GI Surgery: Dr Deepak Govil & Dr Vivek Tandon - An experienced team of GI Surgeons

  Clinical History We present two cases with massive ventral hernias with damaged overlying skin. Both patients gave  a h/o having undergone a laparotomy for intestinal perforation many years earlier with severe wound infection resulting in wound dehiscence in the post operative period. On examination they had massive ventral hernias with  large thin scars on the abdomen under which were multiple bowel loops. Case1 Case 2 Case 1 Case 2 Both patient underwent a successful Ventral mesh Henioplasty with an ONLAY mesh and excision of the scar. Case1 Case 2 Post operatively they had superficial skin necrosis which was managed with  debridement  and secondary suturing.  

 Clinical History A 50 year female presented to the emergency of Metro Multispeciality Hospital with a h/o of acute abdominal pain and recurrent vomiting of 3-4 hours duration and a painful tender swelling in the mid abdomen. She gave a h/o of a swelling in the supra-umbilical region for the last 2-3 years. Clinical examination revealed a tender. Irreducible para-umbilical hernia. Large Irreducible Supraumbilical Swelling  Urgent CT abdomen confirmed a small intestinal loop to be stuck in the hernia sack. She was taken up for urgent laparotomy within 2 hours of presentation to the emergency .On opening the hernia sac a discoloured loop of small intestine was seen. The constricting ring was released and the intestine regained its normal colour and viability – allowing for the intestine to be saved. Patient underwent a Mesh Henioplasty and was discharged on the 2nd post operative day. TIMELY AND QUICK INTERVENTION SAVED THE PATIENT FROM AN INTESTINAL RESECTION AND ALLOWED FOR A  QUICK

A Cholecystohepatic duct is a rare anatomical anomaly related to the gallbladder where a direct communication exists between the gallbladder and the liver.  This is in addition to the normal communication between the gallbladder and the bile duct (i.e the cystic duct). This has major importance during surgery done to remove the gallbladder (Cholecystectomy).  If it is not identified at surgery and divided it can cause leakage of bile and its collection inside the abdomen after the surgery.  The consequences for the patient can be disastrous and life threatening. It is important that every surgeon performing cholecystectomies be aware of the condition and how to suitably handle it when encountered.  The photographs show one of our patients in whom this anomaly was seen and appropriately treated.  

ROBOTIC VENTRAL RECTOPEXY DR DEEPAK GOVIL

Mirrizi’sSyndrome- Stone in Gallbladder Remnant Resulting in High Biliary Stricture- a challenging scenario A 34yearold gentleman, a known case of diabetes and hypertension, underwent surgery for symptomatic gallstones in December 2018 at an outside hospital. The surgery was started laparoscopically but converted to open procedure. As per the surgeon’s notes the reason for conversion was a technically difficult cholecystectomy. The histopathology of the removed gallbladder was suggestive of chronic cholecystitis. Postoperatively a CT guided drainage of intra-abdominal collection was done. Thereafter, he recovered from the procedure and was asymptomatic. He visited our department with an ultrasound report showing a stone in gallbladder remnant with dilated biliary system. The liver function tests were suggestive of biliary obstruction (raised ALP and GGT). MRCP was suggestive of a gallbladder remnant along with large calculus (2 cm) in GB bed with compression at biliary conflue

Cystic lesion of pancreas treated with distal pancreatico-splenectomy A 62 yearold gentleman presented to us with complaints of upper abdominal pain with radiation to back since 2 months. He also complained of weight loss, however this was not significant. Ultrasound and contrast enhanced CT scan of the abdomen (figure 1) was suggestive of a cystic lesion in body and tail of pancreas. To further characterize the lesion a MRI with MRCP of the abdomen was done. This was suggestive of a mixed-micro & macro-cystic lesion in tail of pancreas. A communication between the lesion and pancreatic duct was demonstrated (figure 2). These features pointed to a branch duct intraductal papillary mucinous neoplasm (BD-IPMN). An endoscopic ultrasound (figure 3) was suggestive of a mixed micro- and macrocystic lesion of pancreas and myxoid material was aspirated. The cyst fluid amylase and CEA was 154 U/L and 0.12 ng/ml respectively and were normal, indicating a non-mucinous cyst. In view o