Delayed primary wound closure versus primary wound closure - a dilemma in contaminated abdominal surgeries

INTRODUCTION: Majority of emergency surgeries are performed through midline laparotomy wound; however when it comes to the closure of midline wound surgeons deploy various options. Technique of Primary closure of the wound is simple and cost effective as no other procedure is required. However, some surgeons favor technique of delayed primary closure because of decreased frequency of wound infection

OBJECTIVE: The purpose of our study was comparison of primary wound closure technique and delayed primary wound closure techniques with respect to rate of wound infection and other complication associated with wound infection like wound dehiscence, stitch sinuses, incisional hernias

PATIENT AND METHOD: This comparative study carried out among fifty patients who underwent midline exploratory laparotomy for perforated abdominal viscera in Surgical Unit I of Civil hospital Karachi. Patients were divided into two groups. The sample size was calculated using significance level of 0.05 and power of 80% for difference in wound infection rates in the two groups. All patients of both genders; in each group; who underwent emergency laparotomy having identical pathologies were taken in account. Patients with co-morbid were excluded. In the study group [Group A], primary closure technique was used and in group B, delayed primary closure was utilized. All patients were followed for post-operative wound complications

RESULTS: In our study male to female ratio was 2:1 and the mean age was 33+/-10 years. Wound healed normally with no signs of infection in 23[46%] out of 50 patients. The overall infection rate was considerably low in delayed closure group [40%] when compared to the primary closure group which was 68% [p<0.05]. There was significant decrease in other complication related to wound infection like stitch abscess formation and wound dehiscence in delayed closure group [p- < 0.05]

CONCLUSION: Our results demonstrate that the delayed primary closure technique is a better technique with low frequency of wound infection and other related complications when compared with primary wound closure technique

Non therapeutic laparotomies in penetrating abdominal trauma patients: time to change the trend

Objective: To determine the frequency of non therapeutic laparotomies in penetrating abdominal trauma patients, their relation with the diagnostic procedures and hemodynamic status of patients and the final outcome in terms of morbidity and mortality

Study design: Case series

Place and duration of study: A and E Department of Dow University of Health Sciences and Civil Hospital Karachi, from January 2011 to June 2014

Methodology: Patients with penetrating abdominal injuries who presented to Accident and Emergency Department and underwent exploratory laparotomy were included in the study. Laparotomies were labeled as therapeutic if intra-abdominal injuries required surgical intervention and repair done, while laparotomies with injuries that did not require surgical intervention i.e, serosal tear, non expanding retroperitoneal, mesenteric and visceral hematoma were labeled as non therapeutic. Patient's vital instability and investigations directed to find out intra-peritoneal visceral injuries and local wound exploration findings were recorded along with the outcome in terms of morbidity and mortality

Results: A total of 115 patients with penetrating abdominal injuries were included. Majority [n=109- 94.8%] of the patients were young males. Most common cause of panetrating injury was firearm [n=106 92.2%]. Non therapeutic explorations were done in 23 [20%] patients. The major causes of non-therapeutic explorations were vital instability due to associated injuries [34.7%] and peritoneal breach confirmation on local wound exploration [n=12 - 52.17%]. One patient who underwent non therapeutic laparotomy along with thoracotomy due to associated chest injury died on table. One patient developed wound infection and other developed respiratory infection. Average hospital stay was 8.1 days

Conclusion: The study highlighted the need of selective nonoperative approach for the clinically stable patients with penetrating abdominal trauma. With the use of CT scan abdomen or diagnostic laparoscopy along with repetitive clinical examination the frequency of nontherapeutic explorations can be minimized

Postoperative renal impairment in patients with obstructive jaundice

To determine the frequency of postoperative renal impairment in patients with obstructive jaundice. Descriptive case series. Surgical Unit II Civil Hospital Dow University of Health Sciences Karachi, from March 2011 to April 2014. Patients of obstructive jaundice, with age more than fifteen year, serum bilirubin levels above 3 mg/dL, admitted for surgical procedure were selected. Data containing details of age, etiology of jaundice, duration of jaundice, preoperative liver function tests, coagulation profile, procedure, pre and postoperative renal function, urine output, complications and mortality were collected. Creatinine clearance [C24] was done. If the patient had postoperative serum creatinine levels of >1.3 mg/ dL or urine output < 800 ml in 24 hours then C24 was also done. Renal impairment was labeled if C24 was < 40ml/min. All the data was analyzed on SPSS 17. A total of 38 patients were included. Majority of the patients had history of jaundice for more than six week [mean=6.1 +/- 5.8 weeks]. Ten [26%] patients developed renal impairment post-operatively out of which 4 [10%] had benign disease and 6 [15%] had malignant condition. No patient developed acute renal failure in immediate postoperative period. Postoperative renal impairment in obstructive jaundice patients occurred in quarter of the cohort studied despite adequate volume expansion

Surgical audit of unit ii, department of surgery abbasi Shaheed Hospital, Karachi

To report the experience of one year audit of general surgical procedures and comparison of results with other audit data. This study was carried out from January 2005 to December 2005 in the Department of Surgery, unit II, of Abbasi Shaheed Hospital, Karachi. Total numbers of patients were 881, majority of them were between 16 to 50 years of age group [73.4%]. Elective surgeries were performed in 449 [50.9%] cases whereas 315 [35.7%] cases underwent emergency surgical procedures. Rest of the patients were managed conservatively i.e. 117 [13.2%] cases. The most frequent region was gastrointestinal tract [36.1%], in which appendiceal pathologies were commonly encountered. Average duration of stay was 12 days. There was an overall mortality of 1.2% and a complication rate 5.9%. We conclude that audit is essential for better health practice and should be perform yearly. Moreover, there should be proper audit program and committse for this purpose