Pawanindra Lal

Lok Nayak Hospital, New Dilli, NCT, India

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Publications (36)

  • Article · Jan 2015
  • Anubhav Vindal · Pawanindra Lal
    Article · Jan 2015 · BJOG An International Journal of Obstetrics & Gynaecology
  • Conference Paper · Dec 2014
  • Anubhav Vindal · Jagdish Chander · Pawanindra Lal · Balu Mahendra
    [Show abstract] [Hide abstract] ABSTRACT: Background: 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. Methods: Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance. Results: There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8%) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3%) showed a false-positive result on IOC which had to be resolved with choledochoscopy. Conclusions: The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.
    Article · Aug 2014 · Surgical Endoscopy
  • Anshula Tayal · Pawanindra Lal · Beena Uppal
    [Show abstract] [Hide abstract] ABSTRACT: Single and multiple liver abscesses in Delhi are predominantly amoebic and must be distinguished from pyogenic abscesses which frequently require drainage. Mixed abscesses are larger, harbouring Gram negative rods. Multiple abscesses are not always pyogenic and presence of bacteria does not imply a primary pyogenic source.
    Article · Apr 2013 · Tropical Doctor
  • [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.
    Article · Aug 2012 · Surgical laparoscopy, endoscopy & percutaneous techniques
  • Pawanindra Lal · Nitin Leekha · Jagdish Chander · [...] · Vinod K Ramteke
    [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.
    Article · Apr 2012 · Journal of Minimal Access Surgery
  • [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.
    Article · Dec 2011 · Journal of Laparoendoscopic & Advanced Surgical Techniques
  • Pawanindra Lal · Anubhav Vindal · Rajeev Sharma · [...] · Vinod Kumar Ramteke
    [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.
    Article · Aug 2011 · Surgical Endoscopy
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    Jagdish Chander · Anubhav Vindal · Pawanindra Lal · [...] · Vinod Kumar Ramteke
    [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).
    Full-text Article · Jan 2011 · Surgical Endoscopy
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    Jagdish Chander · Nikhil Gupta · Pawanindra Lal · [...] · Vinod K Ramteke
    [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.
    Full-text Article · Oct 2010 · Journal of Minimal Access Surgery
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    [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.
    Full-text Article · Jul 2010 · Surgical Endoscopy
  • Pawanindra Lal · Rakesh Kumar · Nitin Leekha · [...] · V.K. Ramteke
    [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.
    Article · Jun 2010 · Journal of Laparoendoscopic & Advanced Surgical Techniques
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    Nikhil Gupta · Pawanindra Lal · Anubhav Vindal · [...] · Nita Khurana
    Full-text Article · Jun 2010 · Journal of vector borne diseases
  • [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.
    Article · Feb 2010 · Surgical Endoscopy
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    [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.
    Full-text Article · Jan 2010 · Cancer biomarkers: section A of Disease markers
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    N Gupta · A Katoch · P Lal · N S Hadke
    [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.
    Full-text Article · Dec 2009 · Colorectal Disease
  • Article · Apr 2009 · Indian Journal of Community Medicine
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    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.
    Full-text Article · Apr 2009 · American journal of surgery
  • Article · Jul 2008 · Indian Journal of Community Medicine