Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411122EnglishN2019November29HealthcareLumbosacral Transitional Vertebrae - Occurrence and Significance English0104Chowki Parvez AbutaherEnglish Patil Rashmi AvinashEnglishAims: • To study the occurrence and type of sacralisation of fifth lumbar vertebra • To correlate embryological basis of the various types of anomalies in the Lumbosacral vertebrae Methodology: 98 adult human sacra were examined in the department of Anatomy of Seth GSMC, Mumbai. Damaged, mutilated and deformed sacra were excluded from the study. The data were collected by naked eye examination, compiled and statistically analysed and compared with other similar studies. Results: The sacralisation of the fifth lumbar vertebra and lumbarisation of first sacral vertebra was respectively seen in 18 out of the 98 sacra studied. This is in close relation with the observations from other studies on Indian population. Conclusions: Genetic factors play an important role in the embryogenesis of lumbosacral Transitional Vertebrae (LSTV). It is important for the clinicians and surgeons to have knowledge of the existence and incidence of LSTVs while performing various clinical and surgical procedures EnglishLumbosacral Transitional Vertebrae (LSTV), Lumbar vertebra, Sacrum, Sacralisation, Lumbarisation, VariationIntroduction: The Sacrum is a wedge or triangular shaped bone present between the two hip bones. Anatomically, it is formed by the fusion of five vertebrae. Sacrum along with the two hip bones articulates to form the bony pelvis. The base or the upper end of this triangular bone articulates with the fifth lumbar vertebra and the apex or the lower end articulates with the coccyx. It has four pairs of ventral and dorsal sacral foramina that communicate with the sacral canal.1 Like any other region in the human body, congenital anomalies are very common in this region with an incidence ranging from 3.6% to 18%.2 These variations are collectively referred to as Lumbosacral Transitional Vertebrae (LSTV). LSTV include sacralisation and lumbarisation. Sacralisation refers to fusion of the lowest (fifth) lumbar vertebral body to the sacrum and lumbarisation refers to the fusion of the uppermost (first) sacral segment to the lumbar vertebra. In LSTV, the vertebral bodies demonstrate varying morphology, ranging from broadened transverse process to complete fusion.3 Clinically, patients with these variations present with low back pain and lower limb pain. Low back pain associated with an LSTV may arise from the level above the transition or from the anomalous articulation. The association of pain with this congenital anomaly was described by Bertolotti in 1917.4 It is an important clinical entity as the presence of a LSTV may misguide the diagnosis and treatment. Itis thus essential for the clinicians and surgeons to identify the LSTV to avoid an intervention or surgery at an incorrect level.3 Materials and methods An observational study was carried out on 98 adult human dry sacra in the Department of Anatomy of Seth GSMC, Mumbai. Damaged, mutilated and deformed sacra were excluded from the study. The data was collected by naked eye examination. It was compiled, statistically analyzed and compared with other similar studies. Lumbarisation and sacralisation were identified based on the examination of the bodies, transverse process and the number of ventral and dorsal sacral foramina. The number of sacra with lumbarisation and the number of sacralisation of lumbar vertebra was noted. (Fig. 1) Depending on degree of fusion of lumbar and sacral vertebrae, sacralisation of the fifth lumbar vertebra was classified as follows:5 Complete fusion: The fifth lumbar vertebra is completely fused with the sacrum. (Fig. 2) Incomplete fusion: The fifth lumbar vertebra is incompletely fused with the sacrum. Incomplete fusion is of following types: Bilateral sacralisation: (Fig. 3) Unilateral sacralisation: (Fig. 4) Study design: This is a randomized cross sectional study by observations. Descriptive statistics is done by measuring measures of proportions. Observations and results: Of the 98 sacra studied, sacralisation of the fifth lumbar vertebra was seen in eighteen (18) and lumbarisation was seen in eighteen (18) sacra. The sacral hiatus and cornua appeared to be normal in contour in all the sacra studied except for the one sacrum where lumbarisation was seen. (Fig.1) Out of eighteen (18) sacralised bones, 10 bones showedcomplete fusion between fifth lumbarvertebra and first sacral vertebra, remaining 08 bones showed incomplete fusion between fifth lumbar vertebra and first sacral vertebra. (Table 1) Out of 08 incomplete fused bones 04 bones showed bilateral fusion between fifth lumbar vertebra and first sacral vertebra and 04 bones showed unilateral fusion between fifth lumbar vertebra and first sacral vertebra. This unilateral fusion was present in two (02) bones on right side and in two (02) bones on left side. (Table 2) Discussion & Clinical Significance: Sacralisation and lumbarisation are the two major components of LSTV. These variations are affected by gender, developmental factors and race. It has been proved that this anomaly is seen to affect males more than females.6 In the present study we could not study the gender predisposition because of the lack of the available data. It is also proved that sacralisation is more common in occurrence than lumbarisation (2:1).6 In our study, we found the incidence of sacralisation and lumbarisation was equal as out of the 98 sacra studied 18 were sacralised and 18 were lumbarised. This could be probably because the data studied was insufficient to quote the incidence rate. But still, our incidence rate of 18% is closer to the incidence reported by Mitchell7 in Australian aboriginals as 18% and by Bustami F8 in Indians as 16%. Incidence of sacralisation of fifth lumbar vertebra in our study was much higher than incidence reported by Moore & Illinois9 in Americans as 3.6% and by Brailsford10 in Natives of Britain as 8 %. (Table 3) According to Catellvi et al. classification, four types of LSTVs can be identified radiologically. Type I includes unilateral (Ia) or bilateral (Ib) dysplastic transverse process measuring atleast 19 mm in its craniocaudal width. Type II includes incomplete unilateral (IIa) or bilateral (IIB) lumbarisation / sacralisation with an enlarged transverse process that has a diarthrodial joint between itself and the sacrum. Type III indicates unilateral (IIIa) or bilateral (IIIb) lumbarisation / sacralisation with complete osseous fusion of the transverse process to sacrum. Type IV involves unilateral type II transition with a type III on the contralateral side.10 Majority of the studies refer Catellvi’s classification, but since our study was on dried bones we preferred classification given in Cunnighams manual of Practical Anatomy.5 According to it in our study, we found that out of the 18 sacralised vertebrae, 10 bones showed complete fusion between fifth lumbar vertebra and first sacral vertebra, remaining 08 bones showed incomplete fusion between fifth lumbar vertebra and first sacral vertebra. Out of 08 incomplete fused bones 04 bones showed bilateral fusion between fifth lumbar vertebra and first sacral vertebra and 04 bones showed unilateral fusion between fifth lumbar vertebra and first sacral vertebra. This unilateral fusion was present in two (02) bones on right side and in two (02) bones on left side. Embryologically, each vertebra is developed from caudal half of onesclerotome and from the cranial half of succeedingsclerotome. Genetically, Notch and the Wnt (Portmanteau of Int and Wg and stands for Wingless-related integration site) signaling pathways are involved in patterning of vertebral column. Simultaneously wavefront of FGF8 expressionthat moves from the cranial to caudal direction is responsible for patterning of vertebral column. FGF8 expression is lowest in the most cranial, and highest in the most caudal, presomitic mesoderm.11, 12 Changes in above mentioned gene groups may lead to border shifts which finally would lead to various deformities of vertebral column including LSTV. Sacralisation of fifth lumbar vertebra is due to cranial shift and the lumbarisation of the first sacral vertebra is due to the caudal shift.6 Conclusions: Lumbosacral Transitional Vertebrae (LSTV) is a condition comprising of either sacralisation or lumbarisation. Genetic factors play an important role in the embryogenesis of this clinical entity. It is important for the clinicians and surgeons to have knowledge of the existence and incidence of LSTVs while performing various clinical and surgical procedures. Knowledge of sacralisation of fifth lumbar vertebra is important in various therapeutic and diagnostic procedures. Counting of vertebrae from lower end, while doing lumbar puncture or giving spinal anesthesia and epidural anesthesia, may be incorrect in cases of sacralisation of fifth lumbar vertebra. In this condition there is reduced space between L5 and S1 because of which there may be compression of L5 nerve root causing low back pain and sciatic pain. Acknowledgment Authors acknowledge Dr. Lakshmi Rajgopal, Ex-Professor (Additional), Department of Anatomy, Seth GSMC, Mumbai. Dr. Pritha S Bhuiyan, Professor and Head, Dept. of Anatomy, Seth G.SMC, Mumbai. Dean, Seth GSMC & KEMH, Mumbai. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of funding: Not applicable Conflict of interest: NIL Englishhttp://ijcrr.com/abstract.php?article_id=2641http://ijcrr.com/article_html.php?did=2641 Adibatti M and Asha K. Lumbarisation of the First Sacral Vertebra a Rare Form of Lumbosacral Transitional Vertebra. Int. J. Morphol. 2015, 33(1): 48-50. Nikumbh R.D, Wanjari A.N, Nikumbh D.B. Morphological Study of Sacralisation of Fifth Lumbar Vertebra and Its Clinical Relevance. Indian Journal of Anatomy. 2017; 6(2):119-122. Konin G.P and Walz D.M. Lumbosacral Transitional Vertebrae: Classification, Imaging Findings, and Clinical Relevance. American Journal of Neuroradiology. 2010; 31(10):1778-1786. Alonzo F, Cobar A, Cahueque M, Prieto JA. Bertolotti’s Syndrome: an underdiagnosed cause for lower back pain. Journal of Surgical Case Reports. 2018; 10: 1-4. Rachel K. Cunningham’s manual of practical anatomy,16th edition vol. 2, oxford university press, UK;2017:103. Deepa TK, John MK. A Study of Lumbarisation of First Sacral Vertebra Among the South Indians. International Journal of Medical Research and Health Sciences. 2014; 3(1): 1-4. Mitchell GA. The significance of lumbosacral transitional vertebrae. British Journal of Surgery. 1936 Jul;24 (93):147-58. Bustami F. The anatomical features and functional significance of lumbar transitional vertebra. Jordan Med J. 1989;23:49-59. Moore BH. Sacralisation of the fifth lumbar vertebra. JBJS. 1925 Apr 1;7 (2):271-278. Ravikanth R. Majumdar P. Bertolotti’s syndrome in low-backache population: Classification and imaging findings. Tzu Chi Medical Journal. 2019; 31(2):90-95. Brailsford JF. Deformities of the lumbosacral region of the spine. British Journal of Surgery. 1929 Apr;16(64):562-627. Moore KL, Persaud TV, Torchia MG. Before we are born: essentials of embryology and birth defects. Elsevier Health Sciences; 2016; 348-356.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411122EnglishN2019November29HealthcarePort Site Incisional Hernia Incidence in Laparoscopic Cholecystectomy Following Non-Fascial Sheath Closure: Experience from a Busy Centre English0508Abdul Maajed JehangeerEnglish Rohi WaniEnglish Wasim LoneEnglish Syed Aga NadeemEnglishAim: To study the incidence of post-operative port site hernias in patients undergoing laparoscopic cholecystectomy in our centre. Methodology: This study was carried out on patients undergoing laparoscopic cholecystectomy with non-closure of port-site fascial sheath who attended for follow-up in our outpatient clinic up to one year from the date of surgery. Results: None of the patients in our study came up with any indication of port site hernia. Conclusion: Port-site closure of fascial sheath ≤10 mm may not be necessary in laparoscopic cholecystectomy to prevent port-site incisional hernias. EnglishLaparoscopy, Port site, Hernia, TrocarIntroduction Laparoscopic cholecystectomy is one of the most frequently performed procedures in our centre. The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased post-operative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits1. Larger port size and increasing the number of ports needed to perform more complex laparoscopic procedures is likely to increase the incidence of port site hernias. These hernias tend to develop more frequently at umbilical and midline port sites due to the thinness of the umbilical skin and weakness in the linea alba2. Incisional hernia is a rare complication that can also occur after laparoscopic surgeries. The incidence of port site hernia after laparoscopic surgery lies between 0.38% to 5.4% with overall incidence of 1.73. Port site hernia can cause a whole range of presentations ranging from being asymptomatic to serious complication like strangulated bowel hernia. The interval between operation and diagnosis of port site hernia varies between studies and depends on follow-up regimes. Where data are available, time to diagnosis ranged from 5 days to 3 years with an average of 9.2 months4. Bowel involvement can present as bowel incarceration, bowel obstruction or bowel evisceration. Again, these presentations can occur as early as within 2 days of surgery to weeks after surgery5. Material and Methods: This is a prospective study of 324 patients, all of whom underwent laparoscopic cholecystectomy in our department from 1st September 2017 till 31st August 2018. Patients with past history of lower segment caesarean section (LSCS- both lower mid-line and pfannenstiel incisions), hypertensive and/or hypothyroid patients and elderly upto 70 years of age were included. Patients with mild to moderate chronic obstructive pulmonary disease (COPD) and children between 8-12 years of age were also included. Patients with diabetes, those with previous upper mid-line or upper paramedian incisions and obese patients were excluded. In our series, at the time of laparoscopic cholecystectomy, umbilical port for camera was inserted by 10 mm trocar both by the open and closed technique. We used two 10 mm ports for the umbilical and epigastric region. The remaining two lateral ports were 5mm each. In all our patients, fascia was not closed, and only subcuticular suturing was done in all ports. A suction drain was used in all patients during procedure and was removed on post op day 1 before the patient was discharged. All relevant data were collected in a proforma mentioning age, sex, associated co-morbidities, ASA score, per operative and postoperative complications and pain measurement through numeric rating scale. Patients were followed up in our clinic for regular antiseptic dressings on alternate days following surgery till sutures were removed, usually on the 9th or 10th post-operative day. Afterwards, all patients were followed up one month after surgery and then after three months and six months. Finally, all patients were asked to appear for follow-up consultation one-year post surgery. Results: All patients in our series underwent laparoscopic cholecystectomy. Out of a total of 324 patients 249 were female (77%) and 75 were male (23%). 146 patients had co-morbidities like hypertension, hypothyroidism and COPD (45%). All of them were ASA I or ASA II. There were four children between the ages of 8-12 years in our study (Table 1). Per/post-operative complications were the following: Three cases were converted to open cholecystectomy due to difficult dissection. Out of these, one patient needed blood transfusion due to injury to the middle hepatic vein during surgery. One patient needed external biliary drainage by T-tube placement. One patient needed epigastric port site fascial extension for retrieval of a difficult gallbladder. Her fascial sheath was closed by 2 0 vicryl. Two patients had subcutaneous bruising following open port placement which subsided before suture removal. One patient had prolonged bile leak which subsided three weeks following surgery. Four patients had port site hypertrophic scars appreciable between 3-6 months post-surgery. One patient had prolonged epigastric port site infection which lasted for 3 weeks but resolved with oral antibiotics. After suture removal, follow-up was at one-month post-surgery in which 292 patients attended (90%). The second follow-up was scheduled three months post-surgery and 266 patients complied (82%). The third follow-up was at six months post-procedure and 201 patients attended (62%). Finally, 165 patients came to our final follow-up scheduled one-year post surgery (51%). We found no incidence of positive cough impulse or herniation in all our patients who attended clinic for follow-up upto a period of one-year post procedure. Discussion: Laparoscopic cholecystectomy has become the “gold standard” for surgical management of uncomplicated gallstone disease as it offers a myriad of advantages resulting in rapid post-operative recovery. However, the adoption of this technique has resulted in the emergence of new, specific operative complications. The occurrence of an incisional hernia at the site of entry of a port is a serious complication in laparoscopy because most port site hernias require further surgery6. Our study shows that 10 mm ports created for laparoscopic cholecystectomy without closure of the fascial sheath are not at risk for port site hernia formation up-to a period of one-yearpost surgery. More studies will be needed to look for this complication beyond the post-procedure period of one year. Coda et al4 noted that the onset of port site hernia occurs later rather than immediately after surgery and might elude a surgeon in many surveys unless an extended follow-up procedure has been established. As such, there is possibility of under reporting in the literature especially for studies reporting on non-fascial sheath closure in ports up to 10 mm diameter. Data from literature encourages fascial closure of ports > 10 mm for other surgeries like laparoscopic colon-rectal and bariatric procedures or for those laparoscopic cholecystectomy patients in whom port-sites have been extended for retrieval of a difficult gallbladder. It points towards fascial closure in all such cases as incidence of port site hernia increases with the size of the trocar3,7although there are other risk factors involved like wound infection, diabetes mellitus, obesity, connective tissue disorders operating times, port-site manipulations among others. Some authors like Duron et al8have doubted that any effects of fascial closure are related to a trocar site hernia. They commented that although it has been stated that fascia closure of trocar holes, which is sometimes difficult, might preclude or decrease the incidence of obstructions, his study as well as that by Tonouchi et al9has reported that adhesions or incarcerations, whether median or lateral can still occur after a fascial closure. Similarly, Liu and McFadden10conclude that the use of non-bladed laparoscopic trocars preclude the need for fascia closure even in ports up to 12 mm in diameter. Singal et al2arrive at a similar conclusion and state that non-obese patients undergoing their first laparoscopic surgery with 10mm port created by trocar may not need fascia closure. However, not closing the fascial defect is thought to be implicated in port site hernia formation by many authors6,9,11 although closing the fascia is certainly not preventive. This is demonstrated by the fact that in some studies, hernias were identified despite fascial closure in all cases8,9,11,12. Conclusion: Port site hernia is a rare complication of laparoscopic surgery but assumes significance due to the associated morbidity and need for a revision procedure which may preclude benefits offered by the primary procedure. While there is consensus in the literature about closure of fascia in larger, 12mm ports there is, however conflict about fascial closure in lesser ≤ 10 mm ports with some authors deeming it unnecessary while others advocating proper fascial closure before subcuticular suturing. Our prospective study has followed up patients who have had no fascial closure of any of their port sites. Also, after reviewing literature we note that this condition may be overlooked due to the short follow-up of patients after surgery, as such we carried out this study for a longer, one-year post-operative time period. In conclusion, we acknowledge that even though there is conflict in literature regarding fascial closure of ≤ 10mm ports however, our data suggests that patients with our selection criteria undergoing laparoscopic cholecystectomy with ≤ 10mm ports may not need fascial closure. Acknowledgement Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors /publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of Funding: Nil. Conflict of interest: Nil. Informed consent: The corresponding author can confirm that informed consent was obtained from every patient prior to procedure and the benefits and risks of the procedure were explained prior to surgery by the operating surgeon. Englishhttp://ijcrr.com/abstract.php?article_id=2642http://ijcrr.com/article_html.php?did=26421. Mandrioli M, Inaba K, Piccinni A, Biscardi A, Sartelli M, Agresta F, et al. World J Gastroenterol. 2016 Jan 14; 22(2): 668-680. 2.Singal R, Zaman M, Mittal A, Singal S, Sandhu K, Mittal A. No need of fascia closure to reduce trocar site hernia rate in laparoscopic surgery: A prospective study of 200 non-obese patients. Gastroenterology Res. 2016 Oct; 9 (4-5): 70-73. 3.Bunting DM. Port-site hernia following laparoscopic cholecystectomy. JSLS. 2010 Oct-Dec; 14 (4): 490-7. 4. Coda A, Bossotti M, Ferri F, Mattio R, Ramellini G, Poma A, et al. Incisional hernia and fascial defect following laparoscopic surgery. Surg Laparosc Endosc Percutan Tech. 2000 Feb; 10(1): 34-8. 5.Sharma R, Mehta D, Goyal M, Gupta S. The earliest presenting umbilical port site hernia following laparoscopic cholecystectomy: A case report. J Clin Diagn Res. 2016 Jul; 10(7): PD18-PD19. 6.Callery MP, Strasberg SM, Soper NJ. Complications of laparoscopic general surgery. Gastrointest Endosc Clin N Am 1996 Apr; 6(2):423-444. 7.Kadar N,Reich H, Liu CY, Manko GF, Gimpelson R. Incisional hernias after major gynaecologic procedures. AMJ Obstet Gynecol 1993 May; 168(5):1493-1495. 8.Duron JJ, Hay JM, Msika S, Gaschard D, et al. Prevalence and mechanisms of small intestinal obstruction following laparoscopic abdominal surgery: a retrospective multicenter study. Arch Surg 2000 Feb; 135(2):208-212. 9. Tonouchi H, Ohmori Y, Kobayashi M, Kusunoki M.  Trocar site hernia. Arch Surg. 2004 Nov; 139(11): 1248-1256. 10. Liu CD, McFadden DW. Laparoscopic port sites do not require fascial closure when nonbladed trocars are used.  Am Surg. 2000 Sep; 66(9): 853-854. 11.Nassar AH, Ashkar KA, Rashed AA, Abdulmoneum MG. Laparoscopic cholecystectomy and the umbilicus. Br J Surg. 1997 May; 84(5): 630-633. 12.Azurin DJ, Go LS, Arroyo LR, Kirkland ML. Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia.  Am Surg 1995 Aug; 61 (8):718-20.