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Modified Grahams' omentopexy in acute perforation of first part of duodenum; A tertiary level experience in South India
Mani Charan Satapathy, Dharitri Dash, Charan Panda
September-December 2013, 1(2):33-36
Background: Despite the rarity (5%) of acute perforation of first part of duodenum (D1) and the advancement in surgical, anesthetic and ancillary facilities, still there are life-threatening dimensions. A variety of surgical techniques evolved over time, but none is without drawbacks. Thus, the need arise for surgeon friendly, suitable surgical technique with better outcome. By this retrospective analysis, we aimed to compare between the Graham's omentopexy (GO) and modified Grahams' omentopexy (MGO) to find the suitable method of managing this acute catastrophe. Materials and Methods: This is a retrospective study design for the period June 2009-May 2012. All the patients with only D1 perforation admitted and treated at our institution were included. Patients with perforation other than D1 site, multiple perforations, poly-trauma and associated co-morbidity were excluded. Patients were randomly subjected for either GO or MGO. Post-operatively, all were followed-up for 3 months at out-patients department. Results: Out of the 122 patients, 112 were males and 10 were females with M:F ratio 11.2:1. MGO group had comparatively less chances of biliary fistula, burst abdomen and mortality, but, more chances of wound infections with longer hospital stay and better outcome at 3 month follow-up in contrast to GO group. The overall mortality rate was 4.09%. Conclusion: MGO is surgically suitable technique than GO for patients with D1 perforation with better post-surgical outcome.
  13,446 2,885 -
Pancreatic calculi: A case report and review of literature
Mervyn Correia, Dilip Amonkar, Pandarinath Audi, Lalit Banswal, Dattaprasad Samant
May-August 2013, 1(1):14-18
Pancreatic ductal calculi are rare and most often associated with chronic pancreatitis. Radiological features of chronic pancreatitis are readily evident in the presence of these calculi. We present the case of a 66-year old woman who presented to our emergency department with severe upper abdominal pain and vomiting. She had been having repeated attacks of similar but milder upper abdominal pain, for which she would visit her general practitioner, and be treated for gastritis. This time however the pain was excruciating and accompanied by vomiting. She was a known diabetic for which she was receiving treatment. Both abdominal ultrasound and contrast enhanced computerized tomography scan of the abdomen revealed an atrophic pancreas, and a dilated pancreatic duct filled with an enormous load of calculi. Laparotomy and the Frey procedure which consists of coring out of the pancreatic head and longitudinal pancreaticojejunostomy were done.
  6,249 373 -
How long to stay in hospital: Stapled versus open hemorrhoidectomy?
Robinson George, S Vivek, K Suprej
September-December 2016, 4(3):108-112
Background: Haemorrhoids is a common condition seen in general surgery practice. Treatment includes many methods ranging from rubber band ligation, infrared photocoagulation, sclerotherapy to stapler hemorrhoidectomy. Our study is done to evaluate the efficacy of both the procedures in a rural setting. Objectives of the study was to study the efficacy of two surgical methods of treatment of hemorrhoids, in terms of (1) operation time; (2) post-operative pain; (3) hospital stay; (4) return to normal activity and return to work. Methods: A comparative study was done between open and stapling methods for the treatment of symptomatic hemorrhoids in Al Azhar Medical College, Thodupuzha, India. Results: There was major statistically significant difference seen among different parameters between the two procedures of haemorrhoidectomy, open versus stapler procedure for prolapsing hemorrhoids (PPH) as evident from the p value. Conclusions: In our study there is a definite difference noted between two surgical methods in terms of hospital stay and return to work. As far as satisfaction of patient is considered in both the groups satisfaction is similar except for the cost of surgery which was the only cause of dissatisfaction.
  6,292 216 1
Effectiveness of teaching operation notes to surgical residents
Adel Johari, Nisar Haider Zaidi, Rakan F Bokhari, Abdulmalik Altaf
May-August 2013, 1(1):8-12
Objective: The effectiveness of teaching operative notes in surgical resident training program at King Abdulaziz University Hospital, Jeddah was studied. Materials and Methods: This was a prospective study done at Department of Surgery, King Abdulaziz University Hospital to evaluate the effect of teaching the surgical residents how to write operative notes. Twenty-one residents were asked to write operative notes of appendicectomy. Their operative notes were evaluated for medical record number (MRN), date and time of the operation, preoperative and postoperative diagnosis, names of surgeon, assistant, and anesthetist, name of the operation, incision, findings, closure, hemostasis, estimated blood loss, whether histopathology specimen was sent to the pathology department or not, postoperative orders, whether the patient went to the recovery room in a satisfactory condition or not, and signature of the operating surgeon. Two months of effective teaching of operative notes was given to them. They were again asked to write operative notes of appendicectomy. Notes were collected and studied and comparison was made with previous notes. Legibility of the operative notes was also studied. Results: In our study, we found that there was improvement of 29-39.9% in recording MRN and the date of operation by our residents after they were taught the art of writing operation notes. There was marginal improvement (4.7%) in stating whether it was elective or emergency operation. Documentation of surgeon's name, assistant's name, and anesthetist's name improved to 12.4-32.8%. Writing the name of the procedure and pre- and postoperative diagnosis improved to 31%. Details of the procedure such as position of patient and incision improved marginally to 5.9%. Mentioning the findings and description of the procedure showed no improvement, as it was 100% before teaching. Documenting hemostasis, estimated blood loss, and transfer to recovery room improved to 58.4%; however, there was no improvement in writing post-op orders and histopathology sent to the pathology department.Improvement of signature was only 9%. Conclusion: Effective teaching of how to write operative notes helps in the training of surgical residents.
  4,999 288 1
Role of laparoscopy in nonspecific abdominal pain
Mir Mujtaba Ahmad, Hanief Mohamed Dar, Malik Waseem, Hilal wani, Irfan Nazir, Asif Jeelani
September-December 2014, 2(3):71-74
Objective: The aim was to determine the role of laparoscopy in the management of nonspecific abdominal pain (NSAP). Background: NSAP constitutes a good proportion of surgical admissions, both in emergency and elective settings with considerable diagnostic dilemma. Patients and Methods: All patients who presented with pain abdomen with no immediate cause and were labeled as NSAP after clinical assessment and investigations and following that underwent laparoscopy to make a definitive diagnosis were included in the study. Results: A total of 88 patients were included in the study. There were 59 (67%) females and 29 (33%) males. The mean age was 26 years (range 18-58 year). The common mode of admission was out-patient department 69 (78.4%) patients. Twenty-five (28.4%) patients presented with NSAP in lower abdomen, followed by 21 (23.8%) with right lower abdominal pain and 19 (21.5%) with central pain radiating to right lower abdomen. Diagnosis was established in 75 (85.2%) patients. In 13 (14.7%) no pathology was found. The most common diagnosis was pathology of appendix in 29 (32.9%) patients followed by pelvic pathology in 18 (20.4%) and abdominal tuberculosis in 14 (15.9%) patients. Most 37 (42%) of the patients stayed in the hospital for 24 h. There was no readmission and no major postoperative complications. Conclusions: Laparoscopy has a definitive role in diagnostic dilemma associated with NSAP. It has at the same time role in treatment of the condition; hence laparoscopy has a diagnostic and a therapeutic implication in management of NSAP.
  2,256 2,146 1
Aphallia: Case report and review of the literature
Amarendra Kumar, Nameer Faiz
January-April 2015, 3(1):13-16
Aphallia or absence of the penis is a very rare congenital anomaly with an estimated incidence of 1 in 10,000,000 births. A total of about 80 cases have been documented so far. We present a case of 1-day neonate who was born preterm at 30 weeks by normal vaginal delivery with a birth weight of 1.9 kg. The neonate's phallus was absent, the scrotum was normal with two normally descended testes with palpable vas deferens. Urethral meatus could not be located anywhere in the scrotum or over the pubis. Meconium was mixed with urine which was due to a urethrorectal fistula. Urethral opening was catheterized with 5 no. infant feeding tube. The neonate was in respiratory distress with tachypnea, tachycardia, central cyanosis, and bilateral coarse crepitations on auscultation. The patient was referred to the Neonatal Intensive Care Unit where the neonate was intubated and kept on a ventilator for neonatal respiratory distress syndrome.
  3,835 279 -
Bile duct injuries following laparoscopic cholecystectomy and repair involving lowering of the hilar plate
Bilal O Al-Jiffry, Yassir Al Nemary, Hashem Niyaz, Hesham Elmakhzangy, Mohammed Hatem
May-August 2013, 1(1):1-6
Background: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic cholelithiasis, but is associated with a higher incidence of bile duct injuries than the open approach. We evaluated a multidisciplinary approach for managing these injuries after LC. Materials and Methods: From April 2006 to August 2011, all patients who developed bile duct injury after LC and were treated by the hepatobiliary team of Al-Hada Armed Forces Hospital, Taif, Saudi Arabia were included in our study. If an injury was suspected intraoperatively, intraoperative cholangiography was performed; thereafter, if the injury was confirmed, immediate laparotomy and primary repair or hepaticojejunostomy (H-J) involving lowering of the hilar plate were performed. Injuries occurring postoperatively were treated by endoscopic cholangiopancreatography (ERCP) to diagnose the type of Strasberg injury. Strasberg type A injuries were managed endoscopically, and more advanced cases underwent open surgery. Results: Of 30 females and 18 males (mean age, 45 years; range, 18-90 years), 6 cases of bile duct injuries were discovered intraoperatively. Of these, two were classified as type C and underwent primary repair with internal stenting. The other four were classified as type E and were treated by Roux-en-Y H-J reconstruction. Forty-two cases of bile duct injuries presented postoperatively, including 18 Strasberg type A and 24 Strasberg type E injuries. Type A injuries were treated with ERCP and stenting, and six with endoscopic removal of a retained stone. Of the 28 patients who underwent H-J, 20 underwent the technique involving lowering of the hilar plate. Of these, three subsequently developed anastomotic strictures and were treated with percutaneous transhepatic balloon dilatation. There were no mortalities. The mean follow-up was for 36 months. Conclusion: Early referral to a specialized surgeon and a multidisciplinary approach help manage bile duct injury after LC in all patients with an acceptable low stricture rate.
  3,585 323 -
Early versus delayed presentation of posterior urethral valves in children: Consequences and outcome of vesico-ureteric reflux
Amit Sharma, Irfan Shaikh, Radheshyam Chaudhari, Mukund Andankar, Hemant Pathak
September-December 2015, 3(3):61-64
Introduction: Delayed presentation of patients with posterior urethral valve (PUV) is common in our country and is usually associated with complications and morbidities. Objective: To determine the pattern of presentation of PUVs and its complications and outcomes in these patients with respect to decrease or resolution of vesico-ureteric reflux (VUR) and/or requirement of additional operative procedures. Materials and Methods: A retrospective study was conducted, and 30 children of PUV were analyzed with respect to the pattern of presentation, duration of symptoms, age at primary fulguration, grade of VUR and its outcome. Results: Patients with early presentation were diagnosed early, had their PUV fulgurated early and had lesser grades and better resolution of their VUR and good outcome. The reverse was seen in those patients who presented late and already had some form of renal impairment such as higher and bilateral grades of VUR and higher serum creatinine levels. Some of them also required additional procedures which added to their morbidity. Discussion: Delayed presentation of PUV is common in our country and is associated with an increased incidence and a higher grade of VUR which does not decrease or resolve on follow-up and usually requires additional operative interventions adding to the morbidity of both the parents and the child. On the other hand, early presentation leads to early diagnosis and early relief of obstruction and is associated with lesser VUR, which resolves over time. Conclusion: With early presentation, diagnosis and treatment, the outcome of patients with PUVs is expected to improve. Efforts at improving awareness and early diagnosis and referral among the health team should be encouraged.
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Pneumatic reduction of intussusception in children
Aditya Pratap Singh, Ramesh Tanger, Vinay Mathur, Arun Kumar Gupta
January-April 2017, 5(1):21-25
Context and Aims: Pneumatic reduction has a higher success rate and lower incidence of complications compared to barium enema and hydrostatic reductions. What is deterrent to its common use is the cumbersome technique. Our technique is simple that can be used in any hospital with locally available facilities. Settings and Design: This was a prospective study. Subjects and Methods: A total of 25 children were enrolled in the study between September 2015 and June 2016 at our institute. Patients were given air enema under US guidance using locally assembled equipment. The intraluminal pressure was monitored with a pressure gauge and was not permitted to go above 100 mmHg. A total of three attempts of 3 min each were allowed. Statistical Analysis Used: We just used simple statistic to calculate average. Results: There were 17 males and 8 females. The average age of the patients was 8.5 months. Twenty-two (88%) of the cases were reduced successfully while 3 (12%) failed to reduce. A majority of those that did not reduced had symptoms for at least 4 days. No bowel perforation occurred in our study. All cases of the intussusception have length <5 cm were reduced with pneumatic reduction in our study. Conclusions: The technique described is easy to assemble, safe, and effective. We recommend it for regular use in pneumatic reduction of intussusception, especially in the center have limited resources.
  3,465 230 -
Does wound pH modulation with 3% citric acid solution dressing help in wound healing: A pilot study
Vinod Prabhu, Sadanand Prasadi, Vishrabdha Pawar, Aslam Shivani, Alka Gore
May-August 2014, 2(2):38-46
Objectives: An endeavor to look for cost effective method for dressing wounds to minimize loss of working hours. Three percent citric acid solution (CA) was used for dressing acute lower limb ulcers with the object of pH modulation of wounds at an early stage and to evaluate its effects on wound healing. This solution was compared with Edinburgh University solution of lime (Eusol) in a randomized double-blinded study. Appearance of healthy granulation was the end point of the study. Materials and Methods: An unicentric randomized double blinded study with a parallel design was used to compare patients treated with 3% CA and Eusol solutions, respectively. The results were analyzed using Chi-square and P value using Microsoft Excel and SPSS 22. Patients having fever, altered consciousness, high initial random blood sugar >350 mg%, positive urinary ketones, hypoproteinemia, signs of septicemia and vascular diseases were excluded. Results: Twenty patients were known diabetic out of which 11 were in the CA group, and the rest were in the Eusol group. It was observed that the average total stay in diabetic patients was 16.36 days in CA group and 31 days in Eusol group whereas it was 15.78 and 24.75 days respectively in the nondiabetic group. The ulcer granulation interval showed that the mean stay in CA group was 10.56 days while it was 20.04 days in the Eusol group. The cost of stay was less in CA group. Conclusions: It is concluded that 3% CA solution forms a good alternative for wound dressings that acts by modulating the wound pH to acidic levels thereby contributing to wound healing by increased fibroblast proliferation and probably increasing local oxygen concentration and reducing microbial growth and virulence.
  3,342 295 -
Use of Acute Physiology and Chronic Health Evaluation II score to grade the severity and outcome in patients of typhoid ileal perforation peritonitis
Javid Iqbal, Rajesh Kumar Meena, Mahander Pall, NS Shakhawat
September-December 2016, 4(3):99-103
Background: Typhoid ileal perforation peritonitis is a potentially life-threatening surgical emergency in developing nations. The severity assessment of a disease condition is useful to prioritize treatment and to reduce morbidity and mortality. Aims: The aim of this study was to use Acute Physiology and Chronic Health Evaluation (APACHE) II score to grade the severity and outcome in patients of typhoid ileal perforation peritonitis. Materials and Methods: A prospective analysis of data was done, which was collected over a period of 3 years for 100 cases of secondary peritonitis following typhoid ileal perforations, irrespective of age, sex, and duration of illness. APACHE II score was used to grade the severity and outcome in these patients. Results: Out of 100 patients included in this study, 87 were male and 13 were females. Age ranges between 14 and 65 years, maximum number of patients were in 2 nd and 3 rd decade of life. History of fever, abdominal pain, and abdominal distention were present in all cases. After onset of fever perforation occurred in 65% patients in 1 st week, there was an increase in mortality with increase in APACHE II score, age >50 years was associated with more mortality. The mean Intensive Care Unit stay in this study was 4.33 days, 5.81 days for survivors, and 3.47 days for nonsurvivors. Mortality in our study was 22%. Conclusion: APACHE II score is an easy and objective tool to grade severity of acute peritonitis and can be used for assessment of outcome. According to this study, patients with higher APACHE II score had highest rate of mortality and vice versa.
  1,251 2,226 -
Preventive effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries
Mir Mujtaba Ahmad, Hilal A Wani, Asif Jeelani, Sajad Thakur, Malik Waseem, Irfan Nazir
May-August 2014, 2(2):33-37
Objective: The aim was to study the prophylactic effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries. Background: Acute urinary retention (AUR) after anorectal surgeries is essentially a type of postoperative urinary retention (POUR). It is the most common complication of the procedure. Use of tamsulosin, a super selective alpha 1a adrenergic blocker has been found to reduce the risk of POUR. Patients and Methods: Patients who underwent anorectal surgeries for benign anorectal conditions were included in this study. Patients were randomly assigned into two groups. In one, group (cases), patients were given 0.4 mg of oral tamsulosin only 6 h preoperative and 6-8 h postoperatively. Inability/difficulty to pass urine, which necessitated catheterization after following patient for 24 h was labeled as POUR. Results: A total of 626 patients who underwent surgery for benign anorectal condition were included in the study and grouped into two groups with 313 patients in each group, control and case group. In the control group, 56 patients (17.9%) had inability to pass urine and required catheterization and in the case group, only eight patients (2.5%) needed catheterization following POUR. The difference in the requirement of catheterization following POUR was statistically significant (P = 0.04). Hemorrhoidectomy was the most common anorectal surgery associated with POUR. Conclusion: The use of tamsulosin in preoperative and postoperative period has been found effective to reduce the incidence of POUR following surgeries for benign anorectal pathologies.
  3,047 286 -
Perforated solitary giant true jejunal diverticulum
AF Salama, F Belgrami, ME Abd Ellatif
May-August 2013, 1(1):20-22
Jejunal diverticula are rare and usually asymptomatic. However, they may cause chronic non-specific symptoms or rarely lead to an acute presentation. Here, we report a rare case of a child presenting with a perforated congenital jejunal diverticulum. We report a case of 10-year-old female who presented with severe acute abdominal pain, repeated vomiting, hypotension, and tachycardia of 1 day duration. Chest X-ray showed free air under diaphragm and abdominal X-ray displayed dilated bowel loops. Laboratory investigations showed leukocytosis and hyperamylasemia. After intravenous (IV) fluid resuscitation, diagnostic laparoscopy was performed that detected the presence of perforated solitary giant jejunal diverticulum, about 25 cm from the duodenojejunal junction, in addition to diffuse peritonitis. We had to convert to laparotomy due to the presence of huge amount of undigested food particles. Resection of the diverticulum-bearing segment and anastomosis was done along with thorough peritoneal decontamination and washout. Solitary giant jejunal diverticulum is a rare condition which can present with chronic vague abdominal pain and altered bowel habits, and can present acutely with complications as perforation with significant morbidity.
  3,128 178 -
Sigmoid volvulus in a young patient: Beware of Hirschprung's disease
Chandan R Choudhury, Dipak Ghosh, Sarabarni Biswas
May-August 2013, 1(1):29-31
Sigmoid volvulus is a rare and potentially life-threatening complication of Hirschsprung' disease. A young patient presenting with sigmoid volvulus is not common and Hirschsprung's disease should be suspected in patients in this age group presenting with otherwise unexplained colonic volvulus. Here we report a rare and interesting case of Hirschsprung's disease presenting as sigmoid volvulus in a 15-year-old girl and the sufferings of the patient due to this uncommon entity.
  2,987 253 -
Pyramidal lobe on 99m technetium thyroid scan: Incidence, origin and association with thyroid function
Maseeh uz Zaman, Nosheen Fatima, Unaiza Zaman, Zafar Sajjad
September-December 2013, 1(2):37-40
Purpose: The purpose of the study is to find out the incidence of pyramidal lobe (PL), its position in relation to thyroid and correlation with functioning status of thyroid gland. Materials and Methods : This was a retrospective study conducted in Nuclear Medicine Section, Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan. We evaluated radionuclide thyroid scans performed with technetium-99m pertechnetate from March 2009 to May 2013. As per our departmental protocol, patients were used to swallow 100-150 cc water to wash away secreted esophageal activity and minimizing the possibility of false positive results. Patients with diagnosis of thyroiditis or history of any thyroid surgery were excluded. Presence and position of PL (arising from isthmus or either lobe of thyroid), presence or absence of cold or hot nodule (s), total thyroid uptake and thyroid function test performed within 4 weeks of thyroid scan were noted. Results: A total of 1116 thyroid scans qualified inclusion criteria of the study. PL was appreciable in 156 patients with overall incidence of 14% and an annual incidence of 3.5%/year (P < 0.05). Mean age of the population was 40 ± 12 years and female: Male was 113:43 (P < 0.05). Mean thyroid uptake was 14 ± 9% (P > 0.05). PL had origin from left thyroid lobe in 72 (46%), from the right thyroid lobe 58 (37%) and from the isthmus in 26 (17%) (P < 0.05). 135 (86.5%) patients were toxic (P < 0.05) while 15 (9.6%) euthyroid and 6 (3.8%) were hypothyroid (P > 0.05). Conclusion: We conclude that the incidence of PL on thyroid scanning was 14% with predominance for the female gender, left lobe origin and diffuse toxic goiters. An adequately performed thyroid scan would ensure completeness of thyroidectomies and avoid per-operative inconvenience to surgeons due to false positive scan results.
  2,213 929 -
Acute gastric volvulus with torsion wandering spleen: A rare surgical emergency
Jagdish Gupta, Navneet Sharma, Bhavesh Devkaran, Arun Gupta
September-December 2013, 1(2):53-56
Gastric volvulus, wandering spleen and eventration of diaphragm share a common pathologic cause of absence or laxity of intraperitoneal ligaments. We hereby present a rare case of a 15-year-old male child with cerebral palsy presenting with organo-axial type of acute gastric volvulus resulting in gangrene of whole of stomach, associated with an infarcted wandering spleen, eventration of the diaphragm and cholelithiasis.
  2,849 208 -
Varicose veins of the dorsum of hand and digits: A case report and review of literature
Satpal Hans, Narinder Pal Singh, Kunal Dhall, Sudhir Khichy
January-April 2014, 2(1):26-28
The localized varicosities of the hands and digits are quite rare with only a handful of cases reported in the literature. The cause of upper and lower limb varicosities are almost the same and the same treatment principles should be followed for both. Here, we report a case of 19-year-old male with localized varicosities of the dorsum of his hand and digits. Diagnosis was confirmed by color Doppler ultrasound scanning. He was managed by multiple ligations and excision of varicose veins with excellent results.
  2,786 224 -
Recurrent central odontogenic fibroma: An uncommon clinical presentation
Suresh K. Sachdeva, Pradhuman Verma, Dinesh Verma, Kanika Gupta Verma
January-April 2014, 2(1):22-25
Central odontogenic fibroma (COF) is an uncommon benign neoplasm composed by varying amounts of inactive looking odontogenic epithelium embedded in a neoplastic mature and fibrous stroma. It originates from odontogenic ectomesenchyme and accounts for 0.1% of all odontogenic tumours. It appears as an asymptomatic expansion of the cortical plates of jaws. Radiographically, it appears as unilocular or multilocular radiolucency. It responds well to surgical enucleation. Recurrence is rare. Here is a rare case of recurrence of COF reported in 18-year-old female in the left mandibular posterior region after 1 year.
  2,702 225 -
Solid pseudopapillary tumors of the pancreas: Is there a role for adjuvant treatment?
Anshuma Bansal, Vikrant Kaushal, Rakesh Kapoor
May-August 2016, 4(2):47-51
Solid pseudopapillary tumors of the pancreas are rare tumors commonly found in females. Surgery is the primary treatment and the role of adjuvant chemotherapy or radiation is not well defined. Although they are mostly benign, they have the potential for late metastasis, thereby defining the need for long-term surveillance for such patients. This review article describes these tumors in detail and in addition, focuses on the management of the resected tumors and the need and indications for adjuvant treatment in selective cases.
  2,614 292 -
Complete posterior rectus sheath and total extra-peritoneal hernioplasty
Maulana Mohammed Ansari
September-December 2014, 2(3):80-83
Introduction: Variations in rectus sheath formation have been reported with little realization of its importance to the laparoscopic surgeons doing total extra-peritoneal preperitoneal (TEPP) hernioplasty. Observation of complete rectus sheath during laparoscopic mesh hernioplasty for inguinal hernia through TEP approach and its surgical implication are presented here. Materials and Methods: Setting - Elective. Location for the study - J. N. Medical College and Hospital, A. M. U., Aligarh. Study design - Prospective with effective from April 2010 to August 2013. Study population - Adults (≥18 years). Data collection - Instant documentation and video recording. Method of analysis - All data were computed through on-line calculators (www.graphpad.com/quickcalcs/and http://epitools.ausvet.com.au/). Results: Thirty-five TEPP hernioplasties were carried out in a period of 3 years. All patients were males, with an overall mean age of 48.7 ± 13.4 years. Posterior rectus sheath (PRS) was found complete in four patients with a mean age of 47.28 ± 09.74, and was associated with significantly increased surgical difficulties during the procedure. On Visual Analog Score, endoscopic vision was 4.3 ± 0.6 (4.0-5.5), and the ease of the procedure was 4.5 ± 0.8 (4.0-6.0) that is, both were less than satisfactory. Operating time was 3.1 ± 0.7 h (3.25-4.0). Out of four patients, peritoneal injury occurred in three patients, surgical emphysema in one patient, and postoperative seroma in one patient. Conclusions: PRS was complete in 11.43% of cases studied that was associated with an increased level of surgical difficulties and a higher rate of complications.
  2,710 158 -
Hyperbilirubinemia, C-reactive protein and ultrasonography as predictors of appendiceal perforation: A prospective study
Mumtaz Din Wani, Shabir Ahmad Mir, Jahangeer Ahmad Bhat, Salma Gul, Umar Maqbool, Hakim Adil Moheen
January-April 2014, 2(1):1-5
Background: Acute appendicitis is the most common cause of acute abdomen and subsequent surgery. The diagnosis is essentially based on the clinical grounds and as a result misdiagnosis is a common and crucial problem in general surgery. Delayed or wrong diagnosis in patients with appendicitis can result in perforation and consequently increased morbidity and mortality. Serum bilirubin and C-reactive protein (CRP) have been shown to indicate perforation in appendicitis. Aim: The purpose of this study was to evaluate the role of hyperbilirubinemia, CRP and ultrasonography (USG) as predictors for appendiceal perforation. Materials and Methods: This study consisted of patients admitted with the clinical suspicion of acute appendicitis. The study finally included a group of those 100 patients who had histologically proven appendicitis. Subsequent to hospital admission all patients underwent thorough physical examination and routine lab exams. Preultrasound clinical diagnosis was made based on medical history, physical examination as well as laboratory findings. Real-time, high-resolution (5 MHz, 7.5 MHz) graded compression ultrasound examination was performed by a senior radiologist after a clinical diagnosis was made. Results: Serum bilirubin and CRP were raised in significant number of patients with appendiceal perforation compared to the patients of appendicitis without perforation. Thirty-three of 42 patients with perforated appendix had bilirubin ≥1.5 mg/dl (P < 0.0001). Sensitivity of serum bilirubin in predicting perforation was 78.57%, while as specificity was 89%. Thirty-five of 42 patients with perforated acute appendicitis had raised CRP levels (P < 0.0001). Sensitivity and specificity of CRP in predicting perforation were 83% and 74%, respectively. Abdominal USG in patients with diagnosis of perforated acute appendicitis has a sensitivity of 64.28% and specificity of 79.3% (P < 0.0001). Conclusion: Bilirubin, CRP and ultrasound are effective for differentiation of perforated from nonperforated appendicitis. Bilirubin, CRP and USG are important preoperative biochemical and sonographic markers of perforation, respectively in appendicitis.
  2,520 315 -
Absolute benefit of gastrografin in adhesive small bowel obstruction: A retrospective study and review of the literature
Asri Che Jusoh, Fatimah Halwani Ismail, Ong Yanzie
September-December 2014, 2(3):84-87
Introduction: Adhesive small bowel obstruction (ASBO) is a major cause of postoperative morbidity. The objectives of the study are to evaluate the diagnostic and therapeutic properties of gastrografin (GF) in ASBO. Materials and Methods: A retrospective review of all adult patients admitted from January 2011 to January 2013 with ASBO, who undergone GF test was done. Apart from establishing its diagnostic property, therapeutic effects following the test were also determined such as reduced need for surgery and shortened the hospital stay. An undiluted GF (100 ml) was given once the patient is adequately rehydrated followed by supine abdominal X-ray 4-6 h later. If the contrast is seen in the colon, the test is considered as positive. Otherwise, a repeat X-ray is done 20 h later (24 h postGF). A positive test patient was considered as partially obstructed and selected for nonoperative management. Otherwise, if remain negative at 24 h surgery is considered. Results and Analyses: A total of 21 patients who fulfilled the criteria was analyzed. Majority were male (16 patients, 76.2%), aged between 14 and 84 years (mean 45.3). A total hospital stay was 5 days (median) with only 3 days for successful GF test. Eight patients (38.1%) developed first ASBO following open appendectomy whereas 28.5% (six patients) after colorectal surgery. Previous midline laparotomy was the most common approach seen (57.1%, 12 patients) followed by lanz incision (23.8%, five patients). A positive test was only demonstrated in 66.7%, 38.1% (eight patients), and 28.6% (six patients) at 4 h and 24 h, respectively. Surgery was required in seven patients (33.3%) with only one patient can be approached laparoscopically. We had no adhesion-related bowel gangrene or mortality. Conclusion: Our analysis demonstrated that GF test is safe and very beneficial in managing ASBO. It reduces the need for surgery and shortens hospital stay even in high adhesion risk group.
  2,447 247 -
The "small" wrapping around the "large"!
Santosh Rai, Manohar Pai, Adurthy Priyanka, Irshad Mohammed
September-December 2013, 1(2):50-52
This is a case report of a 32-year-old female who presented with acute intestinal obstruction. The radiological diagnostic possibilty of midgut volvulus with ileo-sigmoid knotting and obstruction of the proximal sigmoid colon and small bowel was given. The diagnosis was confirmed intra-operatively with associated gangrene of the distal jejunum and proximal ileum. Resection of the gangrenous segments of bowel and the release of ileo-sigmoid knotting was performed. The literature about the ileo-sigmoid knot was reviewed. It may be difficult to diagnose this condition before surgery. This is a surgical emergency that requires urgent resection of gangrenous bowel and untwisting of the volvulus. The aim of this short communication is to increase awareness of the pre-operative computed tomography (CT) diagnosis of this condition.
  2,505 162 -
Damage control surgery/laparostomy in nontrauma emergency abdominal surgery: A new concept of care
Asri Che Jusoh, Ong Yanzie
September-December 2014, 2(3):75-79
Introduction: The established success of damage control surgery (DCS) in trauma of torso motivates surgeon to apply similar concept in managing complicated intra-abdominal sepsis. The main objective of this study is to audit our new practice of such in nontrauma emergency abdominal surgery. Materials and Methods: We retrospectively reviewed all emergency abdominal surgeries (nontrauma) done from February 2013 to February 2014. All patients who had damage control procedures done for complicated intra-abdominal sepsis were analyzed. Results: A total of 60 patients were operated within that period. Six patients (10%) had undergone DCS with or without laparostomy. All were male with mean age of 48.5-year-old (26-61-years-old). Most were in ASA 3 (83%, 5 patients) with only one in ASA 4. Primary indications were ischemic bowel with mesenteric vein thrombosis (3 patients, 50%), abdominal compartment syndrome (ACS), bleeding post near total splenectomy for splenic abscess and gangrenous proctitis with purulent peritonitis. Nearly, all patients (5 patients, 83.3%) were severely acidotic with pH <7.2 intra-operatively, which triggered the DCS. Nevertheless, only 3 patients (50%) benefited from laparostomy and all of them achieved complete fascial closure within 2.6 days (mean). Their mean total Intensive Care Unit (ICU) stay was 15 days (9-32 days). Overall predicted mean Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity mortality rate was 51%. However, the observed (actual) mortality rate was only 33% (2 patients). Conclusion: The result of the practice of DCS in the septic abdomen is very encouraging. It appears able to reduce the mortality by 35%. A comparative analysis with larger series is therefore warranted to further confirm the findings.
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Omental infarction: A misleading cause of an acute abdomen
Robinson George, Kukku Leopold, Krishnan Prasad, Veena Nair
September-December 2013, 1(2):46-48
Omental infarction is a rare cause of an acute abdomen. Depending on the site of infarction, it can mimic conditions such as appendicitis, cholecystitis and diverticulitis. Before computed tomography, the diagnosis was made intraoperatively. We report a case of a young man who was treated conservatively following diagnosis using radiologic means, for its rarity and merits of a similar conservative approach in future cases.
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