ABSTRACT:Giant inguinoscrotal hernias (EHS L3) present technical challenges during laparoscopic repair, including difficulty in complete sac dissection, increased risk of seroma formation, injury to cord structures and potential mesh migration in markedly dilated deep inguinal rings (EHS L3). We present a retrospective cohort of seven patients with primary indirect giant inguinoscrotal hernias operated between January and July 2024 using a modified transabdominal pre-peritoneal (TAPP) technique involving dissection of the hernia sac only up to the deep inguinal ring with abandonment of the distal sac, combined with intracorporeal deep ring closure before mesh placement. This aims to minimise dissection-related morbidity and secure mesh position, in line with the Pascal's law principles. In seven patients with primary indirect giant inguinoscrotal hernias (mean deep ring diameter 4.0 cm and range 3.5-5 cm), all underwent TAPP repair with this modification. The mean follow-up was 15 months, during which no recurrences, clinically significant seromas or cord-related complications were observed. This simple, reproducible technique may enhance the outcomes in large L3 hernias by reducing dead space and optimising mesh stability.

BACKGROUND:Laparoscopic intraperitoneal onlay mesh repair with defect closure (intraperitoneal onlay mesh repair with fascial defect [IPOM Plus]) is widely practiced for ventral hernia repair but remains associated with significant postoperative pain and intraperitoneal mesh-related complications. Transabdominal preperitoneal mesh repair with defect closure (vTAPP Plus) offers an anatomical, extraperitoneal alternative that may reduce postoperative pain along with reduced mesh-related complications. High-quality randomized evidence directly comparing these techniques is limited. METHODS:This prospective, single-center, randomized controlled trial was conducted at a tertiary care institute. Adults with small-to-medium primary ventral hernias (2-4 cm) were randomized to undergo laparoscopic IPOM Plus or vTAPP Plus repair. The primary outcome was mean postoperative pain score (Visual Analogue Scale [VAS]) within the first 24 hours. Secondary outcomes included serial pain scores up to 6 months, operative duration, length of hospital stay, postoperative complications, and recurrence. Statistical analysis was performed using appropriate statistical tests. RESULTS:In total, 68 patients were analyzed (IPOM Plus: n = 36; vTAPP Plus: n = 32). Baseline demographic and clinical variables were comparable between groups. vTAPP Plus demonstrated significantly lower postoperative pain at 6, 12, 24, and 48 hours, as well as at 14 and 30 days (P < .001). Differences diminished at 3 months and were not significant at 6 months. Operative time was marginally longer for vTAPP Plus, the hospital stay was significantly lower. Postoperative complication rates were comparable. No mesh infection or hernia recurrence was observed during follow-up. CONCLUSION:vTAPP Plus repair significantly reduces early and intermediate postoperative pain compared with IPOM Plus, without compromising safety or short-term efficacy. Thus, vTAPP Plus represents a better option for selected primary midline ventral hernias.

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:Preclinical and retrospective data indicated that albumin therapy may be associated with endothelial protection and lower net fluid balance in sepsis. However, endothelial protective effect of albumin has never been evaluated in a clinical trial. We therefore hypothesized that an infective, inflammatory condition like perforation peritonitis, which requires substantial fluid replacement, may benefit from albumin therapy. METHODS:Adult patients undergoing emergent/urgent abdominal surgery for perforation peritonitis were randomized to either group A or group P receiving 5% human albumin or Plasma-Lyte fluid therapy, respectively. Serum endothelial glycocalyx degradation products (syndecan-1, heparan sulfate) and inflammatory biomarkers (TNF-a, interleukins [IL]-1b, IL-10, and IL-6) were measured at the baseline, 6 h, and 24 h postoperatively. RESULTS:In this study, n = 50 patients were randomized, and complete outcome data for n = 48 patients were available. Median (interquartile range) values of syndecan-1, heparan sulfate, TNF-a, IL-1b, IL-6, and IL- 10 were statistically similar at all time points. Repeated measured two-way ANOVA reported a significant interaction in heparan sulfate (F [2, 88] = 3.60, P = 0.026), TNF-a (F [2, 88] = 3.75, P = 0.027), and IL-10 (F [2, 88] = 4.84, P = 0.02) between the time point of measurement and type of fluid therapy. Intraoperative vasopressor requirement was lower with albumin [P = 0.047]. CONCLUSIONS:Although 5% albumin-based fluid therapy failed to reduce syndecan-1 level, as compared to Plasma-Lyte, it possibly resulted in better perioperative hemodynamic stability and lesser fluid administration. This finding should be considered as 'hypothesis-generating' and need further validation.

Thyroid lesions, both benign and malignant, are common worldwide. Although conventional open thyroidectomy remains effective, the visible cervical scar is a cosmetic concern, particularly for younger patients. Endoscopic thyroidectomy techniques such as the Axillo-Breast Approach (ABA) and Bilateral Axillo-Breast Approach (BABA) were developed to overcome this limitation. This study aimed to compare these two approaches with respect to postoperative health-related quality of life (QOL). In this randomized controlled trial, 64 adult patients (> 18 years) with Bethesda category III or lower cytology and thyroid gland volume < 40 mL were randomized to undergo endoscopic hemithyroidectomy via either ABA or BABA. The primary outcome was postoperative QOL assessed using the Short Form-36 (SF-36) questionnaire and a thyroid-specific questionnaire at 2, 6, and 12 weeks after surgery. Secondary outcomes included postoperative complications, duration of hospital stay, pain scores, conversion to open surgery, and ease of performing the procedure. At 6 weeks, significantly higher scores were observed in the ABA group for Vitality (p = 0.045) and Social Function (p = 0.027), whereas no significant differences were identified in the remaining SF-36 domains. At 2 weeks, ABA showed a trend toward higher general health and vitality scores. On thyroid-specific assessment at 2 weeks, ABA was associated with significantly less neck and chest numbness (p = 0.0028) and better neck mobility (p = 0.004) compared to BABA; these differences resolved by 6–12 weeks. Minor complications such as subcutaneous emphysema and ecchymosis were self-limiting. Pain scores, operative difficulty, and hospital stay were similar between groups. Both ABA and BABA endoscopic hemithyroidectomy techniques were safe. No statistically significant differences were observed in most quality-of-life outcomes between the two approaches. ABA provided a short-term advantage in reducing early postoperative neck numbness and movement restriction, although these differences resolved during follow-up.

A 46-year-old woman with hypercalcemic primary hyperparathyroidism underwent a Tc-99m SestaMIBI scintigraphy and SPECT-CT, which identified 3 distinct radiotracer-avid intrathyroidal nodules. Following a right hemithyroidectomy and subsequent histopathologic evaluation, it turned out that she had 3 pathologically distinct nodules, that is, intrathyroidal parathyroid adenoma, invasive encapsulated follicular variant of papillary thyroid carcinoma, and tall-cell variant of papillary thyroid microcarcinoma. Our case serves as an important reminder that at times even distinct pathologies can present with identical anatomic features and radiotracer uptake patterns.

PURPOSE:The integrity of the capillary endothelium and the filtration pressure regulate extravascular fluid leakage. A low plasma colloid oncotic pressure can contribute to extravascular leakage, which, when associated with a positive fluid balance, might lead to postoperative complications. METHODS:Cumulative fluid balance and estimated colloid oncotic pressure were noted until postoperative 72 hours in 200 adult patients undergoing major emergency requiring intensive care management. All participants were followed until hospital discharge (or death) for any postoperative complications as per Clavien-Dindo grade. The primary outcome was the association between cumulative fluid balance/estimated colloid oncotic pressure ratio at 48 hours and postoperative complications any time during the hospital stay. RESULTS:One hundred forty-seven of the 197 patients (74.6%) developed at least 1 postoperative complication. The incidence of major postoperative complications, defined as Clavien-Dindo grade IV and V, was 28.4%. Within the follow-up period, 29 patients (14.7%) died. No independent association between the cumulative fluid balance/estimated colloid oncotic pressure ratio at 48 hours and the occurrence of any postoperative complications (P = .093) was found. However, ordinal logistic regression reported that a higher cumulative fluid balance/estimated colloid oncotic pressure ratio at 48 hours was independently associated with a higher grade of complications (P = .009). The cumulative fluid balance/estimated colloid oncotic pressure ratio at 48 hours (P = .012) was also independently associated with major postoperative complications. However, no independent association was found between cumulative fluid balance/estimated colloid oncotic pressure ratio at 48 hours and in-hospital mortality (P = .160) or hospital-free days at day 30 (P = .985). CONCLUSION:The cumulative fluid balance/estimated colloid oncotic pressure ratio at 48 hours was associated with increased postoperative complications, irrespective of the patient's baseline clinical status. Excessive fluid therapy should be discouraged in these patients, especially when serum proteins are low.

BACKGROUND:Giant parathyroid adenomas represent a distinct clinical entity forming a subset under primary hyperparathyroidism (PHPT). They comprise lesions weighing more than 3.5 g. Our study aims to determine the clinical presentation, biochemical profile, outcomes, and pathological characterization of patients with giant parathyroid adenoma. MATERIALS AND METHODS:Retrospective review of data of patients who underwent parathyroid surgery between January 1995 and December 2022 by a single surgeon. A total of 561 patients were identified, and out of these, 78 had glands measuring more than 3.5 g. RESULTS:The mean age was 42 years, and 51 (65%) were females. The most common complaint was bone pain (46%), followed by renal calculi (38%), with 15 (19%) patients presenting with hypercalcemic crisis. Median calcium value was 12.3 mg/dL, with median PTH, vitamin D, and ALP of 1025 pg/mL, 23 ng/mL, and 664 U/L, respectively. Fifty-three (68%) patients underwent focused parathyroidectomy, and 22 (28%) underwent neck exploration, with median postoperative calcium and PTH being 8.35 mg/dL and 37.8 pg/mL, respectively. The median weight was 7 g with a range from 3.58 g to a whopping 31 g. Symptomatic postoperative hypocalcemia was seen in 54 (69%), with 28 (36%) requiring intravenous calcium supplementation, and this was positively correlated with the preoperative ALP and PTH values. CONCLUSION:Giant parathyroid adenomas present with florid symptoms with hypercalcemia and often hypercalcemic crisis. The biochemical workup, localization, and surgical management are similar to any other case of PHPT. Postoperatively these patients are prone to hypocalcemia, and the intravenous requirement of calcium can be predicted by preoperative ALP levels.

Major mammary duct excision technique developed by Professor John Hadfield is associated with necrosis of areola and loss of nipple sensation in a significant proportion of women. The proposed technique has been developed and mastered by the breast surgeons at All India Institute of Medical Sciences, New Delhi. It obviates the above complications.

The surgical treatment for ladies presenting with blood or serous nipple discharge emanating from a single duct is an excision of a diseased milk duct called microdochectomy. It is suitable for nulliparous ladies and those desirous of breast feeding. It entails removal of the diseased milk duct for a length of 5 cm for blood or serous discharge and 1.5 cm for purulent discharge. Currently, the microdochectomy is accomplished through a circumareolar incision avoiding any cut on the nipple. The incision over the nipple may lead to a tender and sometimes hypertrophic scar, and is best avoided.

ABSTRACT:The optimal technique of ventral hernia repair is still debatable. While intraperitoneal onlay mesh repair is the most widely used method, extraperitoneal repair of ventral hernia is gaining popularity, mainly due to its proposed lesser pain and complication profile. This article describes one such method, ventral transabdominal preperitoneal plus repair and also discusses its benefits and post-operative outcomes.

ABSTRACT:Spigelian hernia (SH) is a rare lateral abdominal wall defect that poses diagnostic and technical challenges, especially in large cases. Conventional laparoscopic approaches, such as intra peritoneal onlay meshplasty, total extra peritoneal and standard transabdominal preperitoneal (TAPP), may fall short in achieving ideal closure and mesh placement. We report two female patients presented with left flank swelling and intermittent pain. Imaging confirmed SHs measuring 4-5 cm. Both patients underwent laparoscopic repair using a modified TAPP plus technique. This approach combines transfascial sutures with intracorporeal reinforcement, enabling tension-free closure and optimal mesh fixation while preserving neurovascular structures. Both patients recovered uneventfully, were discharged on post-operative day 1, reported minimal pain and returned to normal activities within 10 days. At 8-month follow-up, no complications or recurrences were observed. The modified TAPP plus technique represents a novel and feasible technique for SH repair, ensuring tension-free closure, secure mesh fixation and early recovery.

Vesicouterine fistula (VUF) is a rare complication following caesarean sections, often presenting with the classic triad of Youssef syndrome (urinary incontinence with cyclic haematuria (menouria) and amenorrhoea) but sometimes without typical symptoms. We report a case of a woman in her early 30s who developed VUF after an emergency lower segment caesarean section, complicated by necrotising soft tissue infection (NSTI) of the left forearm. One week post-surgery, she presented with NSTI symptoms and haematuria, which were managed with broad-spectrum antibiotics and debridement. During her hospital stay, she experienced persistent urinary incontinence and burning micturition. Evaluation of these symptoms revealed acute intestinal obstruction, and a contrast CT indicated vesicouterine communication. Surgical exploration confirmed a perforated uterus with possible retained placental tissue, and a VUF. Subtotal hysterectomy and bladder repair were performed, and her recovery was smooth. This case underscores the importance of considering VUF in patients with post-caesarean urinary symptoms, despite its rarity.