was the earliest warning sign and preceded clinical detection. Post-operative computed tomography revealed SE extending to the neck, thorax, abdominal wall, back and both upper and lower extremities, surpassing all categories of the Aghajanzadeh classification. The patient was managed conservatively with manual decompression and an intentionally open trocar site, with complete resolution. This case illustrates an anatomical distribution extending beyond the territories included in conventional SE grading and underscores EtCO 2 monitoring as a valuable early warning tool.
ABSTRACT:Herlyn-Werner-Wunderlich syndrome, also known as obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome, is a rare congenital Müllerian duct anomaly, occurring in approximately 1 in 1,000,000 females. It is characterised by a triad of uterine didelphys, obstructed hemivagina and ipsilateral renal agenesis. Patients typically present with chronic pelvic pain, dysmenorrhea and endometriosis, which can lead to diagnostic bias and the misattribution of all pelvic pain to their underlying gynaecological condition. We present the case of a 19-year-old female with a known diagnosis of OHVIRA syndrome who presented with acute right iliac fossa (RIF) pain and raised inflammatory markers. Despite her complex gynaecological background, imaging confirmed a diagnosis of acute appendicitis with impending perforation. She underwent a successful laparoscopic appendicectomy. The patient had experienced multiple prior episodes of RIF pain, previously attributed to her gynaecological condition, without further surgical evaluation. This case underscores the importance of maintaining a broad differential diagnosis in patients with complex gynaecological anomalies and highlights the risk of diagnostic overshadowing. A comprehensive assessment for acute surgical pathology should always be considered in this cohort to avoid delays in diagnosis and treatment.
INTRODUCTION:Inguinal hernia repair is one of the most commonly performed surgical procedures worldwide, yet limited large-scale data exist comparing open and laparoscopic approaches in the Indian population. This study aimed to compare outcomes between these surgical techniques across multiple centres in India. PATIENTS AND METHODS:This multi-centric prospective observational study was conducted by Sir Ganga Ram Hospital in collaboration with the Indian Association of Gastrointestinal Endo Surgeons. Data on all groin hernia surgeries performed over 3 months were collected, with patient outcomes assessed at 30 and 90 days postoperatively using the Clavien-Dindo classification system. RESULTS:A total of 2679 patients underwent inguinal hernia repair: 1592 underwent open surgery and 1087 underwent laparoscopic surgery. The laparoscopic group was significantly older with higher body mass index, and bilateral hernias were more common. Laparoscopic repair demonstrated significantly lower post-operative day-one pain scores, reduced major medical complications and lower surgical site infection rates at 30 days. Chronic groin pain at 90 days was significantly less common in the laparoscopic group. No significant differences in recurrence rates were observed at 90 days. CONCLUSION:This large-scale Indian study demonstrates that laparoscopic inguinal hernia repair offers significant advantages, including reduced post-operative pain, lower complication rates and decreased chronic groin pain compared to open repair. The findings support selective laparoscopic application for bilateral hernias, obese patients and those with metabolic comorbidities while highlighting the need for standardised protocols in Indian healthcare settings.
INTRODUCTION:Minimally invasive surgery has been widely recognised as the standard approach for the treatment of colon cancer. At present, right hemicolectomy for colonic malignancy has been widely done using a laparoscopic approach, in high-volume centres, and that has been proven to be both safe and feasible. However, laparoscopic surgery has several limitations, which can be minimised with robotic platforms. Our study aimed to compare the short-term outcomes of robotic right hemicolectomy (RRH) and laparoscopic right hemicolectomy (LRH). PATIENTS AND METHODS:This was a prospective observational study with two comparative arms. All patients who underwent right hemicolectomy for malignant indications were included and who underwent emergency surgeries for perforation or obstruction were excluded. They were followed up for a minimum of 30 days postoperatively. Statistical analysis was performed using SPSS software (IBM Corp., version 28.0). Continuous variables were expressed as mean ± standard deviation. Comparison between two groups were done using Student's t -test or Mann-Whitney U -test for continuous variables. Chi-square test or Fisher's exact test for categorical variables, as appropriate. RESULTS:A total of 70 patients were recruited in the study, with equal numbers in each arm, and they were well matched. The RRH group had significantly longer operative time than the laparoscopic group (177.1 min vs. 144.7 min, P < 0.001). The length of hospital stay and time to passage of first flatus were shorter in the RRH arm, but it was not statistically significant. Post-operative complications were comparable between the two groups. No reoperation and mortality were noted in both groups. The RRH group had a slightly higher mean lymph node harvest than the LRH group (22.1 vs. 21.2), though not statistically significant. CONCLUSION:RRH offers comparable short-term perioperative and oncological adequacy to LRH, with similar length of hospital stay, post-operative complications, return of bowel function and lymph node yield. RRH appears to be a safe and feasible alternative to LRH. The longer operative time and higher cost of the robotic platform still remain as important limitations for wider application. However, a well-designed, multi-centre RCT with a larger sample size is necessary to validate these findings and to recommend a suitable approach.
BACKGROUND:Selected high-risk appendiceal neoplasms with tumour perforation or T4 disease may be considered for risk-reducing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), even without overt radiological peritoneal disease. Since 2012, our centre has offered laparoscopic CRS-HIPEC, and a robotic approach was recently introduced to enhance visualisation, dexterity, and precision while minimising surgical trauma. This study evaluates the feasibility, safety, and early outcomes of risk-reducing robotic CRS-HIPEC (RCRS-HIPEC) in selected patients with high-risk appendiceal neoplasms without radiological peritoneal disease. PATIENTS AND METHODS:This retrospective single-centre case series was conducted at a national referral centre for peritoneal surface malignancy. Eight patients underwent standardised RCRS-HIPEC. The cohort included low-grade appendiceal mucinous neoplasm ( n = 3), goblet cell carcinoma ( n = 4), and appendiceal adenocarcinoma ( n = 1). The standardised operative approach included omentectomy, falciform excision, umbilicectomy, and cholecystectomy or salpingo-oophorectomy where indicated, followed by closed HIPEC. Outcomes assessed included operative time, blood loss, complications, length of stay, histopathology, patient-reported recovery, and preliminary resource utilisation. RESULTS:Mean age was 65.8 years; there were 5 male and 3 female patients. Mean operative time was 6 h 19 min (±25 min), with minimal blood loss (<150 mL). No patient required epidural analgesia, parenteral nutrition, or prolonged critical care. Median time to first flatus was 3 days, and median hospital stay was 5 days. Two patients experienced Clavien-Dindo grade I morbidity, with no major complications. Histopathology demonstrated residual disease in two patients. Early electronic patient-reported outcome measures suggested favourable recovery, and preliminary Patient Level Information and Costing System data indicated potential NHS resource savings. CONCLUSIONS:RCRS-HIPEC is feasible and safe in carefully selected patients with high-risk appendiceal neoplasms without radiological peritoneal disease. A standardised robotic approach may promote reproducibility, support enhanced recovery, and reduce healthcare resource use. Larger comparative studies are warranted.
Abstract Rectal gastrointestinal stromal tumours (GISTs) are uncommon and pose technical challenges due to their deep pelvic location and proximity to the anal sphincter complex. Radical resections, although traditionally preferred, often result in significant morbidity. We describe two cases of rectal GIST successfully managed by transanal minimally invasive surgery (TAMIS). One patient received neoadjuvant imatinib to downsize the tumour before excision. Full-thickness transanal tumour excision was achieved without rupture in both cases, with primary rectal wall closure. At 5 and 4 years of follow-up, respectively, both patients remain recurrence-free with full continence. TAMIS represents a safe, oncologically sound, organ-preserving approach for selected rectal GISTs.
INTRODUCTION:The prevalence of adolescent obesity has increased dramatically over the past several decades. The objective of this investigation was to evaluate the outcomes of Roux-en-Y gastric bypass (RYGB) surgery in adolescents. PATIENTS AND METHODS:This retrospective case series examined 15 adolescents aged 17 years or younger who underwent RYGB surgery. Of the 15 adolescents, 11 presented with severe obesity-related co-morbidities at the time of surgery. The median follow-up was 84 months. RESULTS:The mean Roux limb length was 80.9 ± 46.32 cm, and the mean duration of initial hospitalisation was 6.1 ± 1.19 days. Thirteen (86.67%) patients lost weight, whereas two (13.33%) gained weight. The mean weight loss was 53.67 ± 25.6 kg, while the mean weight gain was 14.5 ± 0.7 kg. The mean time to weight loss was 60.8 ± 48 months, and the mean time to weight gain was 132 ± 9.8 months. Regarding post-operative complications, 3 (20%) patients developed incisional hernia, 3 (20%) patients experienced symptomatic cholelithiasis, 2 (13.33%) patients developed protein-calorie malnutrition and 1 (6.67%) patient had a small-bowel obstruction. Six (40%) patients had no reported complications. CONCLUSION:RYGB operation is a promising intervention for adolescents with morbid obesity, promoting significant weight loss and alleviating related co-morbidities. However, careful evaluation and preparation are crucial to prepare adolescents for lifestyle changes post-surgery. With proper support and follow-up, RYGB can empower young individuals to achieve and maintain healthier weights, offering a promising solution in the fight against adolescent obesity.
INTRODUCTION:Anastomotic leak after oesophagectomy remains a major cause of post-operative morbidity and mortality. Endoscopic placement of fully covered self-expandable metal stents (FC-SEMS) has emerged as a minimally invasive therapeutic option; however, real-world outcome data remain limited. We evaluated the outcomes of FC-SEMS placement for post-oesophagectomy leaks and described a novel clip-through-mesh fixation technique to reduce stent migration. PATIENTS AND METHODS:We conducted a retrospective cohort study of patients with post-oesophagectomy anastomotic leaks treated with FC-SEMS between December 2024 and December 2025 at a tertiary care center. Demographic, clinical, oncologic, surgical and procedural variables were collected. The outcomes assessed included leak characteristics, timing of intervention, stent dwell time, technical success, clinical healing, adverse events, mortality and functional recovery. A modified fixation method was used in all cases, whereby a through-the-scope clip was partially opened, passed through a single diamond-shaped stent mesh cell and deployed at a crossover point into the mucosa. RESULTS:Ten patients underwent FC-SEMS placement. Median time to leak detection was 12 days (range 7-20), and median maximum defect size was 3.25 cm. Multifocal leaks were present in 50% of patients. Surgical approaches included transhiatal (50%), transthoracic (30%) and subdiaphragmatic resections (20%). Technical success was achieved in all patients (100%), and complete clinical healing occurred in eight patients (80%). Two patients with large defects (>4 cm) and severe sepsis died despite technically successful stenting. No major stent-related adverse events were observed. No stent migration occurred during the follow-up. All surviving patients resumed oral intake after FC-SEMS placement, tolerated progressive diet advancement and remained symptom-free after stent removal during the follow-up. CONCLUSION:FC-SEMS placement is a feasible and effective first-line endoscopic therapy for post-esophagectomy anastomotic leaks. Early diagnosis, adequate drainage, antimicrobial therapy and nutritional support remain critical to success. The novel clip-through-mesh fixation technique was safe, reproducible and may help reduce stent migration.
INTRODUCTION:Robotic pelvic surgeries offer distinct advantages regarding intraoperative manoeuvrability and post-operative outcomes. However, the steep Trendelenburg position required for these procedures presents significant physiological challenges. The optimal angle that minimises complications while maintaining surgical efficacy remains undefined. PATIENTS AND METHODS:A prospective, randomised comparative study was conducted involving 100 patients undergoing robotic radical prostatectomy ( n = 50) and robotic hysterectomy ( n = 50). The primary objective was to assess variations in intraocular pressure (IOP) and optic nerve sheath diameter (ONSD) at varying degrees of tilt. The secondary objective was to evaluate haemodynamic stability and surgical feasibility. Patients were randomised in a 1:1 ratio to either a reduced or standard tilt group for their respective procedures. RESULTS:Haemodynamic parameters, including diastolic blood pressure (DBP), mean arterial pressure and arterial DBP, were significantly lower in the 15° and 20° tilt groups. ONSD measurements were marginally higher in prostatectomy patients (4.9 mm) versus hysterectomy patients (4.8 mm) ( P = 0.075). Significant variations in IOP, intracranial pressure and ONSD were observed between hysterectomy groups (15° and 20°) and prostatectomy groups (20° and 25°), with peak parameters typically occurring mid-surgery. Receiver operating characteristic analysis demonstrated superior sensitivity of IOP over ONSD for distinguishing conditions during hysterectomy. Minimal surgical difficulty was achieved at 20° tilt. CONCLUSION:While traditional practices favour angles between 30° and 45°, this study demonstrates that lower angles provide safer alternatives without compromising surgical visualisation. Rather than adhering to a universal rigid angle, we recommend an individualised approach: initiating procedures at moderate tilts (15° for hysterectomy and 20° for prostatectomy) and increasing the angle only if patient-specific anatomical constraints dictate the need for greater exposure.
INTRODUCTION:Anaesthetic management of thoracic surgery for tuberculous empyema is complex, with traditional fluid strategies often causing intraoperative hypotension or volume overload. Lung ultrasound (LUS) provides real-time assessment of pulmonary fluid status, but its combined effect with prophylactic vasopressor support on anaesthetic outcomes in this population is unclear. This study aimed to evaluate the impact of an integrated strategy combining LUS-guided goal-directed fluid therapy and prophylactic vasopressor support on intraoperative haemodynamics and early post-operative recovery in patients undergoing thoracic surgery for tuberculous empyema. PATIENTS AND METHODS:This retrospective cohort study included patients who underwent elective decortication for tuberculous empyema between January 2022 and June 2025. Patients were categorised into the LUS-guided group (LGG) and conventional management group. After 1:1 propensity score matching, 40 patients per group were analysed. Primary outcomes included intraoperative hypotension (mean arterial pressure <65 mmHg for >5 min), while secondary outcomes assessed fluid balance, norepinephrine use, recovery time, pain and post-operative complications. RESULTS:The LGG had a significantly lower incidence and shorter duration of intraoperative hypotension ( P < 0.05). Intraoperative management showed reduced fluid balance, norepinephrine use and fewer vasopressor interventions in the LGG ( P < 0.01). Post-operative recovery was faster, with earlier ambulation and shorter hospital stays ( P < 0.001). The LGG also had lower pain scores and fewer pulmonary complications ( P < 0.05). Multivariable analysis confirmed that the LUS-guided strategy was independently associated with earlier ambulation (β = 6.798, P < 0.001), lower pain scores at rest (β = 0.589, P = 0.018) and reduced pulmonary complications (odds ratio = 3.713, P = 0.049) after adjusting for confounders. Multivariable analysis confirmed the LUS-guided strategy as an independent protective factor against intraoperative hypotension. Diabetes and thoracotomy approach were identified as independent risk factors ( P < 0.05), while fibrous stage empyema showed a trend toward significance ( P = 0.050). CONCLUSION:LUS-guided fluid management with prophylactic vasopressor support enhances intraoperative stability, optimises fluid and vasopressor use and accelerates recovery in thoracic surgery for tuberculous empyema.
INTRODUCTION:Effective surgical therapy of rectal cancer necessitates meticulous selection of suitable surgical procedures contingent upon tumour location, stage and patient characteristics. This research examines surgical procedural trends and results in a tertiary care facility in Kashmir. PATIENTS AND METHODS:A 7-year retrospective-prospective research examined 510 rectal cancer patients who had surgical treatment at SKIMS. Surgical interventions were classified as local excision, low anterior resection (LAR), abdominoperineal resection (APR), Hartmann's technique and palliative operations. Data about surgical approaches (open, laparoscopic and robotic), perioperative parameters and complications were gathered and analysed. RESULTS:Out of 510 patients, 36 (7.05%) had transanal excision, 280 (54.9%) underwent LAR, 145 (28.4%) received APR, 35 (6.9%) were treated with Hartmann's surgery and 14 (2.7%) had unresectable disease necessitating palliative interventions. In the cohort undergoing neoadjuvant treatment, the rates of sphincter-preserving surgery were significantly elevated (62.5% compared to 45.1%, P < 0.05). A laparoscopic technique was employed in 178 individuals (34.9%). Conversion to open surgery was performed in 18 instances (10.1%). CONCLUSION:This institutional experience illustrates the progression of surgical practices, highlighting the growing implementation of sphincter-preserving techniques and less invasive methods. Neoadjuvant treatment profoundly impacts surgical decision-making, facilitating an increased number of sphincter-preserving surgeries. Persistent focus on entire mesorectal excision principles and judicious application of sophisticated surgical methods can enhance oncological and functional results.
BACKGROUND:The presence of metabolic dysfunction-associated steatotic liver disease and liver fibrosis in patients with obesity is associated with poor long-term liver-related outcomes. Liver biopsy is the gold standard. The enhanced liver fibrosis (ELF) panel is a non-invasive test (NIT) with an excellent correlation with liver fibrosis in various liver disorders. The diagnostic utility of this test in the obese population is not yet established. This study aims to assess the diagnostic accuracy of ELF and other NITs in predicting significant and advanced liver fibrosis in obese patients undergoing bariatric surgery. PATIENTS AND METHODS:This prospective cohort study was performed in a tertiary care academic institute in India. All patients underwent standard pre-operative workup according to the institute protocol. Pre-operative NIT values were determined, which included ELF, liver stiffness measurement (LSM) by FibroScan, aspartate aminotransferase-to-platelet ratio index and fibrosis-4 index. The fibrosis stage was graded based on findings of the liver biopsy performed intraoperatively. RESULTS:On liver biopsy, significant fibrosis was present in 13 (33.3%) patients, while advanced fibrosis was present in 7 (17.9%) patients. ELF accuracy improved with fibrosis severity (area under the receiver operating characteristic curve: 0.7-0.9), with best performance for ≥F3 (85.7% - sensitivity, 82.8% - specificity and negative predictive value [NPV] - 96%). LSM demonstrated high sensitivity (83%-95%) but lower specificity, with consistently high NPV (88.9%-95.6%). CONCLUSION:ELF score and LSM demonstrated good diagnostic accuracy to identify liver fibrosis in obese patients undergoing bariatric surgery. Multi-centre studies involving larger sample sizes are needed for optimisation of ELF cut-off values to predict liver fibrosis.
Abstract Oesophageal duplication cyst (ODC) and congenital pulmonary airway malformation (CPAM) are rare congenital anomalies, and their coexistence has been documented only in isolated case reports. Both malformations necessitate surgical intervention, with timing dependent on clinical presentation. Surgical resection is recommended even for asymptomatic patients with incidentally discovered lesions, given the risk of subsequent complications or malignant transformation. We present a rare case of a 4-year-old boy with combined ODC and CPAM malformations. The patient underwent successful surgical treatment via video-assisted thoracoscopic surgery. At follow-up, the child remains asymptomatic with normal growth and development.
Abstract The patent vitello-intestinal duct (PVID) is a persistent embryological remnant of the omphalomesenteric duct, which normally connects the yolk sac to the primitive midgut, and it is obliterated between the 8 th and 9 th weeks of gestation. Failure of this involution results in a spectrum of anomalies, including Meckel’s diverticulum, umbilical sinus, fistula, and cyst. Although such remnants are present in approximately 2% of the population, symptomatic presentation in adulthood is exceedingly rare. We report the case of a 30-year-old male who presented with foul-smelling umbilical discharge from a 0.3 cm × 0.3 cm opening for 24 months. He was successfully treated with laparoscopic resection of the PVID using an endoscopic linear stapler. Adult presentation of PVID with bilio-feculent discharge is exceptionally uncommon and not reported in the literature.
INTRODUCTION:Laparoscopic appendectomy (LA) is the standard of care for acute appendicitis, but the optimal method for appendiceal stump closure remains debated. Endoscopic staplers (ESs) are widely used but expensive, whereas polymeric clips (PCs) offer a cheaper alternative. PATIENTS AND METHODS:We conducted a single-centre, open-label, exploratory randomised controlled trial (September 2021-August 2023) comparing PC (Group A, n = 30) versus ES (Group B, n = 30) for stump closure during LA. Primary outcomes included safety and cost-effectiveness; secondary outcomes included ease and time of application, operative time, hospital stay and complications. Learning curve analysis was performed for a trained surgical resident. RESULTS:Sixty patients (mean age: 30.7 ± 11.6 years) were randomised. Demographics and appendicitis severity were comparable between groups. No stump dehiscence occurred in either group. Operative time was similar (55.1 ± 12.8 vs. 54.5 ± 15.4 min, P = 0.86), although application time was longer with PC (80.1 ± 10.0 vs. 68.3 ± 10.9 s, P < 0.0001). Post-operative complication rates were comparable. Total cost was significantly lower with PC (₹79,815 ± 4,072) versus ES (₹1,19,732 ± 16,061; P < 0.0001). Learning curve analysis showed residents required ~20 cases to achieve operative efficiency. CONCLUSIONS:PCs are a safe, technically simple and cost-effective alternative to staplers for appendiceal stump closure in LA, with comparable outcomes and a short learning curve. Larger multicentre RCTs are warranted.
OBJECTIVE:This study evaluates the feasibility and safety of outpatient management for bariatric surgery, specifically sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), within a regional hospital centre in France. It compares outcomes with existing literature and aims to identify factors affecting the success of the outpatient approach. PATIENTS AND METHODS:An observational, retrospective study was conducted from January 2019 to May 2024, analysing 69 outpatient bariatric surgery patients. The inclusion criteria followed the HAS guidelines. The study assessed demographic data, post-operative conversion to inpatient hospitalisation and its determinants. RESULTS:The average patient age was 36.4 years, with a predominance of females (88.4%) and an average body mass index of 40.7 kg/m 2 . Outpatient procedures included 52 SGs and 17 RYGBs. Conversion to inpatient hospitalisation occurred in 29% of the patients due to issues of unrelieved pain and food intolerance. Eight patients visited the emergency department postoperatively and seven patients required readmissions for complications. No mortality was reported. Mild obstructive sleep apnoea was independently associated with increased odds of conversion to inpatient hospitalisation (adjusted odds ratio [OR]: 3.91, 95% confidence interval [CI]: 1.02-15.00), while increasing age was associated with decreased odds (adjusted OR: 0.93 per year, 95% CI: 0.87-0.99). DISCUSSION:Outpatient bariatric surgery, particularly for selected patients, is generally feasible and safe. However, the study observed a higher conversion rate compared to other centers, attributed to patient selection, pain management and post-operative complications. Effective pre-operative evaluation, refined patient selection, improved post-operative care, patient education on pain and expectations are crucial for optimising outcomes. CONCLUSION:Outpatient bariatric surgery can be successful with expert surgical and anaesthetic management, proper patient selection and rigorous post-operative protocols.
Abstract Gastroduodenal intussusception due to gastric tumours, including gastric cancer, is called ball valve syndrome. Transection of the duodenum is challenging when laparoscopic gastrectomy is performed in patients with ball valve syndrome. An 80-year-old woman with appetite loss was diagnosed with anaemia and gastric cancer and referred to our hospital. Pre-operative examination revealed two gastric cancer lesions in the antrum: one was a 20-mm elevated lesion intussuscepting into the duodenum. Laparoscopic distal gastrectomy with regional lymph node dissection was performed following the clinical diagnosis of early gastric cancer with ball valve syndrome. The prolapsed tumour was moved into the stomach using a pair of laparoscopic forceps and after confirming that the two tumours were present within the stomach using intra-operative endoscopy, the duodenum was transected and Billroth I reconstruction was performed. Gastroduodenal intussusception of small gastric cancers can be managed laparoscopically; however, intra-operative endoscopic confirmation is required to enable duodenal transection.
ABSTRACT:Endoscopic thyroidectomy using the bilateral axillo-breast approach (BABA) provides excellent cosmetic outcomes and surgical completeness. Conventional techniques often require hydro-dissection and, in some modifications, specialized tunnelling instruments for flap creation. Hydro-dissection may impair visualization due to camera fogging and tissue charring, while custom instruments increase procedural cost and limit accessibility in resource-constrained settings. We describe a novel port-guided port placement technique for BABA endoscopic thyroidectomy that eliminates the need for hydro-dissection and specialized tunnelling devices, named by us as P3 modification (P- Port P- guided Port P - Placement) Following standard patient positioning and surface marking, a 10-mm port is introduced through an anterior axillary incision after limited blind subcutaneous dissection with a haemostatic artery forceps. This initial port serves as a guide for the sequential placement of additional working ports in the appropriate plane. Subsequent flap elevation and thyroid dissection are performed under direct endoscopic visualization. The technique is applicable to both hemi- and total thyroidectomy while preserving key structures, including the recurrent laryngeal nerves and parathyroid glands. The proposed modification minimizes blind dissection, avoids complications associated with excessive hydro-dissection, and obviates the need for custom-made instruments. Improved visualization, reduced risk of inadvertent deep or superficial dissection, decreased bleeding, and potentially shorter operative time are additional benefits. The technique also reduces procedural costs and enhances the feasibility of remote-access thyroidectomy in low-resource settings. Port-guided port placement is a simple, safe, and cost-effective modification of BABA endoscopic thyroidectomy that improves accessibility while maintaining the principles of minimally invasive thyroid surgery.
