Medi Magazine kauvery A quarterly magazine from VOLUME - 18 | ISSUE - 04 | OCTOBER 2016 - 18 | ISSUE 04 OCTOBER VOLUME

ARTHROSCOPIC AND ENDOSCOPIC SURGERY FLEXI URS AND LASER IN ORTHOPAEDICS LITHOTRIPSY- A BOON TO PATIENTS AND UROLOGISTS

LAPAROSCOPIC SURGERY FOR LAPAROSCOPIC CYSTIC LESION OF PANCREAS PYELOPLASTY IN A CHILD - CASE REPORT & REVIEW

DREZ RHIZOTOMY TRANSARTERIAL PROCEDURE FOR CHEMOEMBOLISATION(TACE) NEUROPATHIC PAIN FOR LIVER MASSES

KAUVERY MINIMALLY INVASIVE TRICHY MARATHON SURGERY - BRAIN & SPINE

DOCTORS FAM FEST

“SPECIAL EDITION ON MINIMALLY INVASIVE

SURGERY” To download this magazine scan this QR Code with QR scanner APP in your smartphone

This magazine is free circulation for and doctors only, Not for sale. Design and logo of kauvery hospital are property of Kauvery Hospital, To get this magazine copy mail us at: [email protected] | If you want to know any other details contact us on Editorial Address KAUVERY CAPSULE | OCTOBER 2016 INDEX

CAPSULE MAGAZINE

Capsule Magazine is published by Kauvery Hospital

Copyright 2016 © Kauvery Hospital

PATRONS 01 Dr. S. Chandrakumar FROM Dr. S. Manivannan THE EDITOR’S DESK 10 ADVISORY BOARD Dr. D. Senguttuvan FLEXI URS AND LASER Dr. Aravindan Selvaraj LITHOTRIPSY- A BOON TO Dr. T. Senthil Kumar 02 PATIENTS AND UROLOGISTS EDITOR ARTHROSCOPIC AND Dr. S. Senthil Kumar ENDOSCOPIC SURGERY IN ORTHOPAEDICS EDITORIAL TEAM Dr. S. Velmurugan 12 Dr. S. Aravinda Kumar LAPAROSCOPIC Dr. Iyyappan Ponnuswamy 04 PYELOPLASTY IN A CHILD TECHNICAL TEAM LAPAROSCOPIC SURGERY FOR Dr. Ve. Senthil Vel Murugan CYSTIC LESION OF PANCREAS Dr. A. Subramanian - CASE REPORT & REVIEW 14 DREZ RHIZOTOMY ADMIN TEAM Mr. S. Sathishkumar PROCEDURE FOR Mr. A. Madhavan NEUROPATHIC PAIN Mrs. JPJ. Bindhu 06 TRANSARTERIAL CHEMOEMBOLISATION(TACE) CO-ORDINATORS FOR LIVER MASSES Mrs. Percy Ms. R. Priya 15 DOCTORS FAM FEST 2016 DESIGN & LAYOUT Mr. Vahid Ali N. 08 MINIMALLY INVASIVE SURGERY 16 KAUVERY HOSPITAL TRICHY MARATHON 2016

EDITORIAL OFFICE Kauvery Hospital VI Floor, Administrative Office, #6, Royal Road, Cantonment, -620001. Call us at (431) 40 77 777 E: [email protected] W: www. kauveryhospital.com | EDITOR’S DESK KAUVERY CAPSULE OCT 2016 01

FROM THE EDITOR’S DESK DR. S. SENTHIL KUMAR, MS., DNB., (URO) SENIOR CONSULTANT UROLOGIST

Dear Friends, a candle for illumination. In 1901, Kelling performed the Welcome to 18th edition of CAPSULE. In this edition we first examination of the abdomen using a cystoscope in a are presenting ' MINIMAL ACCESS SURGERIES' done in dog. In 1882, Carl Langebuch of Germany had various departments. I thank all the authors and their performed the first open cholecystectomy. One hundred team for their contribution. years later on 12.09.1985. Prof. Dr. Erich Muhe performed the first laparoscopic cholecystectomy. In Surgery is the first and the highest division of the healing 1985, Erich Muhe was ostracized for lap. art, pure in itself and eternal in its applicability. In its Cholecystectomy, until his recognition by SAGES in 1999. history, large incisions were an absolute necessity to a The revolutionary nature of this procedure has been successful procedure. Exposure was the key to a safe and unprecedented in surgical history, and it has been successful operation. concluded to be the cultural change in the field of general surgery, rather than the operation it replaced. Surgeons have traditionally attempted to find new The popularity of Minial Access Surgeries led to a new methods to treat their patients' afflictions while reducing domain surgical field. At Kauvery Hospital, we are the injury caused by the treatment, hence the evolution equipped with the State-of-the-art instruments and of minimally invasive techniques. Though exposure is still highly skilled professionals to perform MAS in essential for a safe and successful operation, it is now Department like , , possible to access body cavities by making smaller Neurosurgery, Cardiothoracic surgery, Ortho, incisions. Gynecology and various other departments.

Minimally invasive surgery may be as old as humanity. Minimal Access Surgery - “ A BIGGEST small The actual practice of MAS (Minimal Access Surgery) can change that can change the quality of life of your be traced to early 18th Century. In 1795 Bozzini patient! developed the Lichtleiter, a crude endoscope which used KAUVERY CAPSULE | OCT 2016 02 “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY

Arthroscopic and Endoscopic Surgery By in Orthopaedics Dr. S. Chockalingam. MBBS, D ortho Sr. Consultant Orthopedics Kauvery Hospital, Trichy

ORTHO+ PAEDICS Causes of muscle tendon Orthopaedics from its humble beginnings of treating deformities pathologies, nerve. in children has matured in treating fractures, dislocations, joint Muscular weakness may either be diseases. Joint replacements and internal fixation of the fractures structural or non structural. Tendon have become everyday practice in an Orthopaedic surgeon’s life. and muscle tears, impingement, muscle contractures, enthesopathies However Orthopaedics has evolved to treat conditions of not form the majority of structural causes. only the bone and arthritis of joints but also the muscles, Rotator cuff tears, Biceps lesions in the tendons, ligaments, fasciae and even the nerves. Tendon and shoulder, Tennis elbow, Dequervains ligament tears, impingement, enthesopathies, nerve entrapment teno synovitis in the wrist, Trigger are now treated successfully with arthroscopic and endoscopic finger in the hand, Iliotibial band surgeries, which help to improve quality of a patient’s life. This syndromes, equinus contractures of article is to highlight the current practice advances in this field. the ankle are some of the examples.

Nerve entrapment such as carpal and Applied Bio mechanics cubital tunnel syndrome, Skeleton forms the back bone for the man to function and Supraspinatus nerve entrapment, protection. 206 bones forming 360 joints with 900 ligaments medial plantar nerve entrapment in stabilize the joints to give controlled movements. There are over the foot are some of the causes 640 skeletal muscles with the help of tendons move the joints and affecting the muscle function thus the limb. (If you want to walk, it takes over 200 muscles to secondarily and causing pain and work in a coordinated way). The muscles do need the nerve to weakness of the limbs. stimulate them and the energy to get them going. The problems thus can be either in the muscles, tendons, ligaments, cartilage, fasciae and pressure on the nerves by other structures.

ARTHROSCOPIC AND ENDOSCOPIC SURGERY IN ORTHOPAEDICS KAUVERY CAPSULE | OCT 2016 03

Endoscopy in Orthopaedics technique. (Endo-inside scopy-visualization) 2. Developmental abnormalities in a 10. Even a major joint surgery such as Visualizing the interior of the body with child such as discoid meniscus can be ankle fusion for arthritis can be done the telescope and assisted with modern treated entirely with this technique with arthroscopic technique. High definition cameras and monitors is 11. Hip arthroscopy is an established the fundamental of endoscopy. Doctors 3. An adult patient who had chronic technique for hip joint pathologies as and patients alike relate to pain in the hindfoot due to bony shown here. gastrointestinal investigations and growth irritating the Achilles tendon can interventions to endoscopy. However be successfully treated with endoscopic the same technique, albeit with different technique instruments are used in other specialities. One would not expect this 4. A middle aged lady who had technique to be used in Orthopaedics, persistent pain and weakness of understandably, through this shoulder was diagnosed to have had a technique dates batch to 1920 rotator cuff tendon tear. This was successfully treated with endoscopic Technique technique and rotator cuff tendon It is common to use 4.5mm telescope repair. to visualize spaces namely joints, bursae. Other tissue planes can be 5. A shuttle player with Anterior opened to visualize muscles, tendons, cruciate ligament tear was successfully Hipscopic nerves and vessels. Radio frequency treated with reconstruction using ENDOSCOPIC SURGERY IN ORTHO- probes are often used to remove tendon graft. Similarly an extra articular PAEDICS IS USEFUL IN THESE unwanted tissues and to open up ligament such as posterior cruciate AREAS spaces for procedures such as repair of ligament was treated with combined tendons. There are smaller telescopes arthroscopic and endoscopic technique. as little as 1mm and longer for procedures in and around hip joints. 6. A middle aged man who had UPPER LIMB SHOULDER, ELBOW, Children do need smaller scopes such persistent pain from tennis elbow was WRIST as 1.9mm and 2.4mm scopes for large treated with endoscopic technique of joints and smaller joints and spaces tendon release. LOWER LIMB HIP, KNEE, ANKLE, LEG need such scopes. Instruments that SUBTALAR JOINT, match these smaller scopes are 7. A young and active man with tear of HINDFOOT available and also for various specific the labrum of shoulder resulting in purposes. recurrent dislocation of shoulder can return to normal life with arthroscopic Conclusion: Gone are the days where X-rays were Case and instrument illustrations technique. equated with Orthopaedics. Magnetic Mechanical clearing instruments such as resonance imaging (MRI) CT Scan shaver, bone clearing burrs, tissue 8. A nerve such as suprascapular nerve Ultrasound with improved clinical ablating radio frequency devices, which needs identification for nerve diagnosis for extremity problems have suture passing and management graft can be isolated with endoscopic changed many a patient’s life and devices are some of the devices in an technique. The same nerve can be functions. Orthopaedic Surgeon’s decompressed when affected with armamentarium. pressure from pathologies such as cyst. We have shared a sample of the Tendons and ligaments do need endoscopic and arthroscopic Fibrewire 9. Tight gastrocnemius muscle, a cause stronger material for repair. techniques, conditions and and ultrabride sutures of heel pain can be lengthened with are so strong armamentarium at an Orthopaedic that they cannot be cut with scissors. endoscopic technique. Carpal tunnel can be decompressed with endoscopic Surgeon’s disposal available right here Sutures need to be anchored to bone in our home town. and we use metal or Biocomposite anchors. Suspension fixation of tissues need strong metals such as titanium and suture cords which self tightens without knots are technical advances.

1. A child with septic arthritis who would normally need open drainage of pus from the joint can be successfully 10. Arthroscopic joint fusion treated with arthroscopic technique. SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY ARTHROSCOPIC AND ENDOSCOPIC SURGERY IN ORTHOPAEDICS KAUVERY CAPSULE | OCT 2016 04 Laparoscopic

Surgery For Cystic By Dr. S. Velmurugan. MS, FRCS (Glas) FRCS (UGI-HPB), CCST (UK) Head-Department of Gastroenterology Sr. Consultant Surgical Gastroenterologist Lesion Of Pancreas - Kauvery Hospital, Trichy

Dr. M Rajasekhar, Dr. Aniket Phutane, Dr. Kasi Viswanath -Case Report DNB Post graduates & Review

“SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY Her CECT abdomen showed a large (10cm), well defined, thin walled cystic mass lesion with internal septations seen involving the body and tail regions of pancreas. Tiny calcifications were seen in the wall and there were internal septations within the cyst. The splenic 36 year old female presented with left vein was not clearly visualized upper abdominal pain of three months (?infiltrated). The lesion was intending CT Showing Cystic Lesion of Pancreas duration. There was history of the posterior surface of greater Her serum tumour markers were within intermittent fever for 1 month and curvature of stomach closely abutting normal limits. CA19-9=16.1 (0-40) and haematemesis (small volume) for 1 the spleen, left adrenal and left kidney, CEA=3.65(0-4.9). A most likely week. She had loss of appetite and however no infiltration seen to these diagnosis of mucinous cystic neoplasm weight. She also had a past medical organs. These features were suggestive of pancreas with splenic vein history of recent onset diabetes. She of possible mucinous cystic neoplasm. obstruction causing isolated gastric underwent medical termination of There was mild splenomegaly, multiple varices was made. After informed pregnancy few weeks back because of dilated portosystemic collaterals seen in consent, we proceeded for laparoscopic her current medical illness. the fundus and the body of stomach, distal pancreatectomy with peripancreatic and splenic hilar regions splenectomy. We were not planning to On examination, patient was afebrile (left sided portal hypertension) and this preserve the spleen because of with stable vitals. Mild pallor was was probably due to splenic vein suspicion of infiltration into splenic vein present. There was minimal tenderness obstruction form the tumour. The uterus causing left sided portal hypertension in left hypochondrium. No other was bulky with minimal fluid collection and also to cure her recurrent upper GI abnormalities were detected. and air pockets (post MTP status) bleed due to gastric varices.

Laparoscopic Distal Pancreatectomy with Splenectomy Procedure : One 10-12mm Excel port, one 10mm and three 5mm ports were placed. The findings were: 10cm sized cystic lesion involving body and tail of pancreas with engorged short gastrics, no peritoneal or omental disease, no gross lymphadenopathy, no liver metastasis. Upper GI endoscopy showed an isolated Gastro-colic omentum mobilized with gastric varix, which was not bleeding at the Harmonic. Lesser sac entered. Short time of endoscopy.

LAPAROSCOPIC SURGERY FOR CYSTIC LESION OF PANCREAS KAUVERY CAPSULE | OCT 2016 05 gastrics clipped and divided. amylase rich fluid enclosed in central calcifications with radiating septa Retropancreatic dissection was done non-epitheliazed wall. It is formed after giving the “sunburst” appearance. close to neck giving margin for the acute pancreatitis, chronic pancreatitis, Resection is rarely needed. Surgery is tumor. Splenic artery ligated, clipped and pancreatic trauma. It takes 4-8 considered only in large tumors (>4cm) and divided just distal to its origin from weeks for the formation of pseudocyst. or rapidly growing lesions. EUS+FNA coeliac. Splenic vein ligated, clipped Up to 50% of the patients are and cystic fluid analysis demonstrate and divided. Pancreatic neck symptomatic. The presence of aspirate with low mucin, low CEA levels transected with Echelon GIA 60 green persistent pain, early satiety, nausea, and low amylase levels. cartridge maintaining margin from the weight loss, elevated pancreatic enzyme tumour. Distal pancreatectomy with levels in plasma suggest the diagnosis. 4) Intraductal Papillary Mucinous splenectomy done enbloc with CT scan and USG are used to diagnose. Neoplasm (IPMN) harmonic. Drain was placed. Specimen ERCP and MRCP are useful to detect Three types of IPMN - side branch, main retrieved through small pfannenstiel ductal anomalies and ductal duct, and mixed types. They present incision after placing the specimen in a communications. Endoscopic USG (EUS) with abdominal pain, and features of large endobag. guided FNAC will help to differentiate acute pancreatitis. EUS+FNA and cystic pseudocyst from the cystic lesions of the fluid analysis demonstrate mucin rich Total operating time was 2 hours and 45 pancreas. The features of pesudocyst on aspirate with high CEA level (>192 minutes and blood loss was 75mls. Her EUS+FNA are high amylase, low mucin ng/ml) and high amylase level. postoperative period was uneventful. and low levels of CEA. a) Side branch IPMN: She was able to ambulate from the These may be focal involving single side second day. Post splenectomy vaccine Spontaneous regression of pseudocyst branch or multifocal with multicystic prophylaxis was given and also started has been documented in 70% of cases, lesions throughout the length of the on oral penicillin. Her drain was this is particularly true for pseudocysts pancreas. Risk of malignancy (10-15%) removed on the 5th day after checking smaller than 4cms. Transgastric or is related to the size of lesion, thickening the drain fluid amylase. She was transduodenal endoscopic drainage are of the cystic wall, jaundice, pain and discharged on the 6th postop day. safe and effective if the pseudocysts are diabetes. in close contact (<1m) with the stomach If the size is <1 cm, risk of malignancy is or duodenum. Surgical drainage small and surveillance with CT or MRI in options are cystogastrostomy, 1 year is appropriate. If size is between cystodudenostomy, roux - en - y - 1-3 cm imaging at 6 months is cystojejunostomy depending upon the appropriate. Lesions more than 3cms, position of cyst. presence of mural nodules or thick walls and symptomatic lesions should 2)Mucinous Cystic Neoplasm(MCN) undergo resection. b) Main duct IPMN: Specimen photograph MCN of the pancreas, more common in females, mean age at presentation is It may be focal or diffuse, malignant risk Histopathology showed mucinous 5th decade, typically found in body and is about 30% to 50% at the time of cystadenoma of pancreas. No features tail of pancreas, presented with vague presentation, thus surgical resection is of invasion or malignancy. No lymph abdominal pain. A history of cornerstone of treatment. nodal metastasis. Resection margins pancreatitis found in 20% of the Partial pancreatectomy is the surgery of were clear. At 1 year follow-up, she is patients. CT characteristics are solitary choice for main duct, symptomatic, and doing well with no evidence of cyst with fine septations and large branch-type IPMNs (>3cm). recurrence or symptoms. surrounded by rim of calcifications. Intraop frozen section should be Discussion : Presence of eggshell calcifications, large performed to ensure clear margins. Cystic Lesions of Pancreas: tumor size, mural nodules on cross A brief review of common cystic lesions sections are features of malignancy. Conclusion: of pancreas: EUS+FNA and cystic fluid analysis Management of cystic lesions of 1) Pseudocyst of Pancreas demonstrate mucin rich aspirate with pancreas varies according to the high CEA levels (>192 ng/ml) and low pathological type of the lesion and it is amylase levels. Standard treatment for important to differentiate them. In MCN is pancreatic resection. If MCN are advanced laparoscopic surgical units, benign no further treatment is required. minimally invasive surgical resection is If malignant, adjuvant chemotherapy safe and has advantages of less may be required. bleeding, reduced morbidity and early recovery without any compromise in 3) Serous Cystic Neoplasm(SCN) the quality of resection. As far as we are More predilection for head of the aware, in literature review, our case This is not a true cystic lesion as it lacks pancreas, occurs in age group of 60-70 report is one of the largest cystic epitheliazed wall. These are more years, presents with mild abdominal neoplasm of the pancreas successfully common than true cystic lesions. pain and obstructive jaundice, resected laparoscopically. Pseudocyst is a chronic collection of radiographic appearance on CT are SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY LAPAROSCOPIC SURGERY FOR CYSTIC LESION OF PANCREAS KAUVERY CAPSULE | OCT 2016 06

Transarterial chemoembolisation (TACE) for liver masses

Chemoembolisation was done successfully in our hospital for primary and secondary malignancy of liver during last month - First time in Trichy “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY

By Dr. Ve. Senthil velmurugan. MBBS, MDRD Sr. Consultant Radiologist Kauvery Hospital, Tennur, Trichy

CASE: 1 A Ninety year old male came to our FIG-1 FIG-3 hospital with the complaints of loss of appetite and weight. His blood investigation showed altered liver function with increase in AFP and His CT showed. It was a large 13x10cm mass in right lobe of liver with extensive neovascularity and dilated hepatic artery. Owing to his old age,

Preprocedural the tumor surgery was replaced with chemoembolisation. Doxirubicin and FIG-4 FIG-2 lipiodal mixture according to the weight of the patient was injected which was followed by an angiogram.

Angiogram embolisation using gelfoam and PVA particles was performed. Embolisation was followed by a CT scan, which showed stasis of drug mixture within Postprocedural the tumor.

TRANSARTERIAL CHEMOEMBOLISATION (TACE) FOR LIVER MASSES KAUVERY CAPSULE | OCT 2016 07

FIG-1 FIG-2 FIG-3 FIG-4

Embolisation with gemcitabin and lipiodal

CASE: 2 DISCUSSION: COMPLICATION: A 72years old female Chemoembolisation is a procedure to 1.Vascular complication ( Dissection , came with nonspecific deploy chemotheraputic agents directly Non tumor embolisation ) symptoms to our to a tumor with minimal exposure to 2. Pulmonary Embolism. physician and found to normal tissue. This also increases the 3.Postembolism syndrome. have mass lesion in right chemotherapeutic agent to stay long 4.Hepatic abscess and biloma. lobe of liver which time in the tumor and finally cut off the 5.Renal Failure. measures 48x34mm. neovascularity to the tumor. 6.Hepatic Failure.

Past history shows that INDICATION: CONCLUSION : she had carcinoma in the 1. Hepatocellular Carcinoma. TACE is a good option for patients with right breast with post-op 2.Metastasis liver tumors where surgical resection status of 25years. USG a. Solitary cannot be performed. Careful selection guided biopsy of lesion b. Multiple of patient and drugs will improve the done to know the nature outcome. Post embolisation volumetric of the lesion and it turned CONTRAINDICATION : analysis and repeat embolisation can be out to be metastatic 1.Portal Vein Thrombosis. done for large volume tumors. adenocarcinoma. She was 2. Cirohsis of liver. subjected to PET scan 3. Obstructive Jaundice. which shows solitory lesion in liver. Case was PROCEDURE: discussed with After femoral puncture 5F sheath is WANTED surgicalgastroenterologist introduced through which 5F pigtail and chemoembolism catheter was inserted and abdominal planned considering her aortogram was performed. Then WANTED FULL TIME / PART TIME general condition. A selective cathetersation of celiac trunk NEPHROLOGIST mixture of gemcitabin and was done and hepatic artery FOR KAUVERY HOSPITAL, lipoidal was injected into delineated. Using microcatheter the HOSUR UNIT. the tumor using selective angiogram of the tumoral CONTACT: +91 94434 01616 microcatheter and vessels done. Delayed phase has taken followed by embolisation. to rule out portal vein thrombosis. Then Post embolisation CT scan chemotherapeutic agent and lipoidal WANTED FULL TIME was performed and it mixure was injected according to the MEDICAL GASTROENTEROLOGIST FOR KAUVERY HOSPITAL shows stasis of drug volume of tumor. Then embolisation CANTONMENT TRICHY mixture within the tumor. using PVA particles or gelform is done. CONTACT: +91 98433 57579 Post embolisation angiogram was performed to ensure the complete cut off the neovascularity. After 24 hours ELIGIBLE PROFESSIONALS MAIL YOUR check, post embolisation, CT was done RESUME TO [email protected] to confirm the exact distribution of drug mixture to the tumor. “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY TRANSARTERIAL CHEMOEMBOLISATION (TACE) FOR LIVER MASSES KAUVERY CAPSULE | OCT 2016 08

Minimally Invasive Surgery - Brain & Spine “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY

By Dr. Jos Jasper. M.Ch(Neuro Surgery) Dr. Madhusudhan. MS., M.Ch., MRCS., Dr. Ramesh Kauvery Brain & Spine Centre, Trichy

Keyhole surgery or MIS has The general steps included in planning will help in methodical approach as well taken the world by storm in and carrying out a MIS procedure are: as pick up any short comings if any. all medical specialities. The significance of MIS is more, 1. Study the image: Study the tumour, 5. Keep incisions simple: Simple especially in the brain and its anatomy, relationship to adjacent linear incisions are easier to plan and spine. Surgeries inside eloquent areas, possible barriers in the carry out. They heal easily with fewer confined spaces are by approach, relationship to the calvarium scars and can be utilised in resurgery if nature very difficult, but etc. A “Keyhole” is very less forgiving to necessary. MIS decreases these any error in marking and has to be done difficulties. right. To illustrate MIS principles: The general trend in 2. Get the long axis of the tumour: MIS of the Brain: neurosurgery has been Plan so that maximal amount of work is Keyhole surgery for the brain can be smaller openings coupled done along the long axis, thereby broadly divided into two based on with enhanced technology, avoiding looking around blind corners. approach for surface/ convexity lesions localisation, navigation, and skull base lesions. and techniques with 3. Use CSF spaces: Early opening of well-designed appropriate CSF pathways relax the brain, open long MIS for convexity lesions: tools. It is also aided by corridors, decrease brain transgression 1. Navigation assisted: A 42 year lady better visualisation with and need to be always integrated into with 4 months history of treatment for newer endoscopes and the initial planning. suspected tubercular lesion of the brain. paradigm shift in the thinking itself. 4. Walk through the surgical steps: As walking through the surgical steps

MINIMALLY INVASIVE SURGERY KAUVERY CAPSULE | OCT 2016 09

Clinically worsening so need for tissue planned minimal approaches are Using MIS approach, initially pedicle diagnosis to confirm the diagnosis. MRI facilitating early recovery with screws were placed percutaneously done showed a lesion on the posterior decreased morbidity. followed by Distraction. Decompression part of the frontal lobe along the was also carried out and biopsy material surface. Using navigation a bur hole Extended Endo Skull Base obtained. Lumbar interbody Fusion was measuring 1*1 cm made directly over Approach: Keyhole approaches for also carried out using a “Bean Cage”. the lesion and excised totally. Patient lesions ranging for the more commonly discharged on the next day. Biopsy Patient was mobilised within 24 hours

confirmed growth of atypical done Transsphenoidal pituitary tumour Mycobacteria and so ATT was adjusted excision to anterior skull base and the patient was discharged. Meningiomas, Trans-Clival Lesions including clipping of A.Comm/ Basilar 2. Endoscopic EDH evacuation: An 8 Aneurysms are possible now. year old boy with frontal Extra Dural Neuro Navigation also plays a very Haematoma(EDH). Usually craniotomy important role in planning the amount and evacuation of EDH is the norm. In of bone removal as well as in planning paediatric population, after surgery the trajectory. differential growth will lead to dysmorphism due to involvement of the MIS in Spine: frontal bone. So bur hole made behind One of the most commonly done MIS the hairline and using the endoscope procedure in the spine is Vertebroplasty. EDH evacuated along with coagulation Building up on the basic principles of of the bleeder. Transpedicular Vertebroplasty, now and discharged with minimal pain. Pedicle screw placements, Within 2 weeks he was able to fly out of Decompressive Laminectomy and even India to restart his schooling. Intra Dural Tumour excision is possible 3. Navigation guided Endoscope using minimal approach. assisted ICH evacuation: In ICH, In MIS, the size of the incision does not The Stryker MIS system is very versatile instead of a craniotomy, using the matter. It is a more focussed principle and also modular so upgrading or Neuro Navigation access is planned wherein the goal is in more minute building up using the pre existing along the long axis of the haematoma. study of , correlating to the system is possible. A bur hole is made and under clinical picture focussing on reducing endoscopic control ICH is evacuated. In the mortality and morbidity by MIS _ PLIF & Pedicle Screw with a sick/ moribund patient instead of a minimising tissue handling, respecting Decompression: long procedure a minimal invasive tissue planes and reducing the amount 15 year boy with almost 6 months of surgery is less devastating. of anatomical disruption caused. MIS h/o back pain, progressive weight loss, ensures lesser injury, faster healing and loss of appetite diagnosed outside with MIS for Skull Base lesions: In happier patient. Trans Pedicle Biopsy as Tuberculosis was approaching skull base lesions, there admitted with difficulty in walking and has been a huge shift in using the sitting. Radiological investigations endoscope as a key player for keyhole revealed a collapsed L5 body causing surgery. Instead of extensive bone compressive radiculopathy. drilling or osteotomies, precisely “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY MINIMALLY INVASIVE SURGERY KAUVERY CAPSULE | OCT 2016 10

Flexi URS & Laser Lithotripsy - A boon to patients and Urologists By Dr. S. Senthilkumar. Ms., DNB., (Uro) Dr. N. Karthickeyan. MS, MRCS, DNB, M.Ch Kauvery Kidney Centre, Tennur, Trichy

Introduction: Urologists have increasingly employed minimally invasive techniques for the past three decades in the Case Report: Discussion:

“SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY management of urolithiasis. With advances in miniaturisation of scopes, ureteroscopic designs and A 56 year Ureteroscopy (URS) was first described accessory instrumentation minimally invasive olddiabetic 25 years ago, since then it has endourological procedures have become the person with progressed from a simple diagnostic standard of care in the treatment of urolithiasis. decompensated procedure to a more complex surgical liver disease intervention allowing access to the came to our entire collecting system. The indications centre after undergoing DJ stenting for for ureteroscopic management of renal right PUJ calculus at a private medical and ureteric calculi are based on renal college, . X-ray KUB showed anatomy, patient characteristics and 2cm right renal calculus. Patient was stone characteristics (Table 1).The diagnosed to have Immune expansion of these indications are thrombocytopenic purpura in 2015 and mainly due to the introduction of was under treatment. His platelet counts 200µm holmium laser fiber and the were varying between 40,000 to 70,000 small diameter flexible ureteroscopes per cubic mm.PT/INR were elevated with active primary and secondary with INR of about 2.24.Complete deflection. haematological workup were done. Cardiac evaluation and renal function ESWL and PCNL are absolutely were normal. contraindicated in patients with uncorrected bleeding diasthesis, leaving Patient underwent Flexible ureteroscopy ureteroscopic lithotripsy as the only (Fig.2) under general anaesthesia as effective therapeutic alternative. Our PCNL and ESWL are contraindicated in patient who had an elevated INR was an bleeding disorders .2cm calculus was ideal candidate for Flexi URS. Patient identified in the lower calyx and the was positioned in lithotomy position stone was relocated to a more after induction with general favourable location. Stone was anaesthetics. Semirigid ureteroscopy completely dusted with holmium laser. was done using 7 Fr ureteroscope to Patient had an uneventful recovery with inspect ureteral anatomy and to allow complete stone clearance with passive dilatation of the ureteric estimated blood loss around less than orifice.After placing 0.035 inch 10ml. guidewire, ureteric access sheath was advanced and positioned in the upper ureter, monitored under fluoroscopy.

FLEXI URS AND LASER LITHOTRIPSY - A BOON TO PATIENTS AND UROLOGISTS KAUVERY CAPSULE | OCT 2016 11

Flexible ureteroscope passed and 2cm Patient characteristics stone was located in the lower 1. Obesity calyx(Fig.3). Stone was relocated to 2. Bleeding diathesis middle calyx using stone basket to 3. Patient preference prevent bending of the flexible scope 4. Musculoskeletal deformities during laser lithotripsy. Using 200µm 5. Pregnancy laser fiber stone was completely dusted 6. Requirement to be stone-free Airline with holmium laser. Patient had an pilots, Astronauts uneventful recovery with negligible blood loss with complete stone Stone characteristics clearance. Fig.1-Flexi URS 1. Failed previous SWL 2. HounsefieldUnit >1000 3. Ureteral location 4. Combined approach with PCNL

Conclusion: Table 1 .Indications for Flexible Flexible ureteroscopy and laser URS: lithotropsy have completely Renal anatomic characteristics: revolutionised the way urolithiasis 1. Calyceal diverticulum being treated. They are a real boon to 2. Infundibular stenosis patients especially with bleeding 3. Horseshoe/ectopic kidney disorders. 4. Concomitant ureteral stricture, UPJ obstruction 5. Lower pole anatomy Infundibular pelvic angle <70Infundibular length >3 cm Infundibular width <5 mm

Fig.2-Lower calyx survey using Flexible URS

Question: 36 year old female presented with severe lower abdominal pain and vomiting. What are the findings? What is the diagnosis?

Send your answers to [email protected] or WhatsApp to +91 95240 64687

Previous Issue’s Question & Answer This is of a 48 years old female with history of acute chest pain and breathlessness. What is the diagnosis? 1) Sinus Tachycardia 2) RBBB 3) ST depression in V2-V3 4) S1 Q2 T3 Acute chest pain with breathlessness tachycardia and RV strain pattern in suggestive of acute pulmonary embolism. “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY FLEXI URS AND LASER LITHOTRIPSY - A BOON TO PATIENTS AND UROLOGISTS & QUIZ KAUVERY CAPSULE | OCT 2016 12

Laparoscopic Pyeloplasty

“SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY in a Child

By Dr. M. Jeevagan.M.S(Gen), DNB(Urology) This one and half year old Senior Consultant child presented with Laser, Laparoscopy and Endourology antenatal followup of a Kauvery Hospital, Chennai congenital Pelviureteric junction obstruction which is progressively worsening in followup scans. The male PORT PLACEMENTS child was weighing 10kg with normal renal function, further investigations were A done. His CT KUB revealed right PUJ obstruction with moderate hydronephrosis with no other anomalies. B Diuretic Isotope Reno-gram revealed Left side normal function with no obstruction C to flow and the T half of 8 CT Reconstruction showing Telescope port placements min, however the right side were made . After retracting Right moderate D function was good with hydronephrosis with the liver , mesocolon severe obstruction to flow contrast not draining in to dissected free and so T half not measurable. the ureter , Left pelvicalyceal duodenum mobilised system and ureter appears medially. Large renal pelvis normal A -5mm port for Liver with a small segment of retraction at the narrow PUJ dissected , epigastrium limited mobilisation of ureter B - 5mm R Hand port done. Dismembered C- 5mm Camera port Anderson Hynes Pyeloplasty D- 5mm L Hand port and done using 5’0 vicryl without DT pelvic anchoring stich after anti grade stent placement.14F suction Diuretic Isotope Reno-gram After anaesthetic assessment, catheter kept as for drainage showing significant the child was taken up for through the left hand port. obstruction on the right with surgery under GA in Left Total estimated blood loss infinity T half value, the left Oblique position using UHD less than 25ml and side is normal with T half of camera , Harmonic scalpel Operating time 115min. 8min and 30 Degree 5mm

LAPAROSCOPIC PYELOPLASTY IN A CHILD KAUVERY CAPSULE | OCT 2016 13

A B Health recipe Beetroot & C D Sesame Roti Preparation Time: 10 mins | Cooking Time: 15 mins Total Time: 25 mins | Makes 8 rotis A. Liver retraction B. Mobilisation of pelvis C. Ureteric spatulation Ingredients D. First stich on spatulated ureter 1/4 cup boiled -peeled and grated beetroot 1 tbsp sesame seeds (til) Child started oral feeds 6 hours from surgery. Urethral 1/2 cup whole wheat flour - (gehun ka atta) catheter removed second day after surgery . Drainage 2 tsp oil 20ml , 10ml become nil on the third day and The child 1/2 tsp chilli powder was discharged after removal of drainage tube. The 1/2 tsp coriander (dhania) powder stent was removed after 6 weeks. Diuretic Isotope 1/4 tsp turmeric powder (haldi) Reno-gram repeated after 3 months from stent removal. a pinch of asafoetida (hing) salt to taste whole wheat flour (gehun ka atta) for rolling 2 tsp oil for cooking

Method 1. Combine all the ingredients in a deep bowl and knead into soft dough, using very little water.

2. Divide the dough into 8 equal portions and roll out each portion into a circle of 100 mm (4") diameter, using a little whole wheat flour for rolling.

3. Heat a non-stick tava (griddle) and cook each roti, using ¼ tsp of oil, till it turns golden brown in colour from both the sides. Both kidneys showing good function with no obstruction.T half of the right kidney is 12min 4. Allow the rotis to cool completely.

It is safe and results are equal to open surgery, duration Nutrient values per Roti of the procedure is comparable to open procedure with Energy 55 cal Fat 3.2 gm less pain and small scars. Protein 1.1 gm Iron 0.5 mg Carbohydrate 5.4 gm Calcium 22.2 mg

How to pack Wrap in an aluminium foil and pack in a tiffin box. “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY HEALTH RECIPE KAUVERY CAPSULE | OCT 2016 14

DREZ Rhizotomy Procedure for

Neuropathic By Dr G Balamurali. MRCS (Edin), FRCS (Sur. Neuro.), MD(UK) Consultant Spine and Neurosurgeon Pain Kauvery Hospital, Chennai

Mr Anandan, from Calicut a 50 years old man, sustained a home or lead a normal family life. Some patients are house crush belt injury in 1988 while he was working in the Gulf. He bound for like 15-20 years having serious psychological was detected to have a complete Brachial Plexus avulsion issues. They lose their job, family, children, friends and social injury. He was operated in 1990 on his arm with no contact,turn out to be the major cause of physiological stress, “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY improvement in function. Pain in the whole of the right upper and a prime reason to commit suicide. Medical treatment limb had been increasing steadily over the years.He had includes high doses of sedative and neuropathic drugs which severe right hand pain which was stabbing, electric shock like will make them drowsy and sleepycontinuously.The and burning, which occurred daily. It medications are very expensive too, is the worst kind of pain that anyone wheremany patients discontinued could have. He had consulted several Neuropathic pain is a complex, medicines due to severe side effects. doctors in the last 10 years and had chronic pain state that usually is all possible allopathic and nature accompanied by tissue injury. With At Kauvery Hospital, Neuro-Spine treatment with no improvement. Mr neuropathic pain, the nerve fibers department, with state-of-art Kiran from Bangalore sustained a themselves may be damaged, amenities performs pain procedures similar Brachial Plexus avulsion injury dysfunctional, or injured. These in the spinal cord. These surgeries from a road accident and suffered damaged nerve fibers send incorrect are performed by only a few from pain for 14 years. He had not signals to other pain centers. surgeons in India and by no one else slept for many years and had a in Chennai. He has treated about 14 terrible life. patients in the last 5 years with more than 90% success in relieving pain. Mrs Jayalakshmi a 45 year old lady sustained a road accident 13 procedures have been done for Brachial plexus pain and and was left paraplegic. She developed severe pain in both one for spinal cord injury pain. This is a microsurgical her legs which did not respond to any medical treatment. procedure on the spinal cord that involves mapping the There were 11 other similar patients with severe neuropathic spinal cord with Intraoperative neuromonitoring and pain failing all other modalities of treatment. After consulting identifying the areas where there is nerve damage in the the Spine Centre at Kauvery Hospital, they got operated and spinal cord and making multiple lesions at a very specific area relieved out of their pain.There are several hundreds of to remove the pain source. This is a high-risk surgery, which is patients with such injury without proper cure to offer. Most technically demanding. Serious side effects like paralysis is common causes of such injuries are road accidents and often possible if the procedure is not done by adequately trained fall from height. 25% of patients with these injuries develop persons. A team of Anaesthetist, Neurologist and severe pain in the whole limb either due to spinal cord Neurosurgeons performed this procedure for about 8-12 damage or avulsion of nerve roots from the spinal cord. The hours. The three patients mentioned above were treated in pain is typically burning, stabbing, prinking, electric shock like, Kauvery hospital and are almost 100% relived of pain. sharp and continuous. The pain can get worsen at times and Surgeries where there is severe pain like Spinal cord Injury, some patients even commit suicide unable to cope with pain. Cancer pain, post herpetic pain, trigeminal neuralgia pain and Pain can be aggravated just by talking, movement of body, spasticity from cerebral palsy can all be treated in a similar breeze from fan, noise from the surroundings and water manner. Kauvery hospital is fully equipped to perform such during bath. They cannot talk to anyone, can’t go out of the procedures with the latest technology.

DREZ RHIZOTOMY PROCEDURE FOR NEUROPATHIC PAIN KAUVERY CAPSULE | OCT 2016 15 “SPECIAL EDITION ON MINIMALLY INVASIVE SURGERY” INVASIVE “SPECIAL EDITION ON MINIMALLY

Doctor’s Fam-Fest 31st July 2016, will always be cherished and remembered by the Doctors and their families, participated in the event of “Fam-Fest-2016”, bringing the profound nostalgic memories associated with the tradition and culture. To commemorate the Doctor’s day on July 1, our referral doctors along with their family members around 189 people participated in the event.

The fun- filled energy was carried around the program throughout encompassing complete happiness across all participants. The day ensured a complete off-beat from the daily chores and ensured a day of celebration and togetherness.

DOCTORS FAM FEST 2016 KAUVERY CAPSULE | OCT 2016 KAUVERY CAPSULE | OCT 2016 16 17

Organ donation is a noble mission, bringing a potential transformation in the humanity. Organ transplant is a significant breakthrough in the medical industry, which helped people to prolong their lives. The organ donation is still in the nascent stage, which needs more awareness to enable a paradigm shift in the lives of the people.

Kauvery Hospital, CII(The Confederation of Indian Industry), and Yi(Young Indians) have joined together to conduct the second successful consecutive marathon event, following the 2015’s grand success. “Kauvery Hospital Trichy Marathon” was organized for the noble cause of organ donation on 25th September 2016. Totally three Lakhs worth prize money was distributed to the winners. The prime motto of this year’s marathon is to raise awareness on the noble cause of “Organ Donation” to reach the ultimate state that “Let no organs be wasted”.

There was an overwhelming response of more than 10,000 participants incorporating categories like 5Km, 10Km and 21Km. The event was flagged off by Mr. Ramesh Kymal, Managing Director of Gamesa. Dr.Meena, former Vice Chancellor of Bharathidasan University was the special guest of honor. Other Key corporate representatives have also participated in this event. Certificates and medals were distributed to all the participants completing the marathon. Totally three Lakhs worth prize money was distributed to the winners. KAUVERY CAPSULE | OCT 2016 17 KAUVERY CAPSULE | OCT 2016 18

Dedicated Liver ICU is opened by the Managing Director Inauguration of Speciality for Liver Dr.Chandra Kumar on 29th August 2016, In the Cantonment Hospital’s ICU complex located at the fifth floor. This marks the Diseases and Liver Transplantation inauguration of Liver Transplant services in Kauvery hospital Cantonment, Trichy.

This ICU is equipped with advanced monitoring facilities, ventilators and CRRT dialysis machines, and HEPA filer ventilation system to facilitate a clean environment and advanced monitoring of Liver failure and Liver transplant patients.

In the Operation Theater unit, two dedicated theaters have been restructured with lamina floor ventilation systems, advanced theater lighting setup, operating tables and Liver transplant related equipments including CUSA, ARGON (APC), Thromboelastogram (TEG), advanced non invasive cardiac monitors and micro vascular surgical instruments.

A dedicated Liver clinic is being conducted every Wednesday at 10 am in Kauvery hospital Cantonment for Liver failure patients.

Kauvery hospital Cantonment- Centre for liver disease and Liver Transplantation Facilities • State-of-the –art theater facilities and equipments • Trained staff for pre-operative care • Dedicated ICU and Liver clinic • Experienced Professional Team KAUVERY CAPSULE | OCT 2016 19

WE EXTEND A HEARTY WELCOME TO OUR KAUVERY FAMILY

DR.M.PRASANNA., DR.T.K.SOWMYA., MD.,DNB(CARDIO).,FNB(INTERVENTION ), CONSULTANT BREAST SURGEON, CONSULTANT - CARDIOLOGIST, TENNUR, TRICHY HEARTCITY, TRICHY

DR.B.ANIS., MS., MRCS., MCH., DR. RAMYA PRASAD., MD., SURGICAL ONCOLOGY, INTERNAL MEDICINE, TENNUR, TRICHY TENNUR, TRICHY

DR.R.MAGUDEESWARAN., MBBS., MD(GENERAL MEDICINE)., DR.S.R.SUSHMA., MBBS,DNB(OBG), CONSULTANT - PHYSICIAN, GYNAECOLOGIST, HEARTCITY, TRICHY HOSUR

DR.C.VIGNESH., MBBS.,MD(PAED), DR. S. RAMESH., M.S., M.CH. (NEURO SURGERY) CONSULTANT - PAEDIATRICIAN JR. CONSULTANT - NEURO SURGEON SPECIALITY, TRICHY KAUVERY BRAIN & SPINE CENTRE, SPECIALITY, TRICHY

DR.G.PALANIVELRAJU., MS (GENERAL SURGERY)., MRCSED., GASTROENTEROLOGY, TENNUR, TRICHY THE NEW AGE FAMILY HOSPITAL

It gives us great pleasure & pride to share with you that the high end & neonatology department of Kauvery Hospital has been recognized by the National Board of Examinations for conducting the DNB Programme in Pediatrics.

This is an important academic milestone in our journey and comes as a crowning glory to the center of excellence in pediatrics & neonatology of Kauvery Hospital.

List of DNB Programmes • General Medicine • General Surgery • Orthopaedics • Paediatrics

For more details contact: [email protected]

kauvery hospital

Trichy-Tennur Trichy-Cantonment Trichy-Cantonment No.1, K.C. Road, Tennur, No.6, Royal Road, Cantonment, Heartcity, No.52, Alexandria Road, Cantonment, Trichy-17. Ph:0431-4022555 Trichy-1. Ph:0431-4077777 Trichy-1. Ph:0431-4003500

Chennai-Alwarpet Karaikudi Hosur No. 81, TTK Road, Alwarpet No. 42, Mudiyarasanar Salai, Near new bus stand, No. 35, Shanthi Nagar, Opp. to CSI Chennai-18. Ph:044-40006000 Karaikudi-630002. Ph:04565-244555 Church,Hosur-635. Ph:04565-244555