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1.  Femoral Hernia with a Twist 
Case Reports in Medicine  2010;2010:650829.
PMCID: PMC2931410  PMID: 20814561
2.  Every Wheeze Does Not Merit a Puffer! Case of an Overnight Cure of Chronic Asthma 
Case Reports in Medicine  2010;2010:498372.
The peril of incorrect diagnostic labelling is highlighted by this case of acute respiratory distress caused by a retrosternal recurrent goitre. An initial clinical diagnosis which cannot be fully validated on investigation with unexpected or poor response to treatment should prompt consideration and investigation for an alternative explanation.
PMCID: PMC2910460  PMID: 20671942
3.  Long-Term Study of Port-Site Incisional Hernia After Laparoscopic Procedures 
Laparoscopic surgery is widely practiced and offers realistic benefits over conventional surgery. There is considerable variation in results between surgeons, concerning port-site complications. The aim of this study was to evaluate the laparoscopic port closure technique and to explore the factors associated with port-site incisional hernia.
Between January 2000 and January 2007, 5541 laparoscopic operations were performed by a single consultant surgeon for different indications. The ports were closed by the classical method using a J-shaped needle after release of pneumoperitoneum. The incidence of port-site incisional hernias was calculated. All patients were followed up by outpatient clinic visits and by their general practitioners.
During a 6-year period, 5541 laparoscopic operations were performed. Eight patients (0.14%) developed port-site hernia during a mean follow-up period of 43 months (range, 25 to 96) and required elective surgery to repair their hernias. No major complications or mortality was reported.
Laparoscopic port closure using the classical method was associated with an acceptable incidence of port-site hernia. Modification of the current methods of closure may lead to a new technique to prevent or reduce the incidence of port-site incisional hernias.
PMCID: PMC3015977  PMID: 19793475
Port-site incisional hernia; Pneumoperitoneum; Port closure
4.  Management of complications after laparoscopic Nissen's fundoplication: a surgeon's perspective 
Gastro-oesophageal reflux disease (GORD) is a common problem in the Western countries, and the interest in the minimal access surgical approaches to treat GORD is increasing. In this study, we would like to discuss the presentations and management of complications we encountered after Laparoscopic Nissen's fundoplication in our District General NHS Hospital. The aim is to recognise these complications at the earliest stage for effective management to minimise the morbidity and mortality.
301 patients underwent laparoscopic treatment for GORD by a single consultant surgeon in our NHS Trust from September 1999. The data was prospectively collected and entered into a database. The data was retrospectively analysed for presentations for complications and their management.
Surgery was completed laparoscopically in all patients, except in five, where the operation was technically difficult due to pre-existing conditions. The complications we encountered during surgery and follow-up period were major intra-operative bleeding (n = 1, 0.33%), severe post-operative nausea and vomiting (n = 1, 0.33%), wound infection (n = 3, 1%), port-site herniation (n = 1, 0.33%), wrap-migration (n = 2, 0.66%), wrap-ischaemia (n = 1, 0.33%), recurrent regurgitation (n = 4, 1.32%), recurrent heartburn (n = 29, 9.63%), tension pneumothorax (n = 2, 0.66%), surgical emphysema (n = 8, 2.66%), and port-site pain (n = 4, 1.33%).
Minimal access approach to treat GORD has presented with some specific and unique complications. It is important to recognise these complications at the earliest possible stage as some of these patients may present in an acute setting requiring emergency surgery. All members of the department, and not just the members of the specialised team, should be aware about these complications to minimise the morbidity and mortality.
PMCID: PMC2644311  PMID: 19193220
5.  Patient Experience With Gallstone Disease in a National Health Service District Hospital 
The prevalence of gallstone disease in the community makes it an important area of service in district general hospitals. Laparoscopic surgical techniques in synergy with modern imaging and endoscopic and interventional techniques have revolutionized the treatment of gallstone disease, making it possible to provide prompt and definitive care to patients.
Patients with gallstone disease were treated based on a predetermined protocol by a special-interest team depending on the patient's mode of presentation. Data were collected and analyzed prospectively.
Our team treated 1332 patients with gallstone disease between September 1999 and December 2007. Patients (249) with acute symptoms presented through Accident and Emergency (A&E). Despite varied presentations, laparoscopic treatment was possible in all but 8 patients. The study comprised 696 patients who underwent laparoscopic cholecystectomy (LC) as in-hospital (23 hour) cases in a stand-alone center, and 257 outpatients and 379 inpatients. Sixty-seven patients with acute cholecystitis had their surgery within 96 hours of acute presentation. Seventy patients had laparoscopic subtotal cholecystectomy. The overall morbidity was 2.33% with 3 patients having residual common bile duct stones; 3 patients had biliary leak from cystic or accessory duct stumps and one had idiopathic right segmental liver atrophy; 19 had wound infections, 5 had port-site hernia. No mortalities occurred during the 30-day follow-up.
We believe that prompt investigation with imaging and endoscopic intervention if needed along with LC at the earliest safe opportunity by a specialized dedicated team represents an effective method for treating gallstone disease in district general hospitals. Our experience with over 1000 patients has offered us the courage of conviction to say that justice is finally here for gallstone sufferers.
PMCID: PMC3016000  PMID: 19275855
Gallstones; Cholecystectomy; Laparoscopic
6.  An apricot story: view through a keyhole 
Very few cases of small bowel obstruction due to ingested fruits have been described in literature, and most of these have managed by a laparotomy. Laparoscopic assisted surgery can effectively deal with such impacted foreign bodies, thereby avoiding a formal laparotomy.
Case presentation
A 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. Investigations were suggestive of acute small bowel obstruction. On laparoscopy, there was an area of sudden change in calibre of small bowel with dilated proximal and collapsed distal segment in distal jejunum. A foreign body, dried undigested apricot, was extracted by mini-laparotomy.
Small bowel obstruction is a frequent cause of emergency surgery, and aetiology may include food bolus obstruction. Diagnosis is usually confirmed intra-operatively. Foreign body impacted in small bowel can be removed by open or laparoscopic methods.
Generally, laparotomy is performed for diagnosis and management in acute bowel obstruction, but with increasing expertise, laparoscopy can be equally effective with all the other advantages of minimal access approach.
PMCID: PMC1976312  PMID: 17697369
7.  Agenesis of the Gallbladder: Lessons to Learn 
Congenital absence of the gallbladder is a rare, usually asymptomatic, anatomical variation. Some affected individuals may present with a clinical picture suggestive of gallbladder disease. This presentation, coupled with the inability of standard abdominal ultrasonography to convincingly diagnose agenesis of the gallbladder, can put the surgeon in a diagnostic and intraoperative dilemma.
Case Report:
A 30-year-old lady presenting with clinical features of cholecystitis and diagnosed with shrunken gallbladder on ultrasonography was scheduled for laparoscopic cholecystectomy. Intraoperatively, the gallbladder could not be seen even after thorough dissection in the region of the porta hepatis. The procedure was terminated at this stage, and further imaging of the extrahepatic biliary system by magnetic resonance cholangiopancreatography and endoscopic ultrasound confirmed the diagnosis of congenital absence of the gallbladder.
Nonvisualization of the gallbladder at laparoscopy, in the absence of any other diagnosed biliary disorder, need not prompt conversion to open exploration of the extrahepatic biliary system. Newer imaging modalities are relatively noninvasive and can provide good delineation of biliary anatomy. This allows well-planned treatment and at the same time prevents the added morbidity of a diagnostic laparotomy performed solely to confirm the absence of the gallbladder.
PMCID: PMC3015765  PMID: 17575771
Gallbladder; Absence; Congenital; Laparoscopy
8.  Gallstones: Best Served Hot 
Acute episodes of gallstone-related diseases have traditionally been managed conservatively. In the event of gallstones obstructing the common bile duct, patients had endoscopic extraction of calculi with interval cholecystectomy after 4 weeks to 6 weeks when acute inflammatory changes have subsided. This placed the patient at risk of recurrent cholecystitis, pancreatitis, or other complications of cholelithiasis.
Patients presenting with acute gallstone-related diseases were investigated and underwent laparoscopic cholecystectomy during the same admission according to a predetermined treatment protocol.
All patients (119) treated according to the study protocol had good results, with no 30-day mortality and no biliary tract injuries. One patient had bleeding from the cystic artery, and 6 patients required conversion to open cholecystectomy.
Growing expertise in laparoscopic cholecystectomy has made it possible for surgeons to perform safe cholecystectomy in the presence of acute gallstone-related disease. Our experience of managing gallstone disease with prompt cholecystectomy during the index admission shows that this approach provides better, safer, and more cost-effective patient care.
PMCID: PMC3015704  PMID: 17212890
Gallstones; Acute disease; Laparoscopic cholecystectomy

Results 1-8 (8)