Highlights The travails in the management of complex duodenal injuries is well known among the surgical fraternity. We here present a salvage technique of primary reinforcement with pedicled rectus abdominis muscle flap (RAMF) for a tenuous post traumatic duodenal perforation (PTDP) of the second part. The majority of the studies in the literature are on the use RAMF for the repair of duodenal fistulas following failed primary repair of peptic perforations of first part of duodenum. Reinforcement with RAMF is a useful rescue technique when the omentum is not available and other simpler techniques are not feasible in the primary repair setting.

Introduction Pancreatic trauma is rare and is usually associated with adjacent organ and vascular injuries, which adds to the high morbidity and mortality. In the American Association for the Surgery of Trauma (AAST) pancreatic trauma (PT) grading system, the higher grades are a composite of less and more severe extents of injuries. We hereby present an observational study of PT with management based on an indigenous algorithmic approach. Our protocol incorporating both the extent of disruption of the main pancreatic duct (MPD) and its amenability to interventions (endoscopic, radiological, or surgical) is pragmatic. Methods Ours is a retrospective observational study of 28 consecutive cases of PT, done over a three-year period in an academic institution, by an expert Surgical Gastroenterology unit. All patients diagnosed with PT on a contrast abdominal CT scan were included. After stabilization, they were stratified and managed according to an indigenous protocol. The primary outcome measure was treatment success in terms of recovery. The secondary outcome measure was morbidity of any form. Results One patient with Grade 1 PT was operated on for associated hollow viscus injury. Two patients with AAST Grade 2 and two patients with AAST Grade 3 injury were managed successfully without surgery. Twelve of 21 patients with Grade 3 PT underwent Kimura’s splenic vessel preserving distal pancreatectomy. Distal pancreatectomy with splenectomy and central pancreatectomy with Roux-en-Y pancreaticojejunostomy (PJ) was done for 7/21 and 2/21 patients, respectively, with Grade 3 PT. Two with Grade 5 injury underwent trauma Whipple. The overall mortality and morbidity rates in our series were 15.7% and 64%, respectively. Conclusion The pathogenesis in PT is a dynamic process and shows temporal evolution. These patients require serial and periodical clinical and radiological monitoring, especially in those managed conservatively initially. PT can be low or high grade. Patients with isolated low-grade PT can be managed according to the standard step-up approach for acute pancreatitis. A carefully selected subgroup of patients with partial MPD disruption either in the head or body of the pancreas can be managed by endotherapy. Complete distal parenchymal transections require early surgery tailored to individual patients in the form of either splenic vessel preserving distal pancreatectomy (SPDP) or distal pancreatectomy with splenectomy (DP+S). Damage control surgery is the dictum in unstable patients with Grades 4 and 5 injuries not responding to resuscitative measures. A trauma Whipple can be done in a carefully selected subgroup of stable patients with proximal massive disruptions in an experienced hepato-pancreatico-biliary (HPB) unit.

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Background: Minimally invasive and endoscopic techniques are increasingly being used by surgeons nowadays in the management of patients with cholelithiasis and choledocholithiasis. However, there is a high failure rate in the extraction of large impacted stones using the conventional flexible choledochoscope by the laparoscopic approach. Improvisation of this technique will reduce the failure rate. The present study explored the safety, feasibility, and efficacy of a semirigid ureteroscope (SRUS) in the laparoscopic management of common bile duct (CBD) stones. Methods: A prospective observational clinical study was carried out in an experienced GI surgical unit from January 2020 to December 2021. It included 36 patients diagnosed with radiologically proven gallstone disease with bile duct calculi who underwent Laparoscopic CBD exploration (LCBDE) and stone extraction using SRUS with lap cholecystectomy (LC) as a single-stage procedure. The success rate in terms of complete CBD clearance is the primary outcome measure. Post-procedure complications, 24 hr pain score, in-hospital stay, and patient satisfaction score are the secondary outcome measures. Results: Mean age of the study subjects was 50.45±9.12 years. The most common clinical symptom was biliary colic followed by jaundice. The primary outcome measure of complete CBD clearance was achieved in 94%. A complication following surgery was bile leak in one patient (3%). There were no surgical site infections or T-tube related complications. The average WHO 24-hour pain score was 4.9±1.9. The mean in-hospital stay was 3.3±1.4 and the mean patient satisfaction score was 2.42±0.3. Conclusion: Laparoscopic approach avoids the complications of endoscopic retrograde cholangiopancreatography (ERCP) sphincterotomy/sphinteroplasty and keeps the sphincter of Oddi (SOD) intact. LCBDE with SRUS is a safe and effective single-stage approach without any radiation hazards. The pneumatic lithotripter with its pneumatic ballistic effect is more efficacious, cost-effective, and safe as compared to other lithotripsy techniques. This lithotripter is capable of dealing with different varieties of stones regardless of their composition, size and degree of impaction. However, future comparative studies are needed to prove the superiority of this technique.

Gallbladder (GB) torsion or volvulus is a rare entity affecting elderly women. Only ~500 cases have been reported in the literature. Incidence is rare seen in ~1 in 365 520. A constant finding is the presence of the GB on a mobile mesentery. Torsion, or volvulus, of the GB occurs when it twists axially, with the subsequent obstruction of bile and/or blood flow. We briefly describe a 75-year-old female patient with acute abdomen and ultrasound and Computed tomography of abdomen revealed a distended GB. On laparotomy, we encountered a twisted GB with gangrene and cholecystectomy was done. GB volvulus is a rare occurrence and clinically mimic’s acute cholecystitis and should be sought with high suspicion especially when encountering a thin elderly woman. Immediate diagnosis is prime as delay may be fatal. Even with recent advances in imaging, it is difficult to make a correct preoperative diagnosis of GB torsion.