Dr Mohinder Singh's blog

26.9.15

Dense adhesions around the liver and gall bladder, including violin-string type (Fitz-Hugh-Curtis), made lap chole difficult, but the procedure was eventually satisfactory.

Another lap chole (Angoori devi, c/o Kammo) was complicated by falling oxygen saturation levels near the end of the procedure. A C-arm image showed left pneumothorax, which necessitated a chest tube insertion and overnight stay in ICU for ventilation to expand the lung. The anesthetist’s explanation was the pneumothorax was due to diaphragmatic injury at surgery!

7.10.15

Visit to Chandigarh with dr Sushil Mittal for purchase of  ETO sterilizers for operation theatres by the health systems corporation. Besides this purchase, another momentous decision was taken here. A suggestion given by dr Sushil Mittal was to stop using cars and instead use the bicycle for visits to the college and back. This proposal was immediately accepted and it was decided that both of us from now onwards will use bicycles rather than cars as far as possible.

18.10.15

Attended a CME on hepatobiliary and pancreatic surgery at Ludhiana (organised by dr Kuldeep Singh) along with dr Grover and Dr Jagga.

24.10.15

A laparotomy for abdominal pain and obstruction due to adhesions, following a traumatic bowel perforation which was treated in DMC with a resection-anastomosis and an ileostomy. This was followed by ileostomy closure, which was complicated by a fecal fistula, which had healed with conservative treatment. But the patient continued to experience pain and distension.

At exploration, extensive bowel adhesions had to be lysed, besides excising the ileo-cecal segment which was too densely adherent with an underlying thick-walled chronic abscess.

abscess cavity

ileum opened up with abscess cavity above

31.10.15

An intended Whipple resection for a cancer of the head of pancreas ended up in only a palliative biliary bypass procedure (cholecystojejunostomy). Once the pancreas was mobilized, the tumor in the head of pancreas was found to be densely adherent with the portal vein and also the gastroduodenal trunk (This was suggested by the CT scan, but still it was decided to go ahead with resection if possible).

4.11.15

An extended right hemicolectomy for a big palpable cancer in the transverse colon in a 60 years old female. The peglec bowel preparation by the residents had resulted in gross distension of all bowel proximal to the tumor, making surgery difficult and prolonged. However, the anastomosis with staples saved some time.

18.6.15

Attended the 350th year celebrations of founding of the city of Anandpur Sahib, as a member of the VVIP medical team. The PM was supposed to attend the same, but instead the home minister Rajnath Singh came.

24.6.15

Laparoscopic nephrectomy in a young (23 years old) female for non-functioning hydronephrotic kidney (congenital PUJ stenosis). The procedure was rather easy.

1.7.15

IPAA made in a young male, who had earlier (on 11.8.14) undergone subtotal colectomy for severe fulminant ulcerative colitis not responding to medical therapy. The completion proctectomy was difficult. The stapled ileal pouch anal anastomosis was not satisfactory, so a proximal ileostomy was added.

4.7.15

Completion thyroidectomy in a 35 years old female following a right thyroid lobectomy and the pathology reporting a papillary carcinoma. Surprisingly, the pathology report this time was not malignant.

8.7.15

A day of difficult cholecystectomies. The first was a young female with a thick-walled mucocele which had to removed piecemeal, after its cystic duct was ligated. The second and third were middle aged females with choledocholithiasis for which they had undergone ERCP, stone extraction and biliary stenting. The gallbladders too were thick-walled and the cystic ducts wide, needing ligation with no 1 vicryl suture.

Summer vacation from 9 July to 16 August

7.8.15

Court evidence at Dhuri through a warrant rather than a summon for expert evidence!12.8.15

Attended the first meeting of the newly constituted Punjab chapter of ASI at Jalandhar.

22.8.15

Failed to create extraperitoneal space in an attempted TEP repair of inguinal hernia due to obesity and poor muscle relaxation. Converted to open procedure.

12.89.15

A stone grown on a forgotten DJ ureteric stent. The stent had been there for more than 10 years. Both the stent and stone were removed via a cystostomy.

16.5.15

An unexpected finding at an apparently routine lap chole. The gallbladder was found to be perforated and gangrenous with lot of bile in the peritoneal cavity. Postoperatively patient continued to have tachycardia and some fever for 2 days, then settled.

27.5.15

An attempted lap chole  in a 45 years old lady failed due to dense adhesions from previously laparotomy (long midline incision going right up to xiphoid, done for liver laceration 2 years back). Even at open cholecystectomy, the procedure was difficult.

3.6.15

Disseminated intraperitoneal hydatid cysts in an 85 years old male presenting with abdominal masses and fever. The cysts had become infected and developed thick walls which were densely adherent all around. All cavities cleaned of pus, debris and grape-skin like small cysts, and drained with wide bore tubes on both sides. postoperatively, drained thick dark bile on second day, and continued to drain for many days.

10.6.15

Neurilemmoma of the thigh, recurred after excision twice. 50 years old female. The big tumor was excised along with sacrifice of the medial cutaneous nerve of the thigh from which it was arising, and along with some of the fascia lata with which it was adherent.

The cremasteric reflex in the 7 years old boy with right-sided undescended testis was nicely captured in a short video clip by a final year medical student.

15.4.15 Right sided undescended testis, in a 7 years old boy, was found to be impalpable and not shown up on the ultrasound scan. However, on exploration by assistant professor (dr djs walia), was found in the inguinal canal and was fixed in the scrotum after mobilization.

An 11 years old girl with torticollis – the tight band of the fibrosed sternocleidomastoid was released from its sternal and clavicular heads, and also from its mastoid attachment, using the harmonic scalpel. 

18.3.15 A frustrating experience with laparoscopic attempt at removal of a large (>6 cm) adrenal incidentaloma of the right adrenal gland in an obese 40 years old man (c/o dr sandhu, senior resident). Poor unhelpful liver retraction of a large pendulous liver by the absent-minded assistants who would rather injure the liver than retract it strongly upwards, poor camerawork by the other unhelpful assistant who would just fail to concentrate on his job, and poor anaesthesia by the junior residents who would just not accept that the patient needs good relaxation, led eventually to conversion to open procedure at which the tumour was easily removed. the biopsy was reported as benign – myelolipoma.

10.11.14 An anomalous duct of Luschka was identified only after division, at a lap chole in a 55-years old female. The proximal end was sought in the liver bed and clipped (Dr GS Sandhu (senior resident)’s case).

13.11.14

A planned LIH repair by TEP approach had to be abandoned and converted to open hernia repair due to a hole in the peritoneum at the time of creation of space, and loss of space thereafter.

20.11.14 An adult intussusception, diagnosed on US and CT, in a 50-years old female, presenting with sub-acute intestinal obstruction of many weeks, was treated by resection of the segment of distal ileum bearing the intussusception. On cut section, it was found to contain a big pedunculated benign-looking tumour arising from the ileum.

7.9.14

A big renal cell carcinoma (more than 19 cm across) involving the superior pole of left kidney and adherent to spleen and tail of pancreas in a 35 years old female, excised through anterior approach. The pedicle slipped leading to considerable bleeding and panic. The bleeding was controlled with the help of a  vascular clamp and sutures.

16 and 17 august

Attended a urology conference (north zone, urological association of india) along with dr sukhpreet and dr grover. Watched interesting surgeries: laparoscopic partial nephrectomy, laparoscopic radical prostatectomy, RIRS and mini-PCNL etc.

27.8.14

Assisted dr Vikram in a lap chole in which a stone (impacted in the neck of gallbladder and had eroded into the wall of the bile duct – Mirizzi syndrome) had caused transient jaundice last week although the LFTs were normal now. The dislodgment of the stone left a defect in the wall of the bile duct. This defect was covered with a flap of the wall of the gallbladder neck which had been left as a long stump after ligating the gallbladder neck. Bile leaked for 10 days through the drain, then dried up.

28.9.14

Repaired a large laryngocele for the first time in life!. Had never seen it actually before this one. An old man ( a chronic smoker) had been having a large swelling on the right side of the neck for a long time, and now had been experiencing some pain and hoarseness of voice. ENT examination revealed an internal component of the laryngocele too which had displaced the larynx to the left.

6.3.14
A 27 yeas old male, HCV positive, presented with a mass (15 cm across) in the left lower abdomen, and found to have an undescended testis on examination. AFP and HCG grossly elevated. At exploration, the big tumour was found to be adherent to the sigmoid colon, which had to be resected along with the tumour.

An arteriovenous malformation on the forehead in a 22 years old man, previously incompletely excised in Haryana, excised again after ligating the feeding superficial temporal and other small vessels.

A breast lump in a 60 years old female, negative on FNAC and Core needle biopsy, excised widely. Cut section typically scirrhous.