Postoperative surgical site infection after incisional hernia repair: link to previous surgical site infection?

Objective: Aim of the study was to determine the affects of different factors in general and previous surgical site infection [SSI] in particular, on postoperative SSI in patients undergoing open ventral Incisional hernia repair in a clean setting as there is still a lot of controversy on this issue

Patients and Methods: This is a Prospective study conducted at Madina Teaching Hospital, University Medical and Dental College, Faisalabad from January 2006 to September 2010. All patients undergoing open ventral Incisional hernia repair in a clean setting were evaluated for a postoperative surgical site infection [SSI]. The development of a postoperative surgical site infection was taken as the primary endpoint. Patients were divided into two groups, without history of postoperative SSI and with history of postoperative SSI. Both groups were compared regarding demographic factors, Perioperative data and development of postoperative SSI

Results: 167 patients met the predefined criteria and were analyzed. Of these, 25patients were having prior wound infection after their previous surgery. Univariate analysis was done. It showed that patients with prior wound infection and those without prior wound infection had similar characteristics [Table 1]. American Society of Anesthesiology [ASA] score [3.1 vs. 3.7; P .003] and percentage of smokers [3.1 vs. 3.7; P .003] was found to be significantly lower in the group with no history of wound infection as compared to other group with history of wound infection. There was no signi?cant difference between two groups regarding use of permanent synthetic mesh [78% vs. 76%; P .571], requirement for an anterior component separation [18% vs. 07%; P .138], surgical site infection within 30 days after surgery [11% vs. 16%; P .487]. The patients requiring surgical debridement after a postoperative SSI were similar in the two groups [31% vs. 25%; P .793] [Table 2]. History of previous wound infection was not a signi?cant factor, when we evaluated for predictors of surgical site infection after ventral hernia repair [odds ratio [OR], 1.47; P .436]. However, a history of chronic obstructive airway disease [COAD] [OR, 4.09; P .018] and a history of smoking [OR, 6.01; P .004] were found to be signi?cant predictors for an increased risk of developing a surgical site infection after ventral hernia repair in this group of patients [Table 3]

Conclusions: We were unable to demonstrate any link between a previous SSI and a higher rate of SSI after open ventral hernia repair. Chronic obstructive airway disease and Smoking were identified as primary risk factors predictive of a postoperative surgical site infection

Patterns of presentation, surgical management and outcome of patients with degloving injures

To describe the patterns of degloving injuries and to identify the outcome of different management techniques in patients with degloving injuries in patients presenting at Allied and Divisional headquarters hospital, Faisalabad. Prospective case study from January, 2008 to July 2008. Surgical floor of Allied and District Headquarters [Teaching] Hospitals, Faisalabad. Detailed data of each patient including presentation, operative findings, procedure performed, post operative outcome was entered on a specially designed Proforma, compiled and analyzed by using SPSS. Between February 2008 and July 2008, a total of 50 patients were included in the study. The etiological factors were road traffic accidents in 78% [39 patients], rotatory machine accidents 16% [8 patients] and domestic trauma in the remaining 6% [3 patients]. Degloving injury more commonly occurred in the lower limb 44% [22 patients], upper limb 16% [8 patients], scalp 22% [11 patients], penoscrotal 10% [5 patients] and miscellaneous group 8% [4 patient]. Associated skeletal fracture was seen in 3 [6%] patients. With increasing road traffic accidents, there is a marked increase in patients presenting to emergency department with degloving injuries. Early recognition and well planned surgical approach is all it takes to prevent complications and salvage a limb

Postoperative nausea and vomiting [PONV]; preoperative dexamethasone in laparoscopic cholecystectomy patients

To evaluate the effect of preoperative single dose injection dexamethasone for prevention of PONV in patients undergoing laparoscopic cholecystectomy and comparing it with normal saline [placebo]. Experimental RCT study. The study was conducted at Madina Teaching hospital, University Medical and Dental College, Faisalabad from January, 2008 to October 2009. After approval from the hospital ethical committee, 200 patients with ASA I and II were included in the study. We divided the patients into two groups; group I received preoperative dexamethasone [8mg] and the group II received normal saline [placebo] 90 minutes before the surgery. Patients were observed for any episodes of nausea or vomiting, need for rescue antiemetics, and complete responses in the postoperative period. The complete response was defined as no nausea, no vomiting, and no ant emetic medication during a 24-h postoperative period. This was also the primary efficacy end point of the study. The data was analyzed using Pearson's Chi square test with P<0.05 taken as significant. Nineteen patients [19%] in the dexamethasone group reported nausea, compared with 43 [43%] in placebo group [p<0.05]. Eight patients [8%] in the dexamethasone group reported vomiting and twenty two patients [22%] in the placebo group reported vomiting [P<0.05]. In group I, thirteen patients [13%] asked for rescue anti-emetic where as in group II [placebo group] thirty six patients [36%] asked for rescue anti-emetic [p<0.05]. Seventy three patients [73%] in the dexamethasone group showed a complete response, compared with 35 [35%] in placebo group [p<0.05]. We concluded that preoperative dexamethasone [8mg] reduces the incidence of PONV as compared to placebo. As it is a cheap, freely available drug causing no complications, it should be used in otherwise fit selected patients undergoing laparoscopic cholecystctomy

Postoperative neuralgia; routine ilioinguinal nerve excision in inguinal hernia repairs: a safe adjunct

To evaluate paresthesia following routine ilioinguinal nerve excision compared to nerve preservation in patients undergoing anterior inguinal hernioraphy. prospective experimental study. The study was conducted at Madina Teaching hospital, University Medical and Dental College, Faisalabad from July 01,2005 to June 30,2007. Two hundred and eighteen patients were operated for their inguinal hernias. Ilio-inguinal nerve preservation [n=96] and nerve excision [n=122] was performed on alternative operation days. All patients were contacted and data was collected on incidence and duration of postoperative paresthesia. Comparison was made by x[2] analysis. The patients with routine neurectomy were similar to the group without neurectomy based on mean age [68 +/- 14 vs. 58 +/- 18 years]. The incidence of postoperative paresthesia was not significantly higher in the neurectomy group versus the nerve preservation group at 1 month: 15% versus 4% [P = 0.078]; 6 months: 11% versus 5% [P = 0.107]; 1 year: 09% versus 05% [P = 0.303]; [Table 2]. In patients with postoperative paresthesia, mean severity scores on a visual analog scale [0-10] were lower in the neurectomy group versus nerve preservation group at 1 month [2.6 +/- 2.0 vs. 5.2 +/- 0.0] and at 6 month [2.4 +/- 2.0 vs. 5.2 +/- 0.0] but similar in the neurectomy and nerve preservation patients at 1 year [2.2 +/- 1.8 vs. 3.8 +/- 0.0] [Table 3]. There is a trend towards increased incidence of subjective paresthesia in patients undergoing routine neurectomy at 1 month, but there is no significant increase at any other end point in time. When performing anterior inguinal hernia repair, routine ilioinguinal neurectomy is a reasonable option

Postoperative pain after laparoscopic cholecystectomy: role of port site and intra-peritoneal infiltration of injection bupivacaine

To study the analgesic role of port site and intra-peritoneal infiltration of injection bupivacaine following laparoscopic cholecystectomy. 60 patients undergoing laparoscopic cholecystectomy were randomized into two groups of 30 each. Group A [study group] received 40 ml of intraperitoneal injection of 0.25% bupivacaine and 20 ml of same concentration in 4 ports, 5 ml each at the end of surgery. Group B [control] received no treatment. Post operative patient monitoring and pain assessment was done by another doctor blinded to the procedure using VAS score at 1,4,12 and 24 hours after surgery. Ketorolac intramuscular was given as rescue analgesic when demanded by patient within first 24 hours. When VAS score was analyzed in the two groups, the study group had less scores compared to control group though it was statistically not significant [p>0.05]. The rescue analgesic requirement was significantly less in study group [p<0.00]. port site and intra-peritoneal injection of bupivacaine is effective in decreasing pain after laparoscopic cholecystectomy

C-reactive protein; a diagnostic tool for acute appendicitis

To determine the efficacy of C-reactive protein in diagnosis of acute appendicitis. Cross-Sectional Descriptive Study. The study was conducted in Surgical Unit I of Allied Hospital, Faisalabad. The study was completed in six months, from 21 April 2005 to 30 June, 2005 and 26 January, 2006 to 26 May, 2006. In 100 patients with pain right iliac fossa, C-reactive protein, complete blood count and urine complete examination was done before appendicectomy. Patients were assigned into group A [normal appendix] and group B [acute appendicitis] on the basis of histopathology. Normal TLC and CRP values, raised TLC, raised CRP level and raised both TLC and CRP values were calculated in these groups. Performance of C Reactive protein in comparison with histopathology [Gold Standard] was assessed. In our study, 62 cases were males and 38 females. 83 cases had acute appendicitis and in 17 cases appendix was found to be normal. Patients having TLC >11,000 were 68 in group B and 03 in group A. Patients having TLC <11,000 were 15 in group B and 14 in group A. Patients having high CRP level were 77 in group B and 4 in group A. Patients having normal CRP level were 6 in group B and 13 in group A. The Specificity, Sensitivity, Predictive value [PV] of positive test, and Predictive value [PV] of negative test for CRP were 76.5%, 92.8%, 95.1% and 68.4% respectively. We found in this study that CRP was a good indicator of acute appendicitis and its routine use can decrease the rate of negative appendicectomies

Focal hyperhydrosis of the face

A case of young adult male is presented who was having chronic sweating of his right half of the face and! dropping the sweat drops all the time from his chin. He traveled from hospital to hospital with this problem. We did the cervical sympathectomy and removal of 1[st] cervical ganglion which relieved the symptoms

Re-operation after abdominal procedures lesion learnt from our two years experience

The objective of the study are to audit our experience of the management of cases presenting with operative complications requiring acute re operation and to identify the factors resulting in the first operation failure requiring re-exploration. A prospective observational/analytical study. Acute re-operative abdominal surgery during two years period 2002-2003 in surgical Unit 1 Allied hospital, Fiasalabd. All the cases which were re-explored after abdominal surgery admitted in surgical unit 1, Allied hospital, Faisalabad are included in the study. The cases fall in three categories, trauma cases [29] 33.71%, non trauma emergency cases [32] 37.25 and elective surgery cases [25] 29.1%. The incidence of our own unit cases subjected to re-operation is 21.9% [24]. The presenting pathologies after first operation are in 6 groups; Gastrointestinal fistulas [38 cases] 41.8%, bowel obstruction [7 cases] 8.15%, abdominal abscesses [12 cases] 13.9%, bleeding [18 cases] 20.9%, miscellaneous [biliary and G.U.] [8 cases] 9.35, abdominal wound dehiscence and evisceration [3 cases] 3.6%. Total of 136 complications are in 70 cases. Mortality of 7 cases [8.14] is shared by the semi-trained surgeons, Medical officer operators [6 cases] and the trainee surgeons [1 case]. Incidence of mortality in elective surgery cases is 4% in trauma cases 10.34%, non trauma emergency cases 9.4%. Intensive resuscitation including nutritional support, team of senior consultants doing the re-operation, intra-operative and post operative monitoring are the hallmarks of the management. Training and retraining [continuous medical education] of surgeons and regionalization of trauma cases are recommended. The facilities for less invasive procedures blessed with low morbidity and very low mortality will shrink this list of re-operations