Pawanindra Lal

All India Institute of Medical Sciences, New Delhi, NCT, India

Are you Pawanindra Lal?

Claim your profile

Publications (24)45.04 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia.
    Surgical endoscopy. 08/2014;
  • [Show abstract] [Hide abstract]
    ABSTRACT: To compare the use of a biliary stent with T-tube for biliary decompression after laparoscopic common bile duct (CBD) exploration. Between September 2004 and March 2008, 60 patients undergoing laparoscopic CBD exploration for CBD stones were randomized to choledochotomy closure over either a biliary stent or a T-tube after CBD clearance. Patients at high risk for surgery and unremitting cholangitis requiring preoperative endoscopic biliary drainage were excluded. There were 29 and 31 patients in the T-tube and stenting groups, respectively. The 2 groups were comparable with respect to their demographic profile and disease characteristics. Patients in the stent group had a significantly shorter operative time and postoperative stay with an earlier return to normal activity (P<0.0001). Choledochotomy closure over a stent results in a shorter postoperative stay and an earlier return to normal activity compared with closure over a T-tube without any increase in morbidity.
    Surgical laparoscopy, endoscopy & percutaneous techniques 08/2012; 22(4):345-8. · 0.88 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Laparoscopic Nissen fundoplication (LNF) is a commonly performed procedure for the treatment of gastro esophageal reflux disease (GERD) worldwide. However, unfavourable postoperative sequel, including gas bloat and dysphagia, has encouraged surgeons to perform alternative procedures such as laparoscopic Toupet fundoplication (LTF). This prospective nonrandomized study was designed to compare LNF with LTF in patients with GERD. Hundred and ten patients symptomatic for GERD were included in the study after having received intensive acid suppression therapy for a minimum of 8 weeks. A 24-hour pH metry was done on all patients. Fifty patients having reflux on 24-hour pH metry were taken up for the surgery. Patients were further divided into group-A (LNF) and group-B (LTF). The median percentage time with esophageal pH < 4 decreased from 10.18% and 12.31% preoperatively to 0.85% and 1.94% postoperatively in LNF and LTF-groups, respectively. There was a significant and comparable increase in length of lower esophageal sphincter (LES), length of intraabdominal part of LES and LES pressure at respiratory inversion point in both the groups. In LNF-group, five patients had early dysphagia that improved afterwards. There were no significant postoperative complications. LNF and LTF are highly effective in the management of GERD with significant improvement in symptoms and objective parameters. LNF may be associated with significantly higher incidence of short onset transient dysphagia that improves with time. Patients in both the groups showed excellent symptom and objective control on 24-hour pH metry on short term follow-up.
    Journal of Minimal Access Surgery 04/2012; 8(2):39-44.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Patients with a dilated common bile duct (CBD) and multiple, primary, or recurrent stones are candidates for choledochoduodenostomy. This article reviews our technique and results of laparoscopic choledochoduodenostomy (LCDD) in patients with CBD stones. Prospectively maintained data of patients with a dilated CBD and multiple, primary, or recurrent CBD stones who underwent LCDD after laparoscopic CBD exploration (LCBDE) at a tertiary-care teaching hospital in New Delhi, India, during a 10-year period from April 2001 to March 2011 were analyzed. During this period, of 195 patients who underwent LCBDE for CBD stones, 27 patients underwent LCDD. The mean age of patients was 45.7±13.5 years. There were 6 male and 21 female patients. Sixteen (59.2%) patients had jaundice at presentation. Average CBD diameter was 19.6±4.4 mm. On average, 11.5±15.7 stones were removed from the CBD. Mean operative time was 156.3±25.4 minutes. Mean operative blood loss was 143.3±85.5 mL. Average postoperative hospital stay was 6.4±3.8 days. CBD clearance was obtained in all cases. One patient had a bile leak that resolved with conservative treatment. There was no mortality. No patient has had recurrence of symptoms or cholangitis after a follow-up of up to 9 years. LCDD can be safely performed in patients with a large stone burden and recurrent or primary CBD stones. Although it requires advanced laparoscopic skills, the benefits of a single-stage laparoscopic procedure can be extended to these patients safely with good results.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 12/2011; 22(1):81-4. · 1.07 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The open technique for the placement of the first trocar in laparoscopic surgery has become the preferred method due to the reduced number of complications associated with it. In 2002 we reported our technique, which has been widely accepted at many centers, including all the units of our hospital. We now report on a series of 6,000 cases in which this technique was used. The method is the same as that reported by us previously (Surg Endosc 16:1366-1370, [10]) except for the minor modification of using a Mayo towel clip instead of the Allis forceps for holding the cicatrix pillar, as the pillar tends not to slip out of the former. During closure, Allis forceps is used to lift the divided rectus sheath on each side to take the suture bite and ensure complete secure closure. A total of 6,000 consecutive cases have been performed using this technique in two tertiary care hospitals over the last 11 years. A total of 6,000 cases (5,350 females and 650 males) were operated on over an 11-year period. There were no visceral or vascular complications. Four hundred seventy-five patients (7.9%) had had previous abdominal surgery. The supraumbilical route was used in 348 patients and lateral entry in 90 patients. Port-site hernias were seen in 25 cases (0.4%) and wound infections in 56 cases (0.9%). The average time for trocar placement was 2 min (range = 1-12 min) and the average port size was 15 mm (range = 12-22 mm). The average time for port closure at the end of the procedure was 3 min (range = 1-7 min). The technique of open-trocar placement in laparoscopic surgery has now become standardized, with its safety having been well established. Our experience has shown that this technique is safe, effective, reproducible, easy to learn, can be performed quickly, and has excellent results.
    Surgical Endoscopy 08/2011; 26(1):182-8. · 3.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Common bile duct stones (CBDS) that are seen in the Asian population are very different from those seen in the west. It is not infrequent to see multiple, large, and impacted stones and a hugely dilated CBD. Many of these patients have been managed by open CBD exploration (OCBDE), even after the advent of laparoscopic cholecystectomy (LC), because these large stones pose significant challenges for extraction by endoscopic retrograde cholangiopancreatography. This series presents the largest experience of managing CBDS using a laparoscopic approach from Indian subcontinent. Between 2003 and 2009, 150 patients with documented CBDS were treated laparoscopically at a tertiary care hospital in New Delhi. Of these, 4 patients were managed through transcystic route and 140 through the transcholedochal route. There were 34 men and 116 women patients with age ranging from 15 to 72 years. The mean size of the CBD on ultrasound was 11.7 ± 3.7 mm and on MRCP 13.8 ± 4.7 mm. The number of stones extracted varied from 1 to 70 and the size of the extracted stones from 5 to 30 mm. The average duration of surgery was 139.9 ± 26.3 min and the mean intraoperative blood loss was 103.4 ± 85.9 ml. There were 6 conversions to open procedures, 1 postoperative death (0.7%), and 23 patients (15%) had nonfatal postoperative complications. Three patients had retained stones (2%) and one developed recurrent stone (0.7%). Even in patients with multiple, large, and impacted CBDS, there is scope for a minimally invasive procedure with its attendant benefits in the form of laparoscopic CBD exploration (LCBDE).
    Surgical Endoscopy 01/2011; 25(1):172-81. · 3.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this study was to evaluate the role of retroperitoneal laparoscopic pyelolithotomy (RPPL) and its comparison with extra corporeal shock wave lithotripsy in the management of renal calculi. The study was carried out in the Department of surgery, Maulana Azad Medical College, New Delhi, India. The study included 86 cases of solitary renal calculi in the retroperitoneoscopic (RPPL) group and 82 cases in the shock wave lithotripsy (SWL) group. The parameters compared were stone clearance, hospital stay, number of postoperative visits, mean time to resume normal activities, number of man days lost, and analgesic requirement. The RPPL group showed better stone clearance, fewer hospital visits, low analgesic requirement, fewer number of man days lost, and early resumption of normal activities, as compared to the SWL group. Shock wave lithotripsy, being a noninvasive modality, is an established procedure all over the world. However RPPL achieves comparable or better results in high volume centers.
    Journal of Minimal Access Surgery 10/2010; 6(4):106-10.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Since the first retroperitoneal laparoscopic pyelolithotomy (RPPL) was reported by Gaur and associates in 1994, its technique has improved considerably. The applicability and indications of the procedure are expanding with advances in technology, expertise, and experience. To date, there has been no prospective study in the literature about the role of preoperative Double-J (D-J) ureteral stenting in patients who undergo RPPL. This study is an endeavor to evaluate the role of preoperative D-J stenting in RPPL. The study included 184 patients, who were randomized into 2 groups. Group A included 95 patients, who underwent RPPL with D-J stenting. Group B included 89 patients, who underwent RPPL without D-J stenting. In group A, D-J stents were inserted under local anesthesia preoperatively, on the side of surgery. Complications during surgery and during the postoperative period were carefully recorded. The duration of drainage and volume in group A was significantly lower than in group B. The duration of postoperative stay was significantly reduced in group A (mean 3.3 vs. 5.74 days). The analgesic requirement in group A also was significantly lower than in group B (mean 378.95 vs. 558.99 mg). No statistically significant difference existed between the two groups, in terms of minor intraoperative and postoperative complications (25.3% vs. 29.2%; p < or = 0.547). D-J stenting and type of renal pelvis influenced the results, i.e., duration of drainage, analgesic requirement, and duration of stay, in patients undergoing RPPL. However, there was no significant difference in operative time, intraoperative blood loss, and postoperative complications. D-J stent group had significant increase in the rate of urinary tract infection postoperatively.
    Surgical Endoscopy 07/2010; 24(7):1722-6. · 3.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Surgical management for gastroesophageal reflux disease (GERD) is indicated for reflux uncontrolled on medical therapy. Few studies have been reported from the Indian subcontinent evaluating laparoscopic fundoplication in GERD. The study was designed to evaluate laparoscopic Nissen fundoplication (LNF) in proven cases of GERD and to evaluate the procedure from using detailed symptomatic, objective parameters. Forty-nine patients symptomatic for GERD and with esophagitis on endoscopy were included in the study. Symptoms were evaluated by DeMeester's score (DS) and modified Visick grade (MVG). All patients underwent an upper gastrointestinal endoscopy with biopsy, ultrasound abdomen, Barium swallow, esophageal manometry, and 24-hour pH metry. Twenty-five of 49 patients showing reflux on 24-hour pH metry underwent LNF. They were followed-up postoperatively at 1, 3, and 6 weeks. Esophageal manometry and 24-hour pH metry were repeated at 6 weeks. The data were compared from using Wilcoxon signed rank test, the Student's t-test, and Spearman's correlation coefficient. At 6 weeks postoperatively, percentage time with esophageal pH <4 decreased from 10.18% preoperatively to 0.85%. Length of lower esophageal sphincter (LES), length of intra-abdominal part of LES and LES pressure at the respiratory inversion point increased significantly from 2.08 cm, 0.85 cm, and 7.82 mm Hg to 3.36 cm, 2.13 cm, and 22.00 mm Hg, respectively. Median DS and MVG decreased from 4.00 and 3.35 preoperatively to 0 and 1, respectively. There was no conversion to open surgery and no mortality. Five patients developed temporary dysphagia to solids, which was relieved before 6 weeks postoperatively. Mean time to return to work was 12.60 days. LNF proved highly effective in the management of Indian patients with GERD who have failed medical therapy and provides significant symptomatic improvement postoperatively with a low incidence of side effects.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 06/2010; 20(5):441-6. · 1.07 Impact Factor
  • Source
    Journal of vector borne diseases 06/2010; 47(2):119-20. · 1.04 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Bilateral laparoscopic totally extraperitoneal (TEP) repair of unilateral hernia is conspicuous in published literature by its absence. There are no studies or data on the feasibility, advantages or disadvantages of bilateral repair in all cases or in any subset of patients with unilateral primary inguinal hernia. The objective of this study is to investigate the feasibility of bilateral laparoscopic exploration for all unilateral cases followed by laparoscopic TEP in all cases and to compare complications, recurrence rates, postoperative pain, patient satisfaction, and return to work retrospectively with a similar number of age-matched retrospective controls. One hundred fifty TEP operations were performed in 75 patients (group A) prospectively and were compared with 75 unilateral TEP operations (group B) in age-matched controls done previously by the same surgeon. All cases were performed under general anesthesia, and TEP repair was performed using three midline ports. All uncomplicated patients were discharged at 24 h, in keeping with departmental policy. Of 75 patients (group A), 25 (33.3%) were clinically diagnosed with bilateral hernia and the rest (50, 66.66%) with unilateral hernia. The distribution of the 25 bilateral cases was 11 bilateral direct and 14 bilateral indirect inguinal hernias. The distribution of the 75 age-matched controls (group B) was all unilateral hernia, of which 47 were right-sided and 28 were left-sided. There were 23 direct hernias and 52 indirect hernias among the control group. The mean operative time for all 150 cases was 76.66 +/- 15.92 min. The operative time in the control group (unilateral hernias) was 66.16 +/- 12.44 min, whereas the operative time in the test group (bilateral repair) was 87.2 +/- 11.32 min. The operative time in the bilateral group was significantly higher, by 21.04 min or 31.88% (p = 0.000). The operative time in the true unilateral group was 82.45 +/- 9.38 min, whereas the operative time in the former group [occult contralateral hernias (OCHs) + bilateral hernias] was 91.35 +/- 11.95 min, which is a statistically significant difference (p = 0.0015). Occult hernia was seen in a total of 15 cases, of which 13 were OCHs (26%) and 2 were occult ipsilateral hernias (OIH). The mean operative time in the OCH cases was 81.46 +/- 7.9 min, whereas in those without OCH it was 82.45 +/- 9.38 min, which is not a statistically significant difference (p = 0.46). Regarding complications, there were no cases of seroma, hematoma, wound infection, visceral injury or postoperative neuralgia in either group A or B. On statistical analysis, visual analog score (VAS)-measured pain score, at 12 h only, was significantly higher in the unilateral repair group as compared with the bilateral TEP group; VAS scores at all other times were not statistically significantly different between the two groups. The average time of return to light routine or activities of daily living was 1 day in group A, whereas in group B it was 1.91 days (range 1-3 days), which is a statistically significant difference (p = 0.000). There was one case of recurrence in this study, in a left-sided hernia in group A, over a follow-up period of 60-72 (mean 66) months; all patients reported for follow-up by office visit or correspondence until 2 years, and two patients were lost to follow-up after 2 years. In group B, there was no recurrence over a follow-up period of 72-84 months, with three patients lost to follow-up after 3 years. In the present study bilateral TEP was performed in three types of patients: those with clinically bilateral hernias, those with clinically unilateral hernia but with an OCH, and in truly unilateral hernias. All of these were compared with unilateral TEPs in clinically unilateral hernias, and we found no significant increase in morbidity, pain, recurrence or complications in bilateral repairs. Convalescence from surgery, as determined by return to activities of daily living and return to work parameters, was also comparable. Surgeons experienced in laparoscopic TEP, in high-volume centers, can provide bilateral repairs in patients with inguinal hernia, bearing in mind its advantages and comparable morbidity. We also feel that, in elective repair of inguinal hernia, the patient should be given the option of bilateral repair. Bilateral repair does not add to the risk of surgery in experienced hands and we strongly feel that unilateral TEP is actually a job half done.
    Surgical Endoscopy 02/2010; 24(7):1737-45. · 3.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: There is evidence that the components of the coagulation/fibrinolytic system play a role in cancer biology and angiogenesis. Studies reveal that at the time of diagnosis, majority of the cancer patients have laboratory evidence of systemic coagulation activation. Our purpose was to investigate the significance of D-Dimer (product of fibrin degradation) and factor VIII levels in breast cancer and to evaluate its relationship with other variables such as histological characteristics, lymph node status and immunohistochemistry markers (ER, PR and Her-2neu). A prospective study was conducted in the Department of Surgery in collaboration with Departments of Medicine, Pathology and Radiodiagnosis & Imaging, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi. Fifty patients with diagnosed cancer breast who were treated in surgery department were evaluated for D Dimer and factor VIII levels. D-dimer and Factor VIII levels were measured three times i.e. at the time of commencement of treatment then after three cycles of Chemotherapy (CAF Regimen) and finally after six weeks of surgery. Significantly higher levels of D Dimer and factor VIII were observed in tumors with significant lymphovascular and adipose tissue invasion in comparison to localized tumors. The reduction in D-dimer and Factor VIII values after Surgery was significant for both D-dimer (p value 0.000) and Factor VIII (p value 0.000). The reduction in D-dimer after 3 cycles of chemotherapy was significant for D-dimer (575.51 ± 572.47 ng/ml vs. 422.45 ± 363.58 ng/ml; p value 0.046) but not significant for Factor VIII (307.83 ± 184.47 ng/ml vs. 288.78 ± 163.02 ng/ml; p value 0.151). D-dimer and factor VIII may be used as yardstick for systemic adjuvant therapy in node negative < 1 cm breast cancer. D-dimer may prove to be a safe, convenient and easily available biomarker which can be combined with conventional sentinel node biopsy in clinically node negative breast cancer to assess metastatic disease in axilla and reduce false negative results.
    Cancer biomarkers: section A of Disease markers 01/2010; 7(6):305-14. · 0.97 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: : Injection sclerotherapy is a commonly used treatment for grade 1 hemorrhoids. Sclerosing agents are highly irritating and toxic substances; injudicious use may give rise to grave complications. Life threatening complications of injection sclerotherapy have been reported . We report a case of a 35 year old male who developed a recto urethral fistula following injection sclerotherapy. No similar complication of injection sclerotherapy has been reported in the literature.
    Colorectal Disease 12/2009; 13(1):105. · 2.08 Impact Factor
  • Source
    Pawanindra Lal, Anubhav Vindal, N S Hadke
    [Show abstract] [Hide abstract]
    ABSTRACT: Giant duodenal ulcer (GDU) perforation remains an extremely uncommon but a rather challenging condition to manage wherein routine surgical procedures are fraught with an extremely high incidence of failure and mortality. It therefore follows that this condition must be identified and managed differently at laparotomy than are most duodenal perforations. We describe a method by which to deal with this condition using triple-tube-ostomy. In a prospective setting, 20 patients underwent surgery using the technique described in the article. During the same period, 20 patients with GDU perforation, who were managed in the conventional manner, were evaluated. The outcomes of the 2 groups were compared. The success rate was 100% in the study group compared with 30% in the control patients. Based on the ease of the technique and the high success of the procedure in our experience in this select group, we recommend this procedure for the management of GDU perforation as a safe, reliable, and easy technique to learn.
    American journal of surgery 04/2009; 198(3):319-23. · 2.36 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Stapled hemorrhoidopexy for prolapsing hemorrhoids has been found to be associated with lesser postoperative pain and consequently earlier mobilization and return to work, in comparison to conventional hemorrhoidectomy. Purse string application remains a crucial step to ensure adequate lifting of the anal mucosa and this step is technically tedious in the presence of large hemorrhoids obscuring the vision using the standard purse string applicator. The proposed method in our technique makes this crucial step more reliable, easier, and safe in the hands of the beginner and the experienced surgeon alike. Thirty healthy adults (21 males and 9 females) with grade 3 or 4 hemorrhoids underwent stapled hemorrhoidopexy at a large university referral hospital in New Delhi. Purse string application was the first step in the entire procedure even before the application of the circular anal dilator. The purse string was applied using authors' method herein after referred to as Maulana Azad Medical College "(MAMC) technique" after the name of the institution. Rest of the procedure was completed as described by Longo et al. The mean operative time was 26 minutes (range 16 to 40 min). The mean visual analog scale (VAS) pain score on day 1 was 1.6 (range 0 to 3). The mean hospital stay was 1.1 days (range 1 to 2 d). There was no major intraoperative complication and one case each of postoperative urinary retention and residual hemorrhoid, there was no recurrence, anal stenosis, or anal incontinence after a mean follow up of 15 months (range 3 to 24 mo). The procedure described is safe, easy to learn, and technically sound, enabling the application of the crucial purse string at the desired distance from the dentate line, in the correct submucosal plane with closely placed bites and at the same transverse level.
    Surgical laparoscopy, endoscopy & percutaneous techniques 01/2008; 17(6):500-3. · 0.88 Impact Factor
  • Pawanindra Lal, K. N. Saxena
    Surgical Endoscopy 12/2007; 22(1):257-257. · 3.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is as efficacious as the open Lichtenstein procedure, can be learned with proper training, and causes less postoperative pain, better cosmesis, and earlier return to work. The one major factor preventing the widespread acceptance of TEP is the requirement for general anesthesia (GA). In contrast, open hernia is performed using local or regional anesthesia, thereby having the advantage of quicker recovery, decreased postoperative nausea and vomiting (PONV), fewer hemodyanamic changes, reduced metabolic responses to surgical stress, and better muscle relaxation. This study attempted to evaluate whether laparoscopic TEP can be performed under less invasive anesthesia, such as regional anesthesia, and to determine its feasibility and limitations All total of 22 male patients were studied between January 2002 and March 2003 in a tertiary care referral hospital. Epidural anesthesia with 2% lignocaine with adrenaline (Adr) was given via a lumbar epidural catheter, achieving a sensory level of T6. The standard technique for TEP was followed, using three midline infraumbilical ports. Twenty-two patients (20 unilateral, 2 bilateral) underwent operation. The mean operating time was 67.8 +/- 18 (range, 40-110) min. All 22 cases were started with epidural anesthesia, 7 of which (31.9%) were converted to GA; the other 15 (68.1%) were completed under epidural anesthesia. All cases were successfully completed laparoscopically, and there were no conversions. There were no intraoperative complications. There was no significant difference between the cases conducted under epidural anesthesia (67.6 +/- 23 min) and those converted to GA (69.3 +/- 7.3 min). There was no statistically significant difference between the conversion rates of smaller versus larger hernias in this study (p value 0.22). A significant association of success of the procedure was seen with a sensory level of T6 and above (2/15 conversions to GA; i.e., 13.3%) and cases with a sensory level below T6 (5/7 converted; i.e., 71.4%) and adequate epidural catheter length (p = 0.015). Prevention and management of pneumoperitoneum and subsequent shoulder-tip pain was the key to preventing conversions (6 of 9 converted to GA; i.e., 67%; p = 0.006). There were no significant postoperative complications, and no recurrences were noted during a mean follow-up period of 29 months (range, 20-36 months). From the present study it is clear that TEP is possible under epidural anesthesia provided a minimal sensory level of T6 is achieved. To achieve that level, an appropriate higher site for catheter insertion and/or adequate intraepidural catheter length needs specific attention. Pneumoperitoneum, shoulder-tip pain, intraoperative straining, and inadequate preperitoneal space are factors whose interplay leads to conversion to GA. The size of the hernia is not related to pneumoperitoneum or conversion to GA.
    Surgical Endoscopy 05/2007; 21(4):595-601. · 3.43 Impact Factor
  • Pawanindra Lal, R K Kajla, J Chander, V K Ramteke
    [Show abstract] [Hide abstract]
    ABSTRACT: Total extraperitoneal (TEP) laparoscopic inguinal hernia repair is preferred to the transabdominal preperitoneal (TAPP) repair since it preserves peritoneal integrity. However, in general it is considered to be more difficult than the latter because of the peculiarity of anatomy and limitation of working space. Therefore it has been assigned with a "steep learning curve" that the surgeon needs to climb steadily and slowly. This paper offers a working protocol, which is aimed at reducing the steep limb of this curve. A total of 61 patients were studied between April 2000 and September 2002. Of these, five patients had a open unilateral Stoppa's preperitoneal operation to learn the detailed anatomy of the extraperitoneal space. Thereafter, laparoscopic TEP procedure was started in the following 56 cases by P.L. In case of difficulty, the procedure was to be converted to the open preperitoneal operation only. Of the first 10 cases, five were converted to unilateral Stoppa's preperitoneal operation for various reasons, and one case was converted after 30 cases. Thus a total of 11 cases were completed by open unilateral Stoppa's preperitoneal operation and 50 cases were completed laparoscopically. The first 30 cases started initially as laparoscopic operations were analyzed in groups of 10 each and compared to another study from Netherlands (evaluating four surgeons) wherein the initial laparoscopic procedures were started with the assistance of a surgeon well experienced in laparoscopic TEP operation. The comparison of our first 30 cases with the Netherlands group showed that while the conversions (five cases) to open operation were higher in the first 10 cases, there were no conversions in the next 20 cases. Also, there were no complications or recurrences in the present study, in striking contrast to three recurrences and 10 complications in the comparative study. The following 26 cases were associated with no recurrence or major complication. In this study we performed a total of 11 open unilateral Stoppa's preperitoneal procedures in our attempt to learn the anatomy of this extraperitoneal space better, and in the absence of any surgeon experienced in laparoscopic TEP procedure. We were able to place a large mesh in each and every case and also recognize double hernias in six cases, thus preventing recurrences and complications. We strongly recommend a minimum of 10 open Stoppa's preperitoneal procedures, to enable a trained laparoscopic surgeon to start laparoscopic TEP operation independently and in the absence of another trained laparoscopic hernia surgeon, whose presence may not prevent complications and recurrences.
    Surgical Endoscopy 05/2004; 18(4):642-5. · 3.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the feasibility of transurethral resection of the prostate (TURP) as catheter-free day-care surgery. The study comprised 64 patients (mean age 62.4 years) with a mean (range) American Urological Association symptom score of 21.4 (9-31) and prostate volume (by ultrasonography) of 32.8 (17-50) mL, and with no significant comorbidity. The patients were admitted on the morning of the surgery and, under brief spinal anaesthesia, underwent standard TURP. After surgery the urethral catheter was removed as soon as the effluent was clear. The patients were discharged after they could pass urine freely and with a good stream. The mean duration of catheterization after TURP was 7.15 h; 59 patients (92%) had their catheter removed within 10 h (mean duration 6.42 h). There were no major complications during or after TURP. After removing the catheter, no patients required its reinsertion for failure to void or for clot retention. The mean hospital stay after TURP was 10.7 h and 98% of patients were discharged within 23 h of surgery. TURP can be conducted safely in a day surgery setting in patients with mild to moderate benign prostatic enlargement and no coexisting medical illness.
    BJU International 10/2003; 92(4):422-5. · 3.05 Impact Factor
  • Pawanindra Lal, R K Kajla, J Chander, R Saha, V K Ramteke
    [Show abstract] [Hide abstract]
    ABSTRACT: Whereas open anterior inguinal herniorrhaphy is a time-tested, safe, and well-understood operation with a high success rate, laparoscopic techniques of inguinal hernia repair are fairly recent. Consequently, short- and long-term outcomes are still being evaluated. Few studies have compared laparoscopic extraperitoneal inguinal hernia repair with tension-free open hernia repair. The current study was conducted to compare complications, operative time, postoperative pain, length of hospital stay, and return to work between open tension-free mesh Lichtenstein (open) repair and laparoscopic total extraperitoneal (TEP) repair. In a prospective randomized study, open hernia repair was performed in one group (n = 25), and TEP repair using a large mesh was performed in another (n = 25). Then intraoperative and postoperative complications and results were compared. The mean operative time in the TEP group was 75.72 +/- 31.6 min, which was significantly longer than the mean operative time in the open group (54 +/- 15) min (p <0.001). The mean pain scores in the TEP group were 2.64 +/- 1.4 at 12 h and 1.76 +/- 1.4 at 24 h. These scores were significantly lower than the corresponding scores of 3.52 +/- 1.7 (p <0.04) and 2.74 +/- 1.5 (p <0.01) in the open repair group. The mean postoperative analgesic dose was 2.6 +/- 2.3 in the TEP group, which was significantly lower than in the open group 5.76 +/- 3.5 (p <0.001). There was no major complication in either group. The time until return to work was significantly lower in the TEP group (12.8 +/- 7.1) days versus 19.3 +/- 4.3 days; than in the open group (p <0.001). In terms of cosmetics, all 25 patients (100%) in TEP group rated themselves as "highly satisfied," as compared with 7 patients (28%) in the open group (p <0.001). After a mean follow-up period of 13 months (range, 9-18 months), no recurrence was seen in either of the two groups. In terms of complications and short-term recurrence, TEP repair is comparable with open repair. Moreover, TEP is significantly less painful in the early postoperative period, leading to earlier ambulation than open repair. Additionally, TEP results in significantly earlier return to work and better cosmetic results. Currently, TEP seems to be a better alternative than the existing open repair, provided the long-term recurrence rates are comparable. Despite the fact that TEP was a new procedure for the surgeon and the study was conducted during the learning phase, the results are comparable with those in the world literature.
    Surgical Endoscopy 06/2003; 17(6):850-6. · 3.43 Impact Factor

Publication Stats

172 Citations
45.04 Total Impact Points

Institutions

  • 2012
    • All India Institute of Medical Sciences
      • Department of Gastrointestinal Surgery
      New Delhi, NCT, India
  • 2002–2012
    • Maulana Azad Medical College
      • Department of Surgery
      New Dilli, NCT, India