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INTRODUCTION: Minimally invasive oesophagectomy is one of the options in the armamentarium of a modern surgeon when faced with treating oesophageal cancer. Trinidad and Tobago has successfully treated a patient using this method. This case report adds to the rich surgical history in the Caribbean. CASE PRESENTATION: Our patient presented with progressive dysphagia, and after being worked up was diagnosed with oesophageal cancer. He underwent neoadjuvant chemotherapy and had a minimally invasive McKeown oesophagectomy done by a fellowship trained, advanced laparoscopic oesophageal and gastric surgeon. CONCLUSION: The patient had an uneventful recovery and was tumor free with excellent quality of life at 4 years, showing that the Caribbean is keeping up with the rest of the surgical world.

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We report a rare case of a mature cystic teratoma found in the retroperitoneum of a 28-year-old woman with vague symptomatology. We review the radiologic and pathologic features of this rare lesion.

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BACKGROUND: The external branch of the Superior Laryngeal nerve (EBSLN) is at high risk of injury in surgery for large multinodular goitre (MNG) since the upper pole is high in the neck, well cephalad to the EBSLN. We present a technique of drawing the lobe caudally by retrograde thyroidectomy in order to minimize nerve injury. DESIGN & METHOD: All patients having surgery for benign MNG were included. Cases with previous thyroid surgery, malignant and toxic disease were excluded. The thyroid lobe was mobilized from its inferior aspect and capsular dissection performed cephalad with bipolar or ligasure cautery, lifting the gland off the trachea while separating it from the parathyroids and branches of the inferior thyroid vessels. The ligament of Berry is divided and the entire lobe freed, attached only by the superior pedicle which is drawn caudally well below the EBSLN prior to ligation. Patients were followed for voice change at 24 hours, 7 days and 3 months. RESULTS: Ninety-one consecutive lobectomies were done in 60 patients, 31 bilateral. Forty-four (73%) patients had voice change at 24h, 10 (11%) at 7days and 1 at 3 months. The patient with persistent voice change complained of change in tone but not volume; vocal cords were normal on indirect laryngoscopy. CONCLUSION: Retrograde thyroidectomy is recommended for large MNG where the EBSLN lies well below the upper pole; it minimizes risk to the nerve.

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INTRODUCTION: Signs in radiology are usually based on many common objects or patterns that are easily recognizable in everyday life. The objective behind this association is to aid in the understanding and diagnosis of the disease process. These signs can be seen in different imaging modalities such as plain radiograph and computed tomography. PRESENTATION OF CASE: 4 consecutive cases of sigmoid volvulus presented at our tertiary hospital between January 2016 and June 2017. 2 of these cases were managed surgically and others were managed conservatively. The CT scan and abdominal radiographs in these patients were reviewed with consultant radiologist, which bear resemblance to the percussion instrument known as the steel pan. DISCUSSION: The literature has described few radiological signs of sigmoid volvulus in the past. In the following case series, we would like to introduce the "Steel pan Sign", a novel radiological pattern which bears a close resemblance to the percussion instrument known as the steel pan. The Steel pan sign is easier to recognize on CT scan of the abdomen. However, in some cases it can be seen on plain X-Rays. CONCLUSION: The appearance of sigmoid volvulus on CT scans as well as on plain abdominal X-rays bears a significant resemblance to the pattern observed on the face of the Trinidadian steel pan, the recognition of which can aid in the diagnosis of this disease.

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OBJECTIVE: Several radiological studies have suggested that the base of the Appendix often does not correspond with Mc Burney's point. The aim of our study is to assess the value of using CT localization of the appendicocaecal junction to guide placement of the appendicectomy incision. DESIGN & METHOD: 32 consecutive patients, booked for open appendicectomy were prospectively included in this study. Coronal and axial CT scans with IV contrast were studied to assess site of the appendicocaecal junction. This information was used to guide placement of the incision. RESULTS: 28 out of 32 patients studied, the appendicocaecal junctions were accurately identified. It was noted that the final incision sites were cephalad to Mc Burney's point in 8, at the point in 3 and caudal in 17. In 1 patient, it was necessary to extend the incision medially by 2cm to retrieve the distal Appendix which had been detached through the site of rupture. CONCLUSION: Mc Burney's point often does not correspond to the base of the appendix. We propose that using CT imaging to guide the appendicectomy incision is safe, facilitates locating the Appendix at surgery, minimizes incision size and decreases the need to extend it.

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Minimally invasive surgery is rapidly expanding its role in almost all of the surgical sub-specialties. There is also a growing demand of this service as patients became more and more concerned about cosmesis in addition to their original surgery. Although its role in thyroid surgery has already been proven earlier; but it is not yet accepted as a routine approach amongst many thyroid surgeons. There is no reported case of laparoscopic thyroid surgery in the English literature from the Caribbean. We are reporting our first clinical experience in performing laparoscopic thyroid surgery in the Caribbean with a successful outcome.

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Bariatric surgery is a well-recognized modality of management of obesity. In addition to obesity, it effectively controls diabetes mellitus, and hypertension. It has been recommended that bariatric surgery should be done in "designated centers" of excellence where there is a high volume of case turnover. Caribbean nations are not spared from the global spread of the obesity epidemic; however, not many patients get the benefits of bariatric surgery. This study aimed to establish that bariatric surgery could be safely and efficiently undertaken in a low-volume center outside the "designated centers" with comparable patient outcomes even in a third world setting. Though "patient numbers" generally imply better outcome, in an environment where these numbers cannot be achieved, patients should not be denied the access to surgery once good outcomes are achieved.

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OBJECTIVES: To determine if there is a beneficial effect of bariatric surgery in the management of Diabetes Mellitus in obese patients in a Caribbean setting. METHODS: A retrospective review of charts of all obese patients with Type-2 Diabetes Mellitus (DM) who had undergone Laparoscopic Roux en Y gastric bypass (LRYGBP) over a 4 year period was undertaken and clinical data recorded. A questionnaire was prospectively administered via telephone to determine the quality of life. RESULTS: Of 146 patients who underwent LRYGBP, 40 were found to have clinically significant DM. Patients of age < 50 years and females had a higher preponderance of DM. Patient body weight decreased significantly from a pre-operative131.2 ± 21.6 [Mean ± Standard Deviation (SD)] to 99.4 ± 16.6 after surgery (p < 0.0001). There was also a significant reduction of BMI from 47.0 ± 7.9 to 34.7 ± 5.8 (p < 0.0001). There was complete resolution of clinically significant DM in 85% of patients, while in 15% there was a significant reduction in the dosage of anti-diabetic medications. Perioperative complications were minimal and there was no mortality. 96% of the patients reported a drastic improvement in their quality of life. CONCLUSIONS: Bariatric surgery for obese diabetic patients resulted in complete resolution, improved diabetes control and overall improvement in the quality of life. Due to better outcomes, the surgery can safely be recommended in the Caribbean multiethnic setting where there is a high prevalence of obesity and Diabetes Mellitus.

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BACKGROUND: This study reports the experience of performing minilaparotomy cholecystectomy (MC) and assesses the peri-operative outcome of this surgery in the setting of a developing country. METHODS: Data of all patients who underwent minilaparotomy cholecystectomy by a single surgical unit were collected and reviewed. These included demographics, surgical technique used, peri-operative complications and length of hospital stay. Descriptive analyses were done. RESULTS: 476 patients who underwent elective minilaparotomy cholecystectomy in a single surgical unit over a 15 year period were studied. Of these, 84.8% were female. The mean age was 47 years. The most common indication for surgery was symptomatic cholelithiasis with chronic cholecystitis (66%). Mean length of the surgical incision was 4.8 cm and mean operating time was 31 min. Rate of conversion to conventional open cholecystectomy was 4%. Median hospital length of stay was 22 hours. Minor wound infection was the only surgical post-operative complication recorded in 7 patients. Nine patients in the converted group and 3 in the minilaparotomy cholecystectomy group had significant vomiting. There was no mortality. CONCLUSION: The study reinforces the view that minilaparotomy cholecystectomy can be safely and effectively performed with minimal peri-operative complications, and is ideal for developing country settings.

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INTRODUCTION: Laparoscopic cholecystectomy has become the gold standard in the definitive treatment of symptomatic gall bladder disease. It boasts superior morbidity and mortality and lower complication rates than open approaches. AIM: This study outlines the experiences associated with 619 laparoscopic cholecystectomies performed in Trinidad. METHODS: The records of 619 consecutive patients who underwent the procedure were reviewed. All cases were either performed or supervised by the senior author. The population comprised 511 females and 108 males. The average age was 48.5 years. RESULTS: The commonest indications for surgery were symptomatic cholelithiasis (380 cases) and acute cholecystitis (111 cases). The mean operating time was 34 minutes. The mean length of stay on the ward was 17.45 hours. Mortality was zero. Only 4 cases were converted to open procedures. The commonest postoperative complication was wound-infection. CONCLUSION: In summary, this study demonstrates that laparoscopic cholecystectomy can be performed safely in a Third World setting with results comparable to those internationally.

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