For surgical novices tested on an in vitro dexterity exercise, a robotically assisted laparoscopic system offers a shorter learning curve and improved accuracy compared to straight stick surgery.

Simultaneous pneumoperitoneum and pneumomediastinum is a rare clinical occurrence. It has been reported in the literature as a complication of various medical and dental procedures. To our knowledge, we present the first case of a non-iatrogenic and traumatic simultaneous pneumoperitoneum and pneumomediastinum in a previously independent 91-year-old man who presented to hospital with back and chest wall pain following mechanical fall from standing. A new radiological diagnosis of diverticular disease with possible perforation was made following admission. Despite appropriate management and supportive measures, the patient died 12 days after admission from a kidney injury.

Malignant melanoma of the anorectal region is a very rare aggressive malignant neoplasm and it constitutes 1% of all malignant lesions of this area. About 70% of these lesions are pigmented, whereas 30% are amelanotic. Demonstration of immune markers of melanoma by immunohistochemistry (IHC) is required for confirming the diagnosis of amelanotic malignant melanoma. Here, we report a case of anorectal malignant amelanotic melanoma in a 65-year-old male with no medical comorbidities, who presented with chief complaints of bleeding per rectum associated with prolapsing mass per rectum of 7 months duration. On external examination and proctoscopy, three prolapsed pedunculated fungating masses were seen externally protruding out of the rectum approximately 4 cm from the anal verge. Contrast-enhanced computed tomography of the whole abdomen and pelvis was suggestive of moderately enhancing lobulated anorectal mass with large polypoidal intraluminal component arising from anorectal walls and extension into mid-lower rectum with liver and locoregional lymph nodes metastasis. The patient was taken up for palliative local excision. Per-operatively, three large irregular highly vascular pedunculated rectal growth was seen. The growth was excised and sent for histopathological examination. Microscopic examination of mass show spindle-to-ovoid tumor cells with hyperchromatic central to eccentric nuclei arranged in intersecting fascicles with a focal alveolar pattern. The large number of atypical mitotic figures (40-50/10 High Power Field (HPF)) was seen along with areas of necrosis and the presence of few bizarre binucleated and multinucleated giant cells. A differential diagnosis of malignant amelanotic melanoma was given along with undifferentiated carcinoma, gastrointestinal stromal tumor, and Non-Hodgkin's lymphoma. On IHC, the tumor cells were reactive for HMB45, S-100, and SOX-10. Thus a diagnosis of malignant amelanotic melanoma was confirmed. The patient had symptomatic improvement.

INTRODUCTIONThe word hernia comes from the Latin for 'Rupture' and the Greek for 'Bud'. 1 A hernia is defined as an abnormal protrusion of a viscera or tissue through a defect in its surrounding wall. Hernias of the groin comprise approximately 75% of all hernias and 95% are hernias of inguinal region. Inguinal hernias are 9 times more common in men. Over all inguinal hernia is the most common hernia in women.2 Indirect hernias represent the most common type of hernia in both men and women. Direct hernias are more common in elderly.The most common presenting symptom for a groin hernia is a dull feeling of discomfort in the groin region that is exacerbated by straining the abdominal musculature, lifting heavy objects, or defecating. These manoeuvres worsen the feeling of discomfort. 4 Factors favouring surgery include symptomatic hernia, the size of the hernia defect and the risk of incarceration. The treatment of all ABSTRACT Background: Polypropylene mesh gives risk of recurrence, owing to overall decrease in the size of mesh and increased subjective foreign body feeling from contracture and scarring. An anatomically contoured 3D mesh for laparoscopic inguinal hernia repair often requires no fixation, with minimal risk of postoperative pain and recurrence rate. Methods: This was a prospective comparative study conducted over a period of 2.5 years. The study enrolled 60 patients, 30 patients in each group. The end points of the study were mesh fixation time, post-operative pain, seroma formation, hospital stay, chronic groin pain, sensory impairment, and cost and affordability. Follow up period was 18 months.

Background: Hemorrhoids are symptomatic anal cushions containing arteriovenous anastomosis. Patient with haemorrhoids can present as bleeding per rectum, something (mass) coming out per rectum, perianal itching, Anaemia due to occult blood loss. Various modalities of treatment have been developed to treat symptomatic haemorrhoids. This study was undertaken to determine the efficacy of rubber band ligation in the management of haemorrhoids.Methods: This study was a prospective study conducted in the Department of Surgery, Government Medical College, Srinagar from June 2015 to June 2018. Patients at any age with first, second- or third-degree internal haemorrhoids were included in the study. Patients with fourth degree, complicated haemorrhoids, previous anorectal surgery or anorectal pathology, and chronic liver disease were excluded. A total of 212 patients were included in the study. Rubber band ligation was done as an OPD procedure. The patients were followed at 2 weeks, 4 weeks, 3-month, 6 month and 1 year after the procedure.Results: In this study, out of 212 patients, 154(72.6%) were males and 58(27.4%) females. The mean age of this study was 38.7 yr. (Range 17-73 yr.). Patients presented with the complaints of bleeding (184, 86.8%), prolapse (114, 53.7%), constipation (116, 54.7%), priuritis ani (36, 17.0%), pain (12, 5.6%). Band ligation was successful in 188(88.8%) patients, 169(79.7%) patients were cured and in 19(8.9%) improvement was obtained. Various complications occurred after band ligation including vasovagal syncope (2, 0.9%), bleeding per anum (6, 2.8%), pain (12, 5.6%), fissure in ano (1, 0.5%). Recurrence after one year was seen in 9(4.2%) patients.Conclusions: Author concluded in this study that RBL is an effective outpatient treatment for grade II and III internal haemorrhoids without much complications.

Background: Laparoscopy is the best available tool and method to manage impalpable undescended testes; management of the impalpable testis often pose a significant diagnostic and therapeutic challenge to a surgeon. The aim of this work was to elucidate and present the sensitivity and the value of laparoscopy, as a surgeon’s tool, for the diagnosis and treatment of the impalpable testis.Methods: From November 2015 to December 2018, 56 patients with 60 impalpable testes were operated upon by laparoscopic approach by a single surgeon. One-stage Fowler-Stephens laparoscopic orchidopexy was performed in 14 cases, while two-stage Fowler-Stephens laparoscopic orchidopexy was performed in 16 cases and Vessel-Intact Laparoscopic Orchidopexy (VILO) was done in 22 cases. In 2 cases vessel and vas was entering through deep ring and inguinal orchidopexy was done. Blind ending vessel/vas was noticed in 4 cases (vanishing/absent testes). Laparoscopic orchidectomy was required in 2 patients for nubin. No case of disorder of sexual dysfunction was (DSD) was found.Results: Laparoscopy was successfully completed in all the cases. 34 testicles were impalpable on right side, 18 on left side and other 4 cases (8 testicles) were bilaterally impalpable. Laparoscopic orchidopexy was carried out for 36 testes at the same. 16 needed a staged procedure. Orchidectomy was done in 2 cases/testes. In 4 cases testes was absent/vanishing. In 2 cases testes was canalicular, standard inguinal orchidopexy was done. The mean operative time was 48 minutes. Patients were allowed oral fluids 6 hours of the operation and were discharged at one day after the procedure.  None of the patients had wound infection. Patients were followed up for a mean period of 12 months. At follow-up, all but one of the testes were well down in the bottom of the scrotum. In one patient, the testis was in a high scrotal position. All testes were of normal size, no atrophy was seen so far and no malignant change is suspected in any case so far. No severe morbidity or death was observed in our study.Conclusions: Laparoscopy offers surgeons a safe and reliable diagnostic and therapeutic option to patients with impalpable testes. No other imaging investigation is required, if well versed with basic laparoscopy. Intra-abdominal dissection allows more testes to be brought down to the scrotum. Even when open orchidopexy is being done for intra-canalicular testes in a child, it is advisable to be ready with laparoscopy if necessary, at the same time, in case open surgery fails to mobilize the testicular vessels adequately. The procedure is best viewed as laparoscopy-assisted; as Orchidopexy has to be done in a conventional manner.

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