Malignant breast phyllodes: Literature review of management and case report Amal Abdullah Abdulkareem Saudi Journal of Laparoscopy 2019 4(1):1-3 The rarity of malignant phyllodes leads to variability in diagnosis and management. Most of the reported cases in the literature are large malignant phyllodes tumor. Malignant phyllodes tumor was seen in the age group between 35 and 55 years. The youngest age reported was an 11-year-old girl. The eldest reported was an 89-year-old woman. Phyllodes tumors are characterized by a typical rapid growth. Phyllodes tumor are composed of epithelial element and connective tissue stroma with stromal increased cellularity, cellular atypia, and pleomorphism with increased mitosis. The most common path of spread is hematological mostly to the lung, pleura, bone, heart, liver, metastasis to the brain and adrenal have been reported. Palpable axillary lymph node is found in 10%–15% cases; only <1% of them is pathologically positive for malignancy. Surgery in the form of breast conservative or mastectomy remains the primary treatment of malignant breast phyllodes. No literature support axillary lymph node dissection. For breast conservative surgery (BCS), 1 cm free margin is recommended less than that will be associated with higher recurrence rate. Mastectomy is indicated only if tumor-free margin cannot be obtained by BCS. In multivariate analysis, patient with more adverse prognostic factors underwent postoperative radiation therapy (RT). The RT groups were not inferior to non-RT groups on cancer-specific survivor regardless of surgery (mastectomy or BCS). But post-operative radiation therapy for BCS will significantly reduce local recurrence. Post-operative chemotherapy is seeing increased in palliation of metastatic cases.

Does laparoscopy has a place in managing urinary stones in the era of mini- and micro-PCNL Mohammed Mahdi Babakri, Kaled A Saed, Faiz Bin Break, Mohammed Lahdan Saudi Journal of Laparoscopy 2019 4(1):4-8 Introduction: Surgical management of urinary stones has witnessed major development in the last few decades. After the successful introduction of Shock wave lithotripsy (SWL), the urologist's armamentarium for treating stones became versatile by adoption of rapidly evolving technologies that increasingly replaced the traditional open surgery.There are special situations when SWL and endourology is not the optimal choice and open surgery was the only option at a time, here comes the role of laparoscopy to replace the open surgery for dealing with these cases where endourology has major limitations. Hereby we will highlight the current international trend in laparoscopic surgery for urolithiasis and demonstrate our limited experience in laparoscopic stone surgery in ten patients in Aden, Yemen. Patient and Method: From March 2011 to September 2017. Ten consecutive patients' ages 4-60 years (mean 38 years) with renal and ureteral stones underwent laparoscopic removal of their stones. The indications for laparoscopy were; unavailability of pediatric PNL setup in two children, failed of SWL in one, renal stones with concomitant PUJO in one, and large impacted ureter stones in the rest of patients. Result: Stone largest diameter ranged from 25 to 45 mm (mean 28 mm), operative time ranged from one to 4 hours (mean 2.3 hours) and hospital stay ranged from four to seven days (mean 5 days). The procedure completed successfully an all, but one patient in whom conversion to open ureterolithotomy performed, because of difficulty to access the large impacted intramural stone, no major intra or post-operative complications, no blood transfusion needed. One patient develop prolonged urine leakage for 10 days managed conservatively. Follow up after three, six and 12 months with plain abdominal x-ray (KUB) ultrasonography (US) and Urography (IVU) when indicated showed no residual stones and no newly developed hydronephrosis. Conclusion: Laparoscopic surgery is safe and effective in management of large renal and ureter stones in patients who are not suitable candidate for endourology.

Safety and feasibility of elective laparoscopic cholecystectomy in liver cirrhosis with portal hypertension Akhter Ganai, Majid Mushtaque, Sheikh Junaid, Arshad Rashid Saudi Journal of Laparoscopy 2019 4(1):9-13 Aims: The aim of the present study was to evaluate the safety of laparoscopic cholecystectomy in patients with liver cirrhosis and portal hypertension. Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of six years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The diagnosis of cirrhosis was made based on preoperative workup, intraoperative findings, and histo-pathological study based on liver biopsy. The outcomes of laparoscopic cholecystectomy in patients with cirrhosis were compared to those without it with regards to perioperative morbidity and mortality. Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them 42 patients were diagnosed to have features of cirrhosis and portal hypertension after laparoscopy and subsequently 36 were confirmed to have cirrhosis on histopathology. There were 15 males and 21 females in these 36 patients. The diagnosis of cirrhosis was established preoperatively in 21 patients. The operative time and hospital stay were significantly increased in the cirrhotic group. None of our patients in the cirrhotic group required conversion. Perioperative complications were seen more often in the patients with cirrhosis [5 (13.89%) versus 207 (6.69%); P value = 0.0126]. Ascites was the most frequent post-operative complication seen in cirrhotic patients. Conclusion: Laparoscopic cholecystectomy, though technically demanding in cirrhotic patients can be safely done even in a peripheral health set-up with acceptable morbidity rate.

Laparoscopic management of symptomatic gallbladder stump calculi Akhter Ganai, Arshad Rashid, Sheikh Junaid, Majid Mushtaque Saudi Journal of Laparoscopy 2019 4(1):14-17 Aim: The aim of the present study was to evaluate the safety of laparoscopic completion cholecystectomy in patients with symptomatic gallbladder stump calculi. Materials and Methods: Ours was a prospective study conducted in three peripheral hospitals over a period of 6 years. All the patients undergoing elective laparoscopic cholecystectomy during this period were enrolled in the study. The outcomes of laparoscopic completion cholecystectomy in patients with gallbladder stump calculi were compared to those undergoing primary laparoscopic cholecystectomy with regards to perioperative morbidity and mortality. Results: A total of 3127 laparoscopic cholecystectomies were performed. Out of them, laparoscopic completion cholecystectomy was done in 36 (1.15%) patients. There were 21 males and 15 females in these 36 patients. The operative time and hospital stay were significantly increased in the completion group. None of our patients in the completion group required conversion. Perioperative complications were seen more often in the patients posted for completion cholecystectomy (6 [6.67%] vs. 207 [6.69%]; P = 0.0026). Bleeding was the most frequent intraoperative complication seen in the patients undergoing completion cholecystectomy. Conclusion: Laparoscopic completion cholecystectomy, though technically demanding, can be safely done even in a peripheral health setup with acceptable morbidity rate.

Laparoscopic management of ectopic pregnancy: An observational study from North Kashmir Sieqa Shah, Samina A Khanday, Majid Mushtaque, Ibrahim R Guru Saudi Journal of Laparoscopy 2019 4(1):18-23 Background: With advancements in field of minimally invasive surgery, increasing number of patients with ectopic pregnancy (EP) can be managed laparoscopically. Aims and Objective: To evaluates our experience of laparoscopic management of ectopic pregnancy in terms of its safety and efficacy. This is an observational study conducted over a period of seven years at Guru Multi-specialty Hospital Sopore, Kashmir, India. Materials and Methods: A total of 84 patients with EP were included in the study. The diagnosis was made by detailed history, clinical examination, βHCG assay, abdominal and transvaginal ultrasonography. All patients underwent laparoscopic salpingectomy or salpingostomy depending on the clinical scenario. The outcome was analysed in terms of details of the procedure, mean operative time, post-operative VAS score (0-10), complications, hospital stay and subsequent fertility. Histopathological examination of the resected fallopian tubes was also evaluated. Statistical analysis was done as a prospective sample survey analyzing percentage and mean values. Results: Sixty-one patients had chronic ectopic while 23 presented acutely. Seventy-seven (91.66%) patients were diagnosed by clinical, laboratory and sonographic modalities while 7 (14.17%) required diagnostic laparoscopy for confirmation. Ampulla was the site of EP in 75% of cases. Ruptured fallopian tubes were found in 20 (86.95%) and 9 (14.75%) patients who presented with acute and chronic ectopic respectively. The patients with chronic ectopic were managed with laparoscopic salpingectomy and laparoscopic salpingostomy in 45 (73.77%) and 16 (26.22%) patients respectively. Patients with acute ectopic were underwent laparoscopic salpingectomy in 18 (78.26%) and salpingostomy in another 5 (21.73%) cases. The operative time was longer in patients with chronic ectopic ranging between 55-135 minutes. A total of five (5.95%) patients required blood transfusions. One each case of chronic and acute ectopic required conversion to open surgery. Histopathological examination of salpingectomy specimen revealed chronic salpingitis was seen in 39.68% of the cases. On follow-up, a total of 18 (29.5%) and 9 (39.13%) patients conceived within a year and another 5 (8.19%) and 2 (8.69%) did so between 1-2 years who presented with chronic and acute ectopic respectively. Conclusions: Laparoscopic approach in treatment of EP is safe and feasible irrespective of the type of presentation with all advantages of minimal access surgery and greatly reduced morbidity.

Difficult laparoscopic cholecystectomy and postoperative requirement of analgesics: An observational study Majid Mushtaque, Arshad R Kema, Samina A Khanday, Umar Q Bacha Saudi Journal of Laparoscopy 2019 4(1):24-28 Context: Despite many advances in laparoscopic cholecystectomy (LC), postoperative pain is still a problem. Difficult and prolonged procedures may cause more postoperative pain. Operative difficulty scores in LC and their correlation with the postoperative visual analog scale (VAS) pain scores and postoperative analgesic requirements in these patients have not been studied before. Aim: The aim of this study is to evaluate the requirement of postoperative analgesics in patients with different grades of intraoperative difficulties in elective LC. Settings and Designs: This was an observational study conducted at two peripheral hospitals in Kashmir. Materials and Methods: A total of 322 patients were scheduled for LC. Nassar scale (grades 1–5) was used to grade the operative difficulty. Postoperatively, intramuscular injection of diclofenac sodium 50 mg BD was used for analgesia. The data recorded were duration of surgery, postoperative VAS score (0–10), and requirement of additional postoperative rescue analgesic with reference to Nassar scale. Statistical Analysis: Chi-square test/one-way ANOVA was used as a test of significance. Results: Sixteen patients required conversion to open cholecystectomy and were excluded from the study. The final study group comprised of a total of 306 patients (112 males and 194 females). The age of the patients ranged between 16 and 60 years with a body mass index of <30. Nassar intraoperative difficulty grades of I, II, III, and IV were observed in 68.3%, 18.6%, 9.80%, and 3.26% of the patients, respectively. The mean operative time was longer with higher Nassar intraoperative grade (P < 0.05). The mean postoperative VAS was persistently higher in patients with Nassar grades of III and IV at different points of time but was statistically significant only at 3 h postoperatively (P < 0.05). Postoperative rescue analgesic was required by 0.95%, 7.01%, 50%, and 70% of patients with Nassar grade of I, II, III, and IV, respectively. Conclusions: With increasing level of difficulty in LC, there is increased postoperative pain and requirement for additional analgesia.

A prospective randomized controlled trial of open Lichtenstein and totally extra-peritoneal repair in men with uncomplicated groin hernia Sheikh Imran Gul, Asim Rafiq Laharwal, Ajaz Ahmad Wani, Arshad Rashid Saudi Journal of Laparoscopy 2019 4(1):29-32 Objective: The objective of this study is to compare laparoscopic totally extra-peritoneal repair (TEP) with Lichtenstein repair for inguinal hernia with regard to mean operative time, complications, postoperative pain, hospital stay, return to work, cosmetic effects (scar size), and recurrence rate. Patients and Methods: This was a prospective randomized controlled study conducted in a district hospital over a period of 3 years. One hundred and thirty-two patients of groin hernias were treated, 66 each by TEP repair and Lichtenstein tension-free repair. Patients were followed up for 1 year. Results: The mean operative time in laparoscopic TEP was 78.56 min against 58.12 min in Lichtenstein repair (P < 0.0001). The intraoperative complication rates did not differ significantly between the two techniques (P = 0.0612). The postoperative pain scores were significantly lesser in the TEP group (P < 0.0001). The postoperative hospital stay was similar in the two groups (P = 0.7125). There was no statistical difference in the total number of postoperative complications in the two groups(P = 0.8381). The TEP group had a smaller average scar size (P < 0.0001) and returned to their activities of daily life much earlier (P < 0.0001). The recurrence rates were, however, similar between the two groups (P = 0.7861). Conclusion: TEP offered a number of advantages over Lichtenstein repair and proved to be the sure winner.

Laparoscopic choledochoduodenostomy: Role, safety, and efficacy? Our experience of 64 cases Rajkumar Janivakula Sankaran, Prabhakaran Raju, Akbar Syed, Anirudh Rajkumar, Hema Tadimari, Aanchal Kothari Saudi Journal of Laparoscopy 2019 4(1):33-38 Context and Aim: Biliary tract obstruction can be bypassed endoscopically or by laparoscopic bypass. This article aims at analyzing the perioperative outcomes of laparoscopic choledochoduodenostomy (LCDD) performed in a single hospital, in patients not amenable to endoscopic drainage, and compares outcomes from three other case series. This is a retrospective analysis of prospectively gathered data. Materials and Methods: From April 2005 to March 2015, 64 patients with biliary stones and inflammatory or postpancreatitis strictures, refractory to endoscopy, underwent LCDD. The operation was performed using five ports technique. The calculi were first extracted through a vertical supraduodenal choledochotomy, followed by a confirmatory choledochoscopy. The biliary bypass was then constructed with a 2.5-cm choledochoduodenal anastomosis using a double-needle holder technique, single-layer interrupted sutures using 3.0 PDS, or Vicryl. Results: A total of 64 patients underwent LCDD. Nine of these had chronic pancreatitis; the rest had choledocholithiasis with distal stricture. In total, 33 were women and 24 were men, with mean age of 42 years. Mean operative time was 95.9 min, mean blood loss was 160 ml, and mean postoperative length of stay was 4.5 days. There was one minor leak that was managed conservatively. There was no mortality. Follow-up ranged from 1 to 11 years. On a mean follow-up of 58.2 months, there were no long-term complications such as recurrent stones, cholangitis, or sump syndrome. Conclusion: LCDD is an effective method of providing biliary bypass in well-selected patients, with uncommon short- and long-term complications.

Minimally invasive combined surgical procedures of digestive, gynecological, and urological disorders: Five-year experience from a developing country Majid Mushtaque, Ajaz A Rather, Arshad Rashid, Saika Shah, Tanveer Iqbal, Umar Q Bacha, Ibrahim R Guru Saudi Journal of Laparoscopy 2019 4(1):39-43 Context: With advancements in the field of minimally invasive surgery, a variety of general surgical, gynecological, and urological diseases are amenable to treatment by this approach. Combined procedures can be performed for treating coexisting abdominal pathologies. Aims: The study aimed to evaluate our experience of combining multiple minimally invasive procedures in terms of its safety and efficacy. Settings and Design: An observational study was conducted at three hospitals in Kashmir. Materials and Methods: A total of 149 patients underwent combined laparoscopic or combined laparoscopic and endoscopic procedures for the treatment of coexisting abdominal diseases. The outcome was analyzed in terms of mean operative time, postoperative visual analog scale score (0–10), requirement of additional postoperative analgesics, complications, hospital stay, and patient satisfaction. Statistical Analysis: Prospective sample survey analyzing the percentage and mean values. Results: Of 149 patients, 48 (32.2%) were male and 101 (67.7%) were female. Age ranged between 18-58 years in females and 24–70 years in males. The mean operative time ranged between 27 and 115 min. It was the longest in patients who underwent laparoscopic cholecystectomy (LC) with laparoscopically assisted vaginal hysterectomy. The most common organ-specific procedures performed were LC, appendectomy, and ovarian cystectomy in 120, 34, and 15 patients, respectively. Urological procedures were done in 36 patients undergoing either LC or appendectomy. Additional parenteral postoperative analgesics were required in 128 (85.9%) patients. A total of five major and 32 minor complications were noted in 22 (14.7%) patients. Three (2.01%) patients required conversion to open surgery. Orals were started on the 1st postoperative day in the majority of the patients. The mean hospital stay was 2.4 days (range 1–6 days). Overall, 93.9% of the patients expressed satisfaction to the combined procedure. Conclusions: Simultaneous minimally invasive procedures are feasible for coexisting abdominal pathologies in selected patients with the advantages of single anesthesia and hospital admission, low morbidity, and excellent patient satisfaction.

Large Hamartoma occupying the whole breast: Creates a Diagnostic Challenge Amal Abdullah Abdulkareem Saudi Journal of Laparoscopy 2019 4(1):44-46 Hamartoma is detected in the breast during screening of breast asymmetry or discovered pathologically in combination with other breast pathologies. Hamartoma should be considered one of the differential diagnoses of breast asymmetry, especially for young women, where mammogram is not frequently ordered or if the patient complains of significant breast asymmetry with no clearly evident breast mass by physical examination and normal breast ultrasound. Hamartoma is detected by mammogram as “'breast within a breast.” Ultrasound can diagnose small localized hamartoma and fine-needle aspiration or core needle biopsy of no significant help in diagnosis of isolated hamartoma not assonating with other pathologies. Mammogram and breast magnetic resonance imaging (MRI) are of great help in diagnosing hamartoma especially if it is large occupying the whole breast. Awareness of isolated hamartoma as a cause of breast asymmetry with the help of mammogram or MRI of the breast will lead to early diagnosis and treatment and avoid patient suffering of undiagnosed breast hamartoma.