Dr Mohinder Singh's blog

7.1.08

did another TEP bilateral

the trocar for the camera went intraperitoneal;

redirected the trocar into the preperitoneal space and deflated the abdomen with a veress needle

Had a lot of trouble because of decreased space

the unrolling of the mesh continues to take a lot of time

 

10.1.08

had a meeting of Patiala IAGES members (dr sukhpreet, dr jagga, dr pawan, dr surinder singh participated) and unanimously decided to vote and support Dr AS Grover for the post of Zonal member of IAGES

19.11.07

TEP – RIH direct and indirect. The direct sac appeared as a pseudosac (stretched fascia transversalis) and the indirect one got torn. The dissection should have started higher up.

29.11.07 to 2.12.07

Attended the IAGES conference for fellowship (FIAGES) at Apollo, Delhi. Held by Dr Ajay Kriplani who did a nice demonstration of TAPP hernia repair, a PUH repair (TAPP type) and a splenectomy (had to be converted to open due to uncontrollable excessive bleeding).

Other procedures shown in workshop – Nissen fundoplication, TLH, TEP, lap chole, lap nephrectomy.

3.12.07

Lap chole started by SR but as the anatomy appeared strange, was called for help. The shape of gall bladder fundus appeared like a shrunken gallbladder and the body of gallbladder under it was then mistaken for the duodenum.

6.12.07

Splenectomy for huge spleen causing hypersplenism. 60 years old male with pain,  and CT showing a big infarct in a huge spleen.

Difficult procedure due to adhesions with diaphragm and colonic flexure.

8.12.07

Went to Ludhiana to attend a meeting called by Dr Kuldeep Singh of DMC for arrangements for the forthcoming ASICON at PAU Ludhiana

13.12.07

Wrong diagnosis of an ovarian cyst 25F.

Actually a chronic ruptured ectopic pregnancy ; reported on US as cyst.

Presacral tumour – possibly a chordoma- eroding the sacral ala on right side. Removal led to severe bleeding from avulsed vessels in the presacral space and tear in the iliac veins which were stretched over it (the internal iliac artery had been already controlled). Very difficult to control ; Pt remained in persistent hypotension. Eventually the external iliac artery was retracted laterally after ligating some of its branches so as to expose a tear in the internal iliac vein under it, the small hole was controlled with a single stitch of 5-0 prolene. Some other venous bleeders from some unidentified veins in the cavity after removing the tumour were also ligated and the wound packed with several (5) lengths of roller gauze. Even then it took some time (nearly an hour in ICU) for the BP to come up to 100. Thereafter she gradually recovered.

Biopsy: neurilemmoma.

25-28 October

Attended ICS-IS conference at Agra.

Very poorly attended conference.

acquired viral fever there too.

29.10.07

Out of 3 lap choles, had to convert 2 to open:

In the first one, after the gallbladder had been removed, bleeding continued alarmingly, could not be located. On opening up, the bleeding was found to be from the liver bed, which was sutured with catgut.

In the second one (60 years old female, mother of a class IV employee here),  there was a CCD (cholecystoduodenal fistula) at the fundus of the gallbladder. Laparoscopic dissection had led to a tear in duodenum. On conversion to open surgery, the fistula was divided and repaired, besides repairing the iatrogenic injury too. She presented 2 weeks later with epigastric pain, S Alk Phos > 700 units. The plan of an ERCP was deferred for some time due to the repaired duodenum. However, in May 2008, at ERCP, 2 stones were extracted from the bile duct.

2.11.07

A congenital diaphragmatic (Bochdalek) hernia (CDH) in a 10 days old male child was repaired with prolene sutures. Its contents included a lot of small bowel loops, the splenic flexure of colon as well as the spleen.

50 F with previous vertical upper abdominal midline incision (for hepatic hydatids, done many years back)

Now had gall stones and pain and repeatedly raised alkaline phosphate values, so ERCP was done; this however revealed CBD to be clear and so we proceeded to lap chole. At operation, very dense adhesions were encountered right in front of the telescope starting from just above the umbilicus right to the top to xiphoid and extending to all of RUQ. All of these adhesions were lysed, taking about 45 minutes. Only then it was possible to  introduce the subxiphoid port, and other two working ports. The distal stomach’s adhesions with the liver were then sharply divided. The gall bladder was still hardly visible. A little further dissection under the liver revealed that the subcostal port was actually in the fundus of the supposed gall bladder. This was reintroduced properly and the liver was then freed from the abdominal wall and made a little mobile so that the gall bladder now could be flipped over.

After this the calots triangle was rather easy.

Drained.

4.10.07

A submandibular sialadenectomy for ch sialadenitis.

 Excision and marsupialisation of a recurred pilonidal sinus.

5.10.07

Big ovarian mass 50 F (Dr Jagga’s case). Investigated in PGI. Mass stuck firmly in pelvis, and adherent with UB, sigmoid and ureter, causing hydronephrosis. Ureter released and mass excised with difficulty, along with TAHBSOP.

Bx – undifferentiated cystadenocarcinoma.

Later sent  for chemo.

6.10.07

Wrong diagnosis. 50 M (Dr Pawan’s case) – CT diagnosis – appx abscess (CT attached).  Pt had fever and leucocytosis too. At surgery, actually a hard mass in cecum firmly fixed to parietes in the paracolic gutter. Also had deposits in right half of omentum. Right hemicolectomy with removal of omentum (right half) performed.

Bx – Adenocarcinoma.

 

8.10.07

1. A cirsoid aneurysm in a 30 years old female. Excised with great difficulty. Bled like hell despite prior ligation of both superficial temporal arteries (photos).

2. A lap varicolectomy for oligospermia in a 30 years old male.

11.10.07

TG cyst was the wrong diagnosis –  30 F with a small cystic swelling in the midline of neck. At operation, while removing the supposed hyoid bone just above the swelling opened up the trachea. Repaired the trachea with vicryl sutures. Retrospectively decided the diagnosis must have been a thyroid cyst arising from the thyroid isthmus.

An 82 years old lady (mother of Raj Dhanetha)  with GOO, visible peristalsis and palpable mobile lump in the distal stomach. UGIE (Dr Parmod Mittal) reported a malignant looking ulcer and complete obstruction; but biopsies came out to be negative.

CT suggested a 3.5 cm tumor distal stomach; no mets.

An easy and quick resection of distal stomach, duodenal stump closed and GJ done.

4th POD – had dehiscence of the abdominal wound which was resutured.

5 lap choles one after the other

Assisted a pyelolithotomy for multiple kidney stones and 26% function on DTPA scan ( NFK on IVU); one stone in upper calyx could not be taken out by the senior resident. Being easily palpable through the thinned out cortex of the kidney, it was taken out through nephrolithotomy route