ASI Time - 06-05-2026

Hinzugefügt: 2026-05-13

[00:00:00]Uh actually it's traveling.

[00:00:02]>> Yes, >> it's uploading to YouTube.

[00:00:10]>> Good evening everyone.

[00:00:11]>> Good evening.

[00:00:12]>> Good evening sir.

[00:00:13]>> Good evening sir.

[00:00:14]>> Good evening Gopal.

[00:00:15]>> Yeah. Good evening sir.

[00:00:18]>> Good evening.

[00:00:18]>> Yeah and all panelist. I can see basar.

[00:00:23]>> Good evening sir. Yeah, you're already live. Yes, sir. Good evening, sir. We are live now on YouTube. So, good evening everybody.

[00:00:36]Welcome to ASI time. This is the first week of the month. We have case capsule the abdominal surprises. Uh to this meeting, I welcome president ASI Dr. Mortu Pandan. I also welcome vice president Dr. Prattab Sinut, academic council director Dr. Raj Gopal Shanai uh convenor of international affairs Dr. Proal Nogi the social welfare director Dr. G Sidesh and moderator Dr. Nerpa and his panelists including Dr. Parakit Malhotra Dr. Ankur Maheshwari Dr. Ban Bihari Mishra and Dr. Shri Mateg good I request president to make the initial uh remarks before we proceed to the program.

[00:01:22]Good evening uh respected the principal office beas Dr. Pratab Draher Madhubida ma'am or Dr. Pbal Dr. Siddesh academic director Rajkala and all the panelists including our moderator Dr. Ba uh first of all my sincere thanks to the moderator and the panelists for having uh participating in this program. I came to know through the academic director that we are going to have two interesting cases. One is diaphragmatic hernia and another one is I think paral hernia. Is it sir? So diaphragmatic hernia really it is an interesting uh topic to be discussed. I had one experience with that management of diaphragmatia 15 years ago I did on left sideed diaphragmatia thoracicoscopically but after 15 years we had recurrence and two months back only we did it laparoscopically from this side but of course patient is fine and doing well uh just want to share that my experience on that diaphragmatic uh with this few I request our Gaga sir to proceed further.

[00:02:41]>> Yeah. I also welcome our honorably honorable treasurer Dr. Madita Mukad to this meeting. Now I request a vice president Dr. Prattapur sir to make some comments.

[00:02:52]>> Thank you very much uh uh Dr. Gerti respected president ASI Dr. Mura Pandin immediate past president Dr. Provin Suryoshi honorary secretary Dr. Gandhi Dewakar honorary treasurer Dr. Maduma Mukapadada director academic council professor Dr. Raj Gopal Shinoy sir conveyor international affairs past president ASI Dr. Prabulogi sir director social welfare council past president ASI Dr. G SE sir and the principal architect of the ASI academics past president ASI respected Dr. Santo John Abraham sir it gives me immense pleasure to welcome all the imminent uh panelists for this interesting case capsule discussion on abdominal surprises Dr. Parikit Malawatra from Mandi Dr. Dr. Ban Bihari Mishra from Katak, Dr. Ankur Mashwari from Indor and Dr. Shrielle Medgood from Belgavi.

[00:04:05]And to add more delight to this entire program, we are honored by the gracious presence of the veteran teacher Dr. Birup Paser from Hyderabad to moderate the entire session.

[00:04:21]Today's case capsule discussion will surely be very interesting considering the entire surgical fraternity all over India.

[00:04:30]And as we come across this surgical s abdominal surprises in our day-to-day practice, we often label abdomen as a Pandora's box where the pre-operative imaging and clinical uh signs may point to one thing but the moment you enter the peronial cavity something entirely unexpected comes in your front.

[00:04:55]Today's case capsule carries the same ethos.

[00:04:58]So I I I am I'm sure that today's case scenarios will be extremely interesting for the entire uh viewers on the YouTube ASI YouTube channel. I wish all the very best for the entire panel for the wonderful hour. Thank you very much.

[00:05:16]>> Thank you sir. Dr. Probal sir, quick comments from you please.

[00:05:22]Uh a very good evening to all uh respected president ASIan vice president Dr. Prattab secretary uh Gandhi treasurer Madhumita uh director academics Raj Gopalar and director social service Siddesh and the very learned panelists headed by Dr. Bapa. It gives me immense pleasure to be part of this ASI program which incidentally I started about couple of years ago during my presidency that is in 2024 and I'm so happy that it to see it flourish under the leadership of my successors and uh Maru Pandan Dr. Marupand and Dr. Prattab have taken it to a new level. They have added more color to it and I'm so thankful to you because this is one time that we needed um the the association needed for teaching for getting our thoughts across then we have lateral talks as well. So I'm so happy to see this uh flourish uh and my best wishes to all of you for a very interesting case series. though the uh the president sir has let the cat out of the bag but nevertheless we will be uh witnessing some interesting uh academic discussions on this. Thank you very much and my best wishes to all of you.

[00:06:50]>> Thank you sir. Uh over to Dr. Raj Gopal Shane sir our director of academics.

[00:06:56]>> Thank you very much Dr. Diwaki with the respect to President Dr. Dr. Barut Pandal and entire top leadership without wasting much time. It's uh it's I welcome each one of you for this wonderful session which we had started in uh March and this is the third case capsule. So and uh these are all interesting ones. They are watched by more than,00,2500 uh viewers. So please make use of this uh interesting topics and uh um without wasting much time Dr. NBA director of uh NIMS Hyderabad you know one of the most eminent personalities and he's actually a very very busy person with lot of uh responsibilities in spite of that sir you have agreed to moderate this wonderful session and uh excellent four panelists are there whom you are going to introduce them and uh and uh I request each one of you especially these are helpful for postgraduates helpful for practicing surgeons. And always remember every time suddenly there may be some guidelines there can be some standard protocol but you may not be in that position to have your instruments with you. It may come a sudden emergency most importantly uh there's a saying called a proof of the pudding lies in eating the results are important our patient should be able to walk home with the minimal accepted you know that morbidity or whatever it is. So with this few comments I would request Dr. N Bira to take over and uh probably you can go ahead with the proceedings.

[00:08:37]Thank you sir. Uh thank you. Good evening uh everyone. Uh it's my pleasure to be here today with uh uh uh ASI uh what do you call as body.

[00:08:49]>> Yeah.

[00:08:50]>> Uh and first let me thank Raj Gopal Shanai for giving me this opportunity.

[00:08:55]So I accepted this in spite of my very very very busy schedule. I don't know when I get a call from government but still I love teaching. Thank you very much sir and thank you the president Mortandandy Wut and Suru Mamci Ghi Diwak Madi Madam Raj Gopal Shai and others thanks for giving me this opportunity and I'm just going to introduce uh this uh Misra from Katak Mahwari from Indor and met good from Karnataka. So I'm Dr. Bira.

[00:09:39]Let me start with one um uh case first case. Uh here we have uh a 60 year 8y year lady uh coming to the hospital uh with a uh symptoms of pain in the abdomen and vomiting since one year on and off mainly food particles and there's no blood, no bile and she was fear to consume food and worsening of the symptoms since 10 days. some fullness in the upper abdomen and also she complains of uh retraal uh burning.

[00:10:18]She's been taking uh proton pump inhibitors as suggested by the doctors and she's a known hypothyroid since 20 years on eloxin 75 micrograms per day.

[00:10:31]She's hypertensive and she's a diabetic since 10 years. So with this history I would like to know from the panelists anybody can answer anybody uh can say that uh what kind of probability diagnosis uh we are uh hinting at.

[00:10:53]So shall I start with uh Malhotra?

[00:10:59]>> Yes sir. Keeping this history in mind, I'll keep the possibility that the patient might be having peptic ulcer disease, a chronic dural ulcer with probably gastric out obstruction developing.

[00:11:10]One the other thing can be cheniththesis because the patient is also hypothyroid and people with hypothyroidism as we know are more prone to developing gallstones and this may be because of the gallstone disease as well.

[00:11:27]>> Yeah.

[00:11:29]Would you like consider any medical problems? Uh Dr. Mishra, Dr. Mishra, Dr. Maheshwari, >> sir Mr. G, unmute yourself, sir.

[00:11:46]>> Yes, sir. Yes, sir.

[00:11:47]>> Sir, with this frank history, I'll put the diagnosis as a case of gastric outlet obstruction at the beginning, whether it is a intrinsic or consider gastric outer obstruction. She never had any kind of you know typical peptic or symptoms. She had only pain and vomiting since one year but it was never uh uh like classical peptic or symptoms. Would you still consider a gastric outlet and a lady of 68 years and so would you consider still peptic ulcer sir and gastric outlet obstruction?

[00:12:33]Why can't we just consider medical problems like gastroparosis because patient is hypothyroid, patient is diabetic and why can't we consider just functional dispsia cyclical oming syndrome something like this?

[00:12:50]Anyone?

[00:12:55]One thing is for sure sir uh he has some amount of or some features of a motility disorder. So >> yeah probably uh would be thinking on those lines >> and that motility disorder has worsened over last 10 days or so but >> the the symptoms were for a longer time.

[00:13:15]>> So that is one fundamental point in the history which is coming.

[00:13:21]>> Hypothyroids also have a penchant for a motility disorder.

[00:13:26]>> Yeah hypothyroid hypothyroid and diabetic. So functional disorder or motility disorder will come into the mind.

[00:13:34]>> Yes. Yes. Any other possibilities? I understand. We should consider gallbladder stones because elderly lady we should also consider pepicula disease. We should also consider I think functional disease also most important gastroparesis also most important. We should consider based on the history I'm talking about. Any other possibilities?

[00:13:56]Can we consider gastro gastroosophasial reflux disease sir in this vomiting?

[00:14:03]>> Yes, that's what any patient know elderly with diabetes and hypertension hypothyroid we can consider but they'll have more of an retraal burning probably that's why she must have responded.

[00:14:15]>> Yeah. So >> this patient has frank vomiting with food particles.

[00:14:19]>> Yes. Food particles. So food particles.

[00:14:23]So definitely pepticulture gastric outlet obstruction and there's no history of loss of weight and appetite.

[00:14:29]So we cannot consider this is basically benign problem not a malignant problem.

[00:14:34]So we may consider an a functional problems as well as a peptic ulcer disease or gallbladder stones gastric outlet syndrome.

[00:14:43]Well, with this uh specific diagnosis and she was examined, her vitals are normal and she has a vague mass in the epigastric region which is a tender and there's no free fluid and bons are present. Any now would you like to revise your diagnosis?

[00:15:03]Vagas pulpable in the epigastic region and tender in elderly lady. Would you consider a malignancy at this stage at least?

[00:15:14]>> Sir, the possibility cannot be excluded.

[00:15:17]But in the presence of a gastric outlet obstruction, unless the stomach is decompressed, we can sometimes get a palpable illdefined palpable mass which will be resonant on percussion. Second possibility if there is a possibility of pancitis pain which she might have not clearly and the development of cyst but to me with this gastric obstruction probably it is just a distended stomach.

[00:15:44]>> Yeah.

[00:15:46]Yes. So any other investigations any other diagnosis? Uh Malhotrai Mahwar metur would you like to add anything? So can we consider the possibility of any mass arising from the left lobe of the liver >> like >> like cystic lesions can be considered s >> immune to say uh but she has any any liver lesions doesn't cause any vomiting. Yeah, they don't cause Yeah, liver lesions doesn't press stomach unless it's an huge lema or leis saroma or something very rarely comes from the liver which compresses the stomach. But any liver lesions doesn't cause vomiting unless patient has an an stomach with the liver metastasis but usually 99% liver lesions doesn't cause vomiting.

[00:16:37]They may have an a pain dull aching pain and symptoms of cystic lesions can have a dull aching pain nothing more than that they're most most of the times they are asymptomatic. So any vague mass path in epigastric region we may not be able to connect to the GI symptoms.

[00:16:56]So she has an a GI symptoms. I definitely consider a distended stomach since she has a vomiting and pain. So pepiculer disease distended stomach and is also possible tender sometimes. Yes, distended stomachs are tender. So >> it may be a complicated gist as well sir which may have caused the pain the sudden increase in pain of late.

[00:17:21]just gastrointestinal stromal tumors.

[00:17:24]Again, the main presentation is of course mass and GI bleed. So, they'll have a gastrointestinal bleed. But this patient, they never had an a GI bleed.

[00:17:34]They'll have a mass and they don't present with any pressure symptoms.

[00:17:39]They don't present with an intestinal obstruction. They will have a huge mass, gastric mass, but still the symptoms are very less.

[00:17:48]So I do not consider uh gist of the stomach but I consider probably in a distended stomach.

[00:17:56]Let's see what investigations uh of course systemic examination is normal and uh chest is normal normal vascular breath sounds and reduced on the right side. So breath sounds are reduced on the right side and nothing other than that systemic examination is normal.

[00:18:17]So what investigations and she had uh severe pain two days back uh and some breathlessness for which uh some X-ray was taken and patient was referred. So how to proceed about uh this patient in an elderly lady 608 year lady on and off pain and vomiting now some breathlessness and some pain in the abdomen and how do you investigate this kind of patients anybody anybody can take up no issues we will start with a chest x-ray and ultrasound of the abdom Also under the abdomen, right? Yeah. And say our clinical diagnosis is now probably on a gastric obstruction.

[00:19:10]That's the first possibility. If that is the case, I definitely I'll not ask ultrasound to the abdomen. That may not be an a good investigation. Rather, I'll put in a rube into the stomach and check what kind of an aspirate it is. If it is only food, food material and all probably I do directly go for after emptying the stomach after emptying the stomach I may go for an endoscopy. But here is the patient uh who has an uh pain long pain and vomiting. So what kind of an investigation ultrasound may show okay distended stomach no other findings would you go >> in this patient we have to look to the patient from three angles. Yes, >> there is chronicity. There is acute acceleration. There is vomiting as well as there is respiratory symptom. So everything mixed together it's a gastric outlet obstruction. There is some amount of respiratory problem and there is probably a palpable stomach distended palpable stomach. So my approach will be to first at the outset before decompression I'll try to take a x-ray of the abdomen x-ray of the chest.

[00:20:21]Ultrasound may not be very effective before the R tube insertion after the nazogastic decompression I will go for ultrasound see all these things and proceed further. See >> yeah mahwari you have anything?

[00:20:38]>> Uh sir I will concur with Mishraas. A basic ultrasound and then further more investigations would be the pertinent thing.

[00:20:47]>> Mhm.

[00:20:49]Okay. Yeah. So yeah >> the now X-ray has been taken. Yeah please please go ahead.

[00:20:56]>> Uh no sir uh in in such a patient like this I think one more important investigation would be an ECG sir with two days history of breathlessness and elderly lady we'll have to rule out uh any uh cardiac issues.

[00:21:13]>> So ECG would be mandatory I feel sir.

[00:21:16]Yes. Yes. Yes. You are correct. Rightly said and in the background of diabetes and hypertension definitely we'd like to rule out medical problems also cardiac is >> will be important from two good points.

[00:21:28]Number one to rule out the cardiac condition. Number two also as a routine before doing endoscopy in an elderly patient that will guide you.

[00:21:37]>> Yeah. Yeah. Correct. Correct. I think one precaution very important is directly one should not go to the endoscopy in these kind of patients because the distended stomach sometimes they may aspirate. So we have to completely empty the stomach and then go for an endoscopy if at all if if necessary. However, as I said x-ray the abdomen or x-ray the chest and then followed by an ultrasound would be useful because we would like to do always noninvasive test first done before going for an invasive. So this is the X-ray uh taken and this is the chest X-ray. Someone wants to comment.

[00:22:17]Yeah. Malhotra or Mishra Maheshwari bet whoever it is. Uh if I look at this X-ray >> because the patient has its aex on the left and I see that there is a part of the god which is in the right chest and this is the mucosal pattern is not clearly visible not mimic the small intestine not to the large intestine I presume that this is still a part of the stomach with distension with liquid as well as the gas. So this is a very clearcut thing that without any doubt even though it may be rare one can say that is this is the presence of the stomach in the right chest.

[00:23:01]>> Yes.

[00:23:02]>> And rest of the lung parangama looks normal excepting little bit changes in the lower jone.

[00:23:09]>> Okay. Okay.

[00:23:12]Anything else sir? Anybody would like to add >> this seems the the uh gas shadow cell the stomach shadow appears to have obscured the part of the heart cell.

[00:23:24]>> The cardiac shadow is not totally visible especially the right side. So it is likely that it is in front of the cardiac shadow. Possibility of something herniating has to be kept in mind. That is one uh uh classical uh shadow which comes obscures the heart shadow.

[00:23:45]>> Okay. You mean to say it's an eventation of the diaphragm?

[00:23:50]>> It's u it doesn't look like an eventration sir but uh >> I would right side right side >> I wouldn't call it as an eventration sir. Probably it is not an eventration sir.

[00:24:05]>> Yeah. and right side eventation is very uncommon.

[00:24:10]So so as I said any any other things >> once it is the eventation the radiology picture of the chest will be totally different. Now if you see in this film only the part that looks like the stomach has gone in but in aation the diaphragm outline will be very clear in the chest cavity.

[00:24:32]>> Yes.

[00:24:35]Correct.

[00:24:36]So how do we proceed? What next?

[00:24:41]We'd like to do barerium or endoscopy or CT scan.

[00:24:46]That's how we ask in the examination postgraduates.

[00:24:50]>> They say we can do uh a water soluble contrast examination fllororoscope.

[00:24:57]>> You mean to say berium berium swallow or you want to go for a CT scan chest and abdomen?

[00:25:04]So CT scan has certain advantages over the it is fast. It will give you additional information regarding other pathologies in the abdomen or or if there is a herniation it will tell about the size the organ that is herniated into the so that are the advantages. So depending if the renal functions are fine we can straight away go with a CT scan.

[00:25:30]>> Yeah correct. the common.

[00:25:35]>> Yes sir.

[00:25:38]for a CT scan would be a wise choice sir because that will give a uh a view of chest as well as abdominas as well as the part connecting both of them the diaphragm >> because whatever pathology is there it is there in the right hemi right hemithorax and you can see uh a airfield level there for a common person a right hemithorax with the air fluid level always will go for a CT scan chest and abdomen and that is a pertinent choice rather than going for any soluble contrast investigation if it is available.

[00:26:13]>> Okay.

[00:26:14]>> I think sir to this patient we must subject the patient for a good hematological bi biochemical parameters and also we must look at the respirator in terms of the oxygen saturation and everything even though theical picture is not very bad. After that the all the parameters we will decompress the stomach first then go for both the upper J endoscopy as well as the CT I don't feel almost the barium which is absolute investigation for this there is no need of water soluble contrast because we are directly go for a CT of the abdomen which will also cover a part of the chest >> what do you think we need to do an upper endoscoping this patient because noninvasive You can straight away go for an CT scan of course the blood investigation ura creatin is normal.

[00:27:09]Where is the need for an upper G endoscopy? I still may be still preferring an endoscopy. But do you have any points in favor of doing an endoscopy?

[00:27:21]Actually if at all required we should go after the CCT because not right now first the CCT should be done then if required we'll go for that otherwise it is not mandatory.

[00:27:35]I think the first thing should be we should sort out the anatomy first and when anatomy is sorted out then uh uh these investigation should be done.

[00:27:46]>> Okay. So the basic investigations are within normal limits and uh this is the sorry >> okay >> and endoscopy has been done in this patient. I have an reason why endoscopy needs to be done. One is to know the gastric mucosa number one. Number two, one is to rule out the malignancy if at all present in this in this age group.

[00:28:10]So and sometimes they may have um medical problems like you know aia, cardia or mal sorry motility problems.

[00:28:20]So I think endoscopy is also another investigation we need to do. It's not a mandatory once if you know the diagnosis of uh parispasal hernia or you know highest hernia uh it's always better to do an endoscope and do rout malignancy and barretts and other pathology in the mucos also so endoscopy has been done and gastro mucosa could not visualize because the retain food particles so and CT has been done this is the CT the uh anybody can read the CD CT >> I think you can see show the one more sittal film because this is just a dilated stomach. The next one it shows that >> yeah if you see this first film that is seen the stomach is dilated >> the antum purus antrum and the first part of the dudum almost they have aentrated and gone to the poster medastinum. So that clinches the diagnosis >> and if you see the antrum antidum they are at a higher level than the gastro superial junction. So it probably suggests something about the gastric valolas. So both the components the anatomy is well established and this rotation is also indirectly reflected by the position of the antidotum above the G junction.

[00:29:54]>> Mhm.

[00:29:55]>> And the RTO is also visible inside.

[00:29:57]>> Yeah, I think that's I'm expecting that you're going to comment and RT is seen.

[00:30:01]>> Yeah, right. So it means that ru has gone into the abdom and into the stomach >> but still the stomach is not evacuated >> decompressed not yes yes yes yes so uh I think what is most important is uh level of the g junction that's most important whether it's in a above diaphragm or below the diaphragm in order to classify the parisophasial hernia hernia so uh So this is the CT and uh the report is stomach is grossly over distended with the distal part of the body and antum pyloris and deodernum appear to display up supports and are noted herniating into the posterior midastronum through isophasilitis with subsegmental collapse of the underlying lung parisophasial hernia diagnos suggestive of with stomach as an content. So there is an a displacement of antrum above the G junction. Stomach appears to be upside down with an antum pyloris suggestive of gastric valvulus and there is narrowing at the gastric outlet. That's why patient has any features of gastric outlet obstruction and nasogastic tube is noted in the uh in the stomach. So what next? So elderly lady with all these problems she has an a paris fasial hernia uh with the gastric valve >> sir uh just one more thing so can can we safely say that uh the vascularity of the herniated stomach has been maintained looking at the films >> yeah yeah I think it's well maintained >> well maintained >> yeah it's well maintained so >> so that is a very important point because you have to decide whether whether you are going for an emergency surgery or a fully prepared surgery.

[00:31:51]>> So that is a very important point. The CT has to decide about the vascularity.

[00:31:56]>> Yes. Yes. And there's no any inflammation around the stomach. And again it shows that there is no uh problem with the vascularity. Rest of the intestines are also having good vascularity.

[00:32:07]>> So there's no gangrine or mucosal necrosis here. So that indicates valvulus is there. There's no necrosis or gangrine or any ulcerations.

[00:32:18]So what should be done next? What next?

[00:32:23]Now we know that it's an aparis fasial hernia with stomach as a content with features suggestive of valless valas and we have placed a r tube. We are going to definitely decompress and check their electrolytes and I'm I'm I'm sure that we're going to uh medically uh resuscitate her or whatever treatment she needs we'll do medical and then take a cardiologist opinion as one of panelist said ECZ and then cardiologist consultation is very important we need to prepare the patient for an surgery I'm sure the panelist will agree with me.

[00:33:03]>> Yeah. Yes sir.

[00:33:05]>> Yes.

[00:33:06]So and then uh what kind of surgery are you planning? How do you plan any preop pre-operative evalation? I said patient needs any cardiac evalation but how do you plan? So this is a you want to do antomy needs a very good planning planning in this sense pre-operative preparation is mandatory. We have to keep the ICU ready. Good glycemic control, thyroid control, everything is done. Our aim is very clear because once the diagnosis has been made probably the treatment is very easy but only thing we have to go transabdominally but mind should be open if required we may go for a soractomy. So accordingly everything must be ready and once we do a laparotomy the next procedure will be decided by seeing the findings only >> yeah sir >> yeah please please >> in part of pre-operative evaluation one important counseling that I would do is that this lady may end up on the ventilator post-operatively and we need to counel about that also sir apart from all the preparation.

[00:34:23]>> Okay fine because longstanding elderly lady and hypertensive hypothyroid maybe yes we need to take consent for an post-operative ventilator support and then see that glycemic control is proper. So uh would you agree uh would you prefer an athoricottomy or would you prefer an laparottomy in this patient laparottomy or laparoscopy tooscope whatever it is you wanted to approach hernia uh through then through a chest or through abdomen that's the point to be discussed here >> I think in the present era the first option should be a laparoscopy second option is laparottomy if it is okay otherwise mind must be opened for labortomy extended to the >> advantage of doing ancotimma or thoracicoscopic uh in this kind of an patients >> many times it is not reducible you can take the help >> okay >> but I I think the way it has migrated it may come out easily so by opening the abdomen it can be decide >> okay okay fine Anything uh from Maheshwari, Malhotra Gi, Mig anything >> laparoscopic >> the symptoms have worsened in last 10 days sir.

[00:35:50]>> So essentially whatever's happened as in last 10 days. So I concur that uh if the contents have to be reduced they will be reduced quite efficiently uh from the laprotomy or laparoscopy incision. Mhm.

[00:36:04]>> The advantage of theoscopy or theottomy or perhaps thoroscopy would be um better visualization of the content and plus if you use carbon dioxide that creates another um uh important things where you can reduce it efficiently. So theoscopy and laparoscopy are two debatable things but I would prefer laparoscopy here. Um that is more pertinent choice. Yeah.

[00:36:34]>> Yeah.

[00:36:34]>> Yeah. I we prefer Yeah, please.

[00:36:38]>> Theoscopy can be kept as an option, sir. But looking at the picture and uh if the stomach is decompressed, I think most of it will come out through the laparoscopy. Sir, >> correct. Correct.

[00:36:51]>> If we effectively decompress it, it should reduce easily, sir.

[00:36:56]>> Yeah. I'll come back again uh why sometimes laparoscopy is full again at the end of the discussion. So this patient had a leprotomy and uh this is case this case is from Manipal uh medical hospital where Raj goal Shana has done surgery. So the operative findings are uh uh she has thickened stomach because of the gastric valulus and probably repeated uh pain abdomen and she must have had uh repeated valulus that's why stomach is thickened and distal stomach including body diodnum herniated and the side of the esophagus and Gj junction is normal in normal position and paris esophasial defect is around 4 cm with the distal stomach and first part of the diardum as a content and there is no evidence of valless probably the valus must have not there at the time of surgery so she must have had but CT scan picture shows it's like valless only and at the time of surgery there's no evidence of valless and the patient also had an colonic diical at the same time so so this is the I can see the stomach wall thickened and professor Raj goal has done a laparottomy and he's reduced the content And uh so and the defect was uh uh closed reduction of the stomach and was it was not in a very easy it seems maybe because of the thickened stomach and stomach was viable and uh and the contents were aspirated 4cm defect noted in the right side of the espigus defect is sutured by using non-absorbable sutures hemodynamically patient was stable at the end of the procedure. So these are the pictures and this is the uh probably this is an area of an big uh highest and uh so it was closed and this is a diagrammatic uh picture of uh the operative findings and very nice to see um professor Ajopalai nurses and boys or assistants and very neat diagram where showing the first part of the don tantrum uh paraphysis vessel hernia in this patient. So this is how that that was then a defect here where it hernia herniated the abdominal contents. So this is then a chest after surgery. You can see so much of difference there's no not much of uh stomach is seen in the chest on the right side of the chest and lungs also clear. probably these patients needs in a post-operative good chest phys therapy spyometry in order to prevent the consolidation or retalis of the base of the lungs.

[00:39:47]So anything else uh would you like to add? What do you think the professor Raj goalshana has done has done like yeah please >> whenever you decide about the approximation of the defect it should be a tensionfree approximation with a nonobser in situation where there is tension probably we have to think of the use of a prosthesis >> yes anything else one is tensionless uh closure measure the defect that's most important chlora and if we are able to approximate fine if not able to approximate as you said uh absorbable mesh or uh needs to be uh placed there and anything else you would like to add one is reduction and then closure of the defect and then anything else would you like to add in this kind of patients is there a need for any fund application that's what I'm I'm I'm expecting from the panel list is >> in this patient probably a phonication is not required is most of the time reserved for the uh sliding ones here uh I do not know I feel that phone application is not required I don't know what is your viewpoint yeah I it's it's an individual preference uh I'll give Yeah manra >> you're saying something >> yeah there is a school of thought some people say that funlyation also prevents the development of the gastric vvulus it prevents it so some people do it for this purpose and if there are symptoms of gird associated with >> yes >> the parisophasial hernia then also people do funlyation >> correct correct Correct. One is to prevent gird. Second is to prevent recurrence also once if you do an funation the recurrence of italia is less. So that's why I add in fact uh I add uh funlocation posterior anterior fundation it's not mandatory always if you think that the the ditto is quite a big and and the chances of recurrence are there and patients had any uh reflex problem severe reflex problem definitely we need to add uh uh pondation however one should be very careful we need to sometimes these patients Patients may also need in a manometric studies in order to rule out motility disorders. So if suppose patient has a motility disorders and we reduced and then close the height test they may develop again uh problems with fundication they may have a dysphasia. So in spite of having an such an uh defect I do not understand why this patient did not have any symptoms of dysphasia. She had only pain and reflex symptoms. So again so funation it's plus minus as I said one is to prevent recurrence second is to in a patient who has a severe gird then we may to add funation yeah anything else we'll just go for a small brief uh review of the diaphragmatic hernia so they classified as type anything else I'll just say few points about the diaphragmatic hernia uh type one usually It's in a sliding type wherein Gjunction is placed above the diaphragm and and parisel hernia that is type 2 to four where defects in the prenisial membrane all the migration of stomach and other structures addition to the G junction. Sometimes the students will get confused what is hital hernia what is diaphragmatic hernia what is parispasal hernia. So diaphragmatic thisal hernia and paris comes under diaphragmatic hernia. Idal it hernia comes as an a type one usually we call it as an sliding one call it as an itis hernia whereas parisophasial one hernas are type two to type four wherein the defect is seen in the freno esophasial membrane which allows the migration of the stomach or other structures adjent to the G junction and most uncommon type of hydia it affects the adults with mean age of 65 to 70 years 75 years therefore types as I said it's the pathophysiology is the hyalan it's mainly because of increased in abdominal pressure that displaces these junction poured into the thorax and resopial shortening from congenital causes here that's what I said a laparoscopy or thoroscopy sorry thoroscopy or thorottomy may be useful in the places where there is a shortening of these figures and that is the causing uh hyrosnia so we mean we may have to mobilize the esophagus or we may have to create new esophagus. So that's why thoroscopia or thorocartum sometimes may be important. So widening of the highest from the congenital are acquired. These are all the pathophysiology of the highest hernia and type one is commonly seen that's in a sliding hernia wherein the G junction is displaced superiorly into the thoracic cavity. Mostly these patients will have an gastrophagial reflex and type two is rolling type stomach migrates into the chest and rolls or isopagus. These patients presence with a dysphasia because the pressure or the esophagus and type three uh and type four. Type four again other contents like intraabdominal contents like colon and deodernum. Type three stomach migrates into the chest rolls over it's in a mixed actually. So these are the commonly seen and um this is a normal uh G junction I just put the slide squas columnar junction. So endoscopy is necessary to rule out uh one I said malignancy second uh any barretts. So we need to add if there's any bars is there the fundation. So these are all the types and the barerium we cannot totally say no for the barerium I feel so so barerium has a role in in identifying the level of G junction as well as uh the content in the parisophasal hernia.

[00:46:19]Endoscope is also important. uh sometimes you may see a Cameron ulcers that's called a linear ulcers because of necrosis and other things and uh uh isel manometry I said to rule out motility disorders the surgical management as you everybody said heral sack dissection and resection of the sack esophagial mobilization if it's possible one should not be overenthusiastic in mobilization of the esophagus because there might be an injury to the vagus nerve so which may cause lot of issues. So repair the cruda and funoplication plus minus. I prefer to do funlocation in a case where there is any more g reflex symptoms and g junction is above. So that's brief about surgical management. So some of the learning points are patients younger than 50 even asymptomatic and older patients with symptoms such as regurgitation, aspiration, cough, anemia. These patients might present with an anemia because of the ulcers which bleed continuously. Our dys should be considered for an surgery and they may not know that patient has an aspiration most important and slowly they develop in a lung issues. The gold standard of repair in most cases nowadays seems to be laparoscopy as still it's in a option surgeons option and use of mesh must be selectively to the patient in which kura is unable to tolerate the tension of the primary closure as mistras said and you may have to add in a baritric surgery if BMI is more than 35. So that's all about uh this case and shall we move on to another case?

[00:48:02]>> Yes sir. after the second case.

[00:48:04]>> Anything I would like to add?

[00:48:08]>> No sir, nothing at at this juncture.

[00:48:11]We'll go for the we'll go for the second case.

[00:48:14]>> Maybe at the end we can take the questions. So >> yes, uh this is uh similar kind of an case capsule. Uh same panelist and this uh young gentleman uh who presented uh uh with uh uh abdominal pain 10 days duration, vomiting since 3 days and chest pain 2 days. Young gentlemen and insidious onset progressive in the epigastic region dull aching which radiates to back which has been aggravated after taking food relieved on vomiting and multiple episodes of vomiting since 3 days non projectile nonbelious and which contained food particles. Chest pain again leftsided since 2 days. No history of alcohol consumption. No history of cough bloodlessness. no previous surgeries and he was diagnosed to have an acute pancreatitis based on elevated serum levels. Of course, the pain was typical of epigastic which was radiating and so they thought it's an acute pancreatitis.

[00:49:22]So he was referred to many hospital for further conditions. So what are the possibilities based on history anybody can take it up? You still agree with acute pancreatitis and this kind of a things or you say no something else? I think this person rightly has been diagnosed as the first diagnosis pancreatitis because he had pain and radiating to the back. So it he may not be alcoholic but it may be a gallstone pancreatitis also. So rightly the first diagnosis we should put as acute pancreatitis. Rest other things we can think asitis ulcer gd anything.

[00:50:01]Yeah, >> have a different viewpoint. Since the vomiting again contains food particles >> and the vomiting brings about relief in pain, it also points towards a pathology a luminal pathology rather than an extra luminal pathology like pancitis.

[00:50:19]>> Mhm.

[00:50:22]So what what kind of luminal pathology you think in this patient?

[00:50:26]>> The history is not that contributory. So broadly I will >> you can ask me I'll tell you can ask me he has an omitting it contains a food and food particles it's nonbelious and >> gastric outer obstruction would be the possibility >> mhm >> what is the cause cannot be said based on the history >> okay why not just simple pancreatitis as Mr. was upset because the pain is there radiating to the back. In south India especially around Manipal area and Kerala we see this kind of patients young guys coming with an abdominal pain. They may not have long history without no history of alcohol but still we have seen these patients having anitis >> but it is mentioned in the history that the vomiting brings about relief in pain. That is a characteristic which is usually not present in penetitis.

[00:51:22]Correct. Correct. Yeah. I agree.

[00:51:25]>> Both the things are both the components are here in this passage. One can think of one can think of aluminum cause and again rest of the things will clarify I think.

[00:51:35]>> Yes. Yes. Yes. As a south Indian I prefer definitely pancreatitis and uh peptic ulcer disease. I'll not rule out and simple uh uh GD also. Yes. Sometime these patients will have severe gastrophial reflex disease. So an examination he was all right and slightly reduced breath sounds on the left side lower zone and he has an esplenomegali ball sounds are present. Would you like to change the diagnosis now?

[00:52:07]Would you consider splenomegali as an important part?

[00:52:13]I don't consider because they might patient might have but it doesn't cause so much of pain >> unless unless patient has an inffort splenic infot >> so unlikely unlikely that spleen which cause so much of pain so I think we stick to the same diagnosis good you would like to ask anything >> no sir pancreatitis gastritis the same diagnosis I would consider sir >> yeah we have seen a good number of >> findings also may be in the presence of pancitis that is also very difficult to exclude that other pathology it can be in the same line of pancitis.

[00:52:52]>> Yes. Yes. So what investigations?

[00:52:57]I think the first line of investigation beyond the again routine the hematological and biochemical should be a abdominal ultrasound and a chest X-ray because the patient has few respiratory findings. So the ultrasound might rule out a pathology may not fully rule out but might rule out a pathology in the gallbladder the millary and the pancreas and the excess to a healthy pathology in the lungs.

[00:53:27]So this is my first in the first attempt I'll go for these two test then I'll proceed further as for the finding here.

[00:53:36]>> Yeah again I have a different viewpoint sir since the RFTs are normal I would straight away like to go for a CT scan because ultrasound sometimes does not show the pancras the radiologist may report that it is obscured by the gases and all those things.

[00:53:53]So a CCT of the abdomen may be more contributo. Ultrasound at the best would tell you about whether it is gallstone induced pancitis or a non- gallolstone cause.

[00:54:05]>> That is why I said that a routine screening ultrasound is mandatory because CT may not show always the presence of the gallstones. It's a scout survey. After that we can go for the CT.

[00:54:17]>> Yeah. In in gallstone pancreatitis the stones are very very small. they in fact they'll have a a sludge rather than a big stones. So I don't think an ultrasound be able to pick up the sludge sometimes which is in the in the common bile duct. Well, it sometimes it may say sludge and patient having a bulky pancreas we might say it's an gallstone induced pancritis but very rare very rarely that sometimes we may miss sludge in the ultround any hemoglobin and blood investigations are within normal limits and electrolytes and LFT is normal and one thing that SGOT SGPT are within normal limits because there will be some elevation uh in in OTP uh in case of gallstone pancritis However, here this serum amal is 117 units per liter. Lip is also 114. Would you still I don't know why CRP is done but uh lipase am as per the uh reports uh they said it's elevated.

[00:55:20]So what next? CRP is it mandatory to have a CR?

[00:55:25]>> Not mandatory probably as a inflammatory marker they have taken CRP and other things. Of course they can add also polo and other things also.

[00:55:36]>> I'm totally against for doing an CRP unless I prove that this is an pancreatitis. I'll not go for a CRP and procal and all those thing. I keep saying my children I'll yeah I'll not pass them if you say CRP and other well as a part of grading as a part of you know uh scoring want to add CRP it's fine >> but the levels of mileage and lips are not >> very high >> not very high to say that it's definitely pancreatitis that's what I wanted to know the range there in their hospital so I could not uh I didn't comment on that any for me it looks like a not very grossly elevated. So I definitely not think of an a pancreatitis. Yes, clinically yes he has typical of pain in the epigastic. We have seen good number of patients young people coming with this kind of patient and found to have an a group pancreatitis wherein the localized pancreatitis confined to head of the pancreas. So we have seen good number of cases. So uh ultrasound is done and which showed pancreas appears mildly hypoquic suggest serum and lame lipase correlation. So um I don't know selenal is present multiple free floating internal leg some urinary tract infection is there and mild to moderate acitis whose sees these reports also reports I'm sure they think it's in a pancreatitis any comments from panelist >> obviously this goes in favor of pancreatitis because there is hypoquate and there is mild moderate asitis >> and the patient has some pulmonary symptoms everything goes in favor of the Yes. Yes.

[00:57:24]>> Okay. And next what next we do?

[00:57:28]>> Shall we go straight away to also CT scan?

[00:57:31]>> The next would be a CT scan.

[00:57:33]>> Next would be a CT scan probably.

[00:57:35]>> What about the X-ray? The X-ray has been done. X-ray.

[00:57:37]>> X-ray chest.

[00:57:39]>> Yeah, X-ray chest has been done because he had complained of some chest pain. So X-ray chest and abdomen has been done.

[00:57:47]So now >> obviously the left dome is elevated.

[00:57:57]>> Mhm.

[00:57:59]>> Yeah. Stomach is seen stomach is seen almost entering into the thoracic cavity.

[00:58:06]>> Yes.

[00:58:07]>> So we can uh consider a possibility of uh eventration on the left side.

[00:58:14]>> Yeah.

[00:58:15]So I think this X-ray is selfexplanatory that this is a ventration and once we see this X-ray we will proceed further to evaluate for the eventress or evaluation of a diaphragmatic.

[00:58:29]>> Yeah. So what next and please justify what kind of investigation you would like to CT scan I believe. So yeah CT scan CT scan please read.

[00:58:43]Very good. What?

[00:58:47]>> Yes. The CT scan the left side it shows uh the at the uh the gastric stomach seems to have migrated up sir.

[00:59:01]>> Yeah. The next >> next film I will clarify. Yeah.

[00:59:05]>> Yes. This definitely the stomach has migrated and there are two bubbles seen sir. One bubble down and one bubble up.

[00:59:13]So part of the stomach has migrated up.

[00:59:16]The right side at least the liver is in normal position and uh I think one more film s I think there is some amount of whirling seen here sir.

[00:59:28]>> Yeah. Yeah.

[00:59:29]>> There some amount of whirling is seen here possibly suggesting that there could be a twist also.

[00:59:35]>> Yeah.

[00:59:36]>> Yeah. Correct.

[00:59:40]And there is linelia also.

[00:59:45]And there's no vascularity. There are some collaterals around the stomach here. If you see there are some collaterals and >> R tube is not seen. S >> from stomach some other soft tissues has also gone up.

[01:00:01]>> Yeah. Correct. Yeah. Probably some momentum.

[01:00:05]>> Yeah. And some part of spleen has also gone up.

[01:00:11]>> Yeah. And uh CT report is gastric valulus with complete eventration of the left diaphragm heap likely uh gastric valulus with mentroaxial uh valvulus this patient has and moderate splengalian mild asitis. So what next?

[01:00:32]We have a diagnosis probably uh gastric valulus with eventration secondary type of gastric valulas directly surgery young man no comorbidities.

[01:00:46]>> I think we should go directly for a surgery.

[01:00:49]>> Yes. Yes.

[01:00:51]>> So plan changed. uh patient was diagnosed to have misentraial gastric valulus with complete eventration. Rail tube insertion was attempted and was successful. That's great. 900 to,000 ml of fluid was aspirated from through the uh rail tube. And if there is any uh uh gastric necrosis you see uh like you know coffee ground uh fluid in the rub probably that's not there. It's not mentioned and patient was taken up for an emergency laprotomy and a urology and CTVs teams were intimate intimated if possible requirement of interoperative assistant probably because of urology some uh u there was some looks like an infection in the in the urinary bladder.

[01:01:37]I do not know why cardiothoracic team was informed probably they wanted to do anyottomy or thricoscopic reduction of the contents. However, professor Raj Gopal Shana has done a surgery has done a leprotomy and again these are the findings and eventation was identified stomach reduced and gastric wolas was there mentraaxial within a massive gastric dilation. No evidence of strangulation or gangrine. Eventation of the left hemodi diaphragmic involving the two/3 of the diaphragm surface.

[01:02:10]Herniation of dilated fundus of the stomach. Superior pole of the spleen was there in the stomach. Left kidney up to second intercostal space. Spenic flexures of the colon and descending colon. If you see in the CT scan we don't see all these findings. So there is an herniation of the stomach, spleen, left kidney, spleen lecture and there's a moderate spleen and there are enlarged mentric nodes probably as there that's why uh some mentric uh uh nodes are enlarged. So while was reduced, stomach contents were aspirated and stomach decompressed.

[01:02:48]Anneal sack was reduced and contents were reduced and closed. There are some additions between the stomach and uh uh between the stomach and the spleenic flexure.

[01:03:01]So ant poster leaflets of the left diaphragm which was formed suda sack closed primarily drain placed in the suda sac cton brought out through eighth intercostal space and uh he will uh professor raj goashna will tell us whether it has done thricotum is also added in this patient gastropixi was done uh and greater curvature was fixed to the left anter abdon wall in order to prevent uh recurrence of the gastric valvulus and drain also placed in the paracolat uh I think Raj Gopal Shana will also explain why the drain is placed in the paracolic gutter. Usually in a clean lepertomy we don't keep any drains neither in the uh in the stomach or in the in the abdomen and abdomen has closed in the layers and patient is doing good and rails to be removed and oral and oral started on the second day and is doing good. So this is in a pre-operative and post-operative.

[01:03:58]There's a good uh uh improvement and the diaphragm is below and it's closed perfectly and only thing is left lung little hazy probably he needs a good face. Yeah. Post-operative and some good PJ therapy and spyometry.

[01:04:16]Biopsy of the mentric lymph node was all was done simultaneously in order to rule out since so since we see a good number of tuberculosis in the recent past unnoticed tuberculosis if you are operating for an say for example we pull procedure and sometimes we see a nodes we take a biopsy it comes as a tuberculosis along with the pancreatic malignancy probably this patient has an ascitis that's why uh treating surgeon has a doubt and did an a biopsy which showed reactive lymphodenitis and posttop operatively is comfortable doing good and reviewed after 3 months and is doing good. Some basic literature review some gastric valulas and as you know stomach has an attachments with the liver, spleen, colon and diaphragm. So gastropotic ligament, gastrosplenic collic ligament and this helps the stomach in a position otherwise the valvulus is most common and as you know there are two kinds of valulus. One is argonaxial and misenterial and so which occurs acutely needs an acute surgery. So in order to there are two types of primary versus secondary.

[01:05:28]Primary is basically the abnormalities in the gastric ligaments and failure of the gastric fixation. Secondary is due to some other problems like this patient has an diaphragmatic ventration and even paris previous patient has an also parispalia. These are the secondary causes of gastric valves and uh failure to insert an uh ry tube uh one of the uh butchards triad sudden onset of pain and recurrent wretching with not able to pass NG tube they're all the symptoms suggestive of an a gastric alvulas and plain film is suggestive and similarly uh CT scan also it it is gastric is in surgical emergency and if the RIT tube doesn't go one should think of an uh gastric wellness and operate on these patients.

[01:06:20]So that's all about the two cases and one spotter from my side and professor Shanai also can contribute. Sir Shai sir I'll just show another pictures please uh for the panelist. Yeah. Oh, nice.

[01:06:37]>> The analyst, I request you to read CT and then give your diagnosis.

[01:06:44]>> It's okay. I done a mistake.

[01:06:48]>> Yeah.

[01:06:49]>> So, there is a mass-like lesion here.

[01:06:52]You can see here.

[01:06:53]>> Yeah.

[01:06:54]>> So, here and here in the chest. So, this is an old long bag. I had operated.

[01:06:59]Suddenly I remembered yesterday after seeing Professor Shana's photographs.

[01:07:04]This is can see this big mass in the right side of the chest. This is a big mass in the right side of the chest. And u see you can see this angagram also CT angagram. This is a spleenic artery going like that. So and spleenic vein going like that. So and there's no spleen here. So that was >> and then that was a spleen in the chest.

[01:07:30]>> Huh? 43 that's >> yeah spleenic art going there the spleen and patient had child patient had uh it's a congenital intrathoracic spleen >> very very rarely seen I do not know how it has gone some congenital abnormalities very few reports I don't have an operate findings operate pictures I tried tried to get operate pictures I didn't get otherwise I would have shown uh so the entire spleen was in the right right chest so I could not bring it because a lot of to the uh spleen in the chest as well as in the abdomen so I have to like get the spleenic artery and then did a spenic spelc in this patient so I'll find out that if there are any pictures operate pictures in this patient very very rare I seen only one case congenital totally patient did not have any uh history of trauma or any surgery I don't know how spleen has gone there and stuck back in the right side of the chest.

[01:08:33]So thank you. Thank you very much uh for giving me this opportunity. Thank you sir for >> Thank you sir. I have there are few questions. First I will uh whatever collected um firstly the uh in in uh um presence of the volume is it possible to decompress?

[01:08:58]I think the you have made very clear I think it's a partial valvous you should be able to decompress correct >> yes yes partial valus if you are not able to pass the rise tube and it's not going into the stomach it means it's in a complete valolas >> usually in the other mental aial many times it is 180° so sometimes it is possible but if it passes you are lucky >> yes Yes.

[01:09:30]>> So can we make use of uh needle aspiration or something to help in decompressing? Of course it will violate the field clean field but then will it be useful sir like uh putting in a whiteboard needle and aspirating and reducing the gastric contents.

[01:09:47]>> You mean on that operation table or pre-operative?

[01:09:50]>> No no on the tables. On the table >> on the table it's not necessary. Once you dr rotate it there's no need automatically get decompressed and you can pass the rail st and decompress. I think one should not put any needle into the any lumen and to as to decompress. We used to do colonic but long time back we don't do now we are >> the policy that when you are droating please pass the rise tube beyond that so that automatically it will be decompressed that is a part of the surgery.

[01:10:19]>> Yes. Yes. Okay sir. one or two uh things from my side uh that is uh both cases have been chosen so as to make the interesting part of it is that how they come carrying actually chest chest X-ray to the hospital the presentation is like you know they come with X-ray like that so this is how the in fact with the simple X-rays one can make a diagnosis our Dr. Naz our chairman and the surgeon from hospitalate she has after looking at the X-ray itself she gave a diagnosis of recurren gastric walls with the history and that x-ray first case first case in the in the YouTube I'm just telling the comments from the YouTube uh that lady in that I never thought of thoracicoscopy or something because right side and I thought it should be easily you should be able to manage that that is about the first case uh weight reduction as the main thing in that lady because she was very obese. Um her hypertension, diabetes, it was also taken as something like a semi-emergency situation. And coming to this boy um this boy actually we did during the time that if you see the RTPCR was done in that you know that one sentence was there.

[01:11:38]>> Yeah >> this particular particular case >> in fact we called the urology help because if you see the kidney in the CT itself is very highly placed >> very high.

[01:11:49]>> Yeah.

[01:11:50]>> Even though it was if you if you see that city city image know already we know that kidney was inside the thorax.

[01:11:56]So and some air shadow which you were talking something about that that was the colon actually.

[01:12:02]>> So >> okay >> and the patient young boy but since the diaphragm diaphragm line was very nicely seen we thought it's definitely ventration that's how we landed. So there was also during time emergency we did so we thought in case it was night I think sometimes so we came we need any help you know that is the reason we involved in in institution you know institutional policies and guidelines are there so that's how we involved but as somebody has asked in the YouTube that any role for ICD intercost tube on that second case that uh >> any yeah second case I think it's better because that that the diaphragm is thinned out invariably end up opening into that and some neimarax will be there. It's better put a ICD and then come out.

[01:12:56]>> If there is if the chest has not been opened at all what we need of ICD >> correct so that's why what happened is these are the anecdotal cases because we don't have much experience in volumes to talk about this where after reduction there's a pseudo sack like thing there.

[01:13:15]>> Yeah. So we the the their the suggestion was that that some seroma or some fluid may collect in that actually plura was not opened in this case. Clear? So we put a tube into that pseudo sack like thing under vision from below but putting it almost like coming out from the lower rib spaces. It is not intercostal but it may drain that cavity.

[01:13:38]>> Sir only thing is what about putting a mess?

[01:13:42]>> Sir >> putting a mess. No no in that we we have not done the mess >> in this present particularly in the era mess was avoided and dissection might have been very difficult here also.

[01:13:54]>> So I know but somehow the both cases we were able to get a good approximation as you rightly put it no without tension.

[01:14:03]So that is the one thing which we did.

[01:14:05]So anyway that is the purpose. These are some of the comments in the this one in the in the YouTube. Uh so >> any other paral in both cases sir especially in diaphragmatic hernia the diaphragm was so thinned out so we put me sir >> that's what I'm telling sir >> both in thoroscopically as well as intra the laparoscopically we put up mesh that is one thing I want to express and one question to Dr. You saw one congenital intrathorax explained.

[01:14:46]>> The mass was seen in the right thorax.

[01:14:49]>> Rightax. Yes. Yes. It was in the right thorax. I don't I'm not able to explain.

[01:14:54]It's in a congenital.

[01:14:56]>> Was it situs inverses?

[01:14:58]>> No, it was not citus invers. It was not citus inverses. No, not at all. You can see the right liver in the right side.

[01:15:05]So even you can see the spleenic arteries going from the super micentric artery from the celiac trunk. It's going going from the superentric artery into the right chest.

[01:15:16]>> So it's a congenital >> intrathoracic spleen.

[01:15:21]>> You can add wanding spleen also sir.

[01:15:25]Yeah, we have seen warning in the >> warning. We have seen we have seen the pelvis and other thing but intrathoracic spleen that is the first. I tried to I tried to pull it into the stomach but it was not even I did a thoroctomy but I could not bring because of lot of additions and spleen was stuck there and capsule tears and started bleeding. So I had to do anctomy.

[01:15:52]>> Can stop sharing sir.

[01:15:54]>> Yeah. Yes sir.

[01:15:55]>> Okay. So thank you sir.

[01:15:58]>> Actually we we have not done we have not done the thoricoscopy or laparoscopy in this uh in this particular situation of a young boy. Um u but the thing is I was talking to some of the experts who are able to even tell that uh the whole thing even kidney and the uretor everything is possible to get it down into the into the retroparitum through the approaches. Yeah.

[01:16:24]>> So that is >> the role of tricottomy or tooscopy comes in a case of an short esophagus congenital short is figus or fibrosis of the short es isopagus because of the fibrosis then we need to lengthen the esophagus and then do either like kis gastroplasty or lengthening mobilization of the isophagus and then do a a funation in order to prevent the recurrence and other things but it'll be very difficult in we end up injuring the vagus nerve and cause some problems. So we do not have much experience in mobilization.

[01:16:59]>> I also want to I also want to just say this 3 years 4 years over now for this I have a followup of this patient every year but the issue is he still has the kidney inside his thorax >> that's what I'm the point which I was trying to tell was that it should have been this was happened during the co time and I I said already it was done as an emergency but he's already economically coming from him. So I said this is what you should keep it in mind.

[01:17:25]Sir, how come is it that it is still it is in the thorax? That means >> yes sir.

[01:17:34]>> No re later I have not done I have not done the what is that uh the the retroparium also it has been slid >> right >> see what we opened we reduced correct the whole complex.

[01:17:54]uh excellent uh case discussions we have short already by 17 minutes we wrote short the time excellent discussion and excellent moderation by learn academician senior teacher Dr. Nva I also uh good discussion from all the panelists uh now I request our honorable treasurer Dr. from Adumita Mukopad to propose of thanks.

[01:18:24]>> Thank you Dr. Dwakar.

[01:18:26]Um my sincere thanks to our president Dr. Marupand, our vice president Dr. Barut and our past president Dr. Praal Nugi for all your valuable contributions.

[01:18:41]Thanks to our uh uh academic advisor Dr. Santo Abraham and our academic director Dr. Shennai for putting up this whole program together.

[01:18:52]Thanks to Dr. Viraa for a very excellent moderation.

[01:18:58]Thanks to our speakers Dr. Mishra, Dr. Malotra, Dr. Ankur and Dr. Midgot. This is a very good discussion.

[01:19:06]Thank you all so much. Thanks to all our viewers. Thanks to Dr. Giagar, our secretary, a very hardworking secretary.

[01:19:15]>> Yes, >> long thanks to all of you. Long live.

[01:19:20]Good night.

[01:19:21]>> Thank you. Good night.

[01:19:22]>> Good night.

[01:19:22]>> One request from my side is we have a lot of case capsules. I might uh uh useful in contributing a lot of case capsules to association of surgeons of India with the permission of the chairpersons and president and director of academics professor Raj Gopai please sir >> yes sir I have a lot of case capsules since I have very lot of case capsules I can say that I have lot of plenty of case capsules I'll be useful in contributing those two Thank you.

[01:19:56]>> Thank you, sir.

[01:19:58]>> Thank you.

[01:19:58]>> Yes, sir. Good night.

[01:20:00]>> Thank you very much.