Three-port versus four-port laparoscopic cholecystectomy - a two years experience at combined military hospital Malir cantt Karachi

Objective: To compare the safety, outcome and advantages of three port laparoscopic cholecystectomy vs. four port laparoscopic cholecystectomy

Study Design: Prospective descriptive study

Place and Duration of Study: The study was done at Combined Military Hospital Malir Cantt Karachi starting, from Mar 2013 to Oct 2015

Material and Methods: Total 200 patients who had undergone gall bladder removal laparospically were studied. Complication rate, duration of operation, insertion of 4th port, converting laparoscopic method to open, duration of hospital admission, early return to work and need of analgesics were studied in patients with three ports laparoscopic cholecystectomy [LC] vs. four ports LC

Results: A total of 200 patients who had removal gall bladder laparospically, three-port LC were performed in 117 [58.5%] patients and four-port LC was performed in 83 [41.5%] patient. There was no significant difference with respect to complication rate, converting to open technique and duration of operation were comparable to four ports LC. One patient required 4th port in left hypochondrium for liver retractor to retract enlarged left liver lobe

Conclusion: LC using thee ports can be performed safely when done by experts in this method. The said procedure has significant benefits over the conventional four-port method with respect to decreased use of pain killers and duration of hospital admission

Fistulotomy vs. fistulectomy in the treatment of simple low anal fistula of male patients

Objective: To compare the efficacy of fistulotomy versus fistulectomy in the treatment of low lying anal fistula in male patients

Study Design: Randomized clinical trial

Place and Duration of Study: Surgery Department, CMH Multan and CMH Malir, from Aug 2008 to Oct 2013

Patients and Methods: Study was done on 262 patients. Patients with anal fistula were divided by simple random allocation into groups A [fistulotomy] and B [fistulectomy]. The patients with simple low anal fistula without any comorbids were included in the study and the patients with recurrent fistula, high fistula or those having any comorbid were excluded from the study. Data was analysed using SPSS 17. Descriptive statistics applied for both quantitative and qualitative variables. Mean and standard deviation for quantitative and frequencies and percentages for qualitative data

Results: Total 262 patients were selected having low lying anal fistula and operated as group A - fistulotomy and group B - fistulectomy, each group constituted of 131 patients each. The operating time was found to be shorter for group A [14.29+3.24 minutes] and group B [25.92 +3.60 minutes]. The group A patients were discharged earlier [3.73 + 0.65 days] than group B [4.88 + 0.35 days]. In group A incidence of postoperative bleeding [0.8%], infection [2.2%] and recurrence was [10.7%]. While in group B bleeding [3.1%], infection [3.8%] and recurrence was [15.3%]. Severity of postoperative pain [as assessed by Numeric Rating Scale] was higher in group B as compared to group A. The healing time was shorter in group A [4.04 + 0.33 weeks] as compared to group B [4.57 + 0.497 weeks] and the patients of group A returned to normal activity earlier [10.9 + 2.05 weeks] than group B patients [15.54 + 0.51 weeks]

Conclusion: In male patients suffering from simple low lying anal fistulas, fistulotomy has a definitive superiority over fistulectomy and is recommended to be adopted as primary surgical modality for the treatment

Usefulness and safety of early against delayed oral intake after appendectomy

To evaluate the usefulness and safety of early versus late oral intake after appendectomy. Randomized clinical trial. Combined Military Hospital Multan from August 2008 to February 2009. One hundred patients with uncomplicated acute appendicitis, undergoing appendectomy under general anesthesia were included in the study and randomly divided into two equal groups. Early oral intake group [group A] was allowed fluids, when patients were out of effects of general anesthesia. Delayed fed [group B] was started oral fluids, on appearance of normal bowel sounds or passage of flatus. Low residue solid diet was started, after tolerance of oral fluids, in both groups. Early oral intake resulted in start of solid diet earlier by average 9 hours; these patients had normal bowel sounds, and passed flatus, earlier, after 4 hours and 5 hours as compared to late feeding group. Six [12%] patients had mild ileus in early fed group whereas 4[8%] patients in delayed fed group had mild ileus. Thirty eight [76%] early fed patients were very satisfied, as compared to 29 [58%] delayed fed patients. The hospital stay was prolonged by 2 days in delayed fed group. Early oral feeding implemented after appendectomy is safe and effective, with a shortened hospital stay as the primary benefit in patients after appendectomy

Comparison of tramadol with bupivacaine as local anaesthetic in postoperative pain control

To determine the effectiveness and duration of postoperative pain relief after local infiltration of tramadol in comparison with bupivacaine, in adult hernia surgery. Quasi experimental study. Department of Surgery, Combined Military Hospital Rawalpindi. Study was conducted on 60 patients aged between 20-60 years with elective mesh repair of inguinal hernia. Patients were divided into two groups of 30 patients for 0.25% bupivacaine [group A] and tramadol [group B]. Patients were assessed for pain at 1, 6, 12, 18 and 24 hours following surgery using visual analogue pain score [VAPS]. Patients with score =5 were given rescue analgesia in the form of 75 mg intramuscular diclofenac sodium. Comparison of first analgesia requirement time and the VAPS between the two groups was done using "t" test taking a p-value of <0.05 as significant. Patients in group A had a mean age of 46 +/- 11.03 years whereas in group B the mean age was 46 +/- 11.39 years. Mean visual analogue pain score after 1 and 6 hours of operation was 2.73 and 4.7 respectively in group A while it was 1.43 and 3.43 in group B. VAPS after 24 hours of operation was 3.47 in group A and 2.53 in group B. Mean time when 1st dose of rescue analgesic used was 8.20 hours in group A and 11.60 hours in group B. independent sample t-test for VAPS between the 2 groups revealed a highly significant difference [p-value <0.05] at 1, 6, 12 and 24 hours but no significant difference was seen at 18 hours. Independent sample t-test for time required for rescue analgesia and total number of doses required was also highly significant [p-value <0.05] between the two groups. Locally infiltrated tramadol provided an improved postoperative analgesia in comparison to bupivacaine and decreased the requirement of postoperative analgesics with early patient mobility and discharge

Acute appendicitis: gaining time in mass casualty scenario

To find out group of drugs best to gain time before appendicectomy in patients of acute appendicitis in mass causalities scenario. Quasi-Experimental. Place and Duration of study: A post earthquake, resource constrained hospital taking care of dependant population of three districts at CMH RawlaKot from 15 Jan 2007 to 15 Jan 2008. Ten patients were selected in each group by convenience sampling. Patients were divided into five groups Group I No Antibiotics, Group II Ampicillin / Gentamicin / Metronidazole, Group III Ceftriaxone / Metronidazole, Group IV Ampicillin / Sulbactum, Group V Cefoperazone / Sulbactum. Group I was taken as control where the appendectomy delay was according to the natural history of the disease. Group II, III, IV and V who had to be triaged and placed on antibiotics regimen before operation. Extreme care was taken so that this approach was only adopted in patients where the delay in appendectomy was inevitable. All patients were operated 24 to 72 hours after onset of symptoms. The grade of operative difficulty was assessed objectively and average difficulty scores were compared between the groups In the one year period 431 appendectomies were performed out of which 50 patients were included in the study. These 50 comprised of 10 patients in each group. Overall male to female ratio was 27:23. Overall average age was 25.14 + 7.54. In Group I an average delay before presentation 57.6 + 12.39 hrs. In Group II to V the overall delay from start of symptoms till operation was 55.63 + 8.37 hrs. The cumulative ease to operative was experienced in group V. In scenario of mass / multiple casualty, the antibiotic containing sulbactum will be best empirical therapy to gain time for patients of acute appendicitis. The one having Cefoperazone has got a definitive edge over the rest

Surgery in a temporary setup- sharing an experience of 16 months

Sharing an experience of surgery in a temporary set up. Descriptive study. This study was carried out at Combined Military Hospital Muzaffarabad after the earthquake of October 2005 over a period of 16 months. The workload that this hospital has managed over the period despite running under tents. The hospital was functioning under the temporary set up. Patients were earth quake victims requiring different surgical procedure. A total of 2887 major and 7471 minor surgical procedures pertaining to the specialty of General Surgery, Orthopedics, ENT, EYE and Gynecology were carried out over a period of 16 months. Though the load was comparable to any [C] class and most of the [B] class hospitals, despite being under tents, there was not a single case of post operative infection. The importance of single-use-only surgical disposables in the good management of surgical patients has also been highlighted. The basic sterilization techniques, if followed religiously stand good in preventing postoperative infection, even in compromised working condition

Total thyroidectomy as primary elective procedure in multinodular thyroid disease

Multinodular goitre is one of the commonest thyroid diseases encountered in the practice of surgery. The most common surgery being performed for multinodular goitre is subtotal thyroidectomy. Total thyroidectomy is designed to remove all of the thyroid tissue. The objective of this study was to evaluate total thyroidectomy as a primary elective procedure for treatment of multinodular thyroid disease. This descriptive study was carried out at Combined Military Hospital Rawalpindi from June 2003 to September 2006. 88 patients of multinodular thyroid disease were included. Patients having evidence of recurrent laryngeal nerve damage, recurrent goitre, evidence of altered parathyroid functions or evidence of malignancy were excluded. All patients underwent total thyroidectomy by the same team of surgeons and the patients were closely followed up for postoperative complications especially in terms of recurrent laryngeal nerve damage and hypocalcaemic tetany. No major postoperative complication was noted. Only 1 patient [1.14%] developed unilateral recurrent laryngeal nerve damage and 2 patients [2.27%] developed transient hypocalcaemia that recovered quickly. Total thyroidectomy as a primary elective procedure in multinodular thyroid disease is a safe option and it removes the disease process completely, lowers local recurrence rates and avoids the substantial risks of reoperative surgery

Comparison between pain relief achieved by Diclofenac alone and the combination of Diclofenac and Hyoscine in the short-term treatment of ureteric colic

This study aims to determine whether the combination of diclofenac and hyoscine gives superior pain relief than diclofenac sodium alone. A prospective, non-randomized comparative study. The study was conducted in the Emergency Department of Surgical Unit III at Combined Military Hospital, Rawalpindi from October 31, 2004 to May 01, 2005. A total of 100 patients were included in the study and distributed between two equal groups. Assessment of pain relief was done at 30 and 60 minutes after the administration of drugs. The diagnosis of ureteric colic was confirmed using urine analysis, plain radiography and ultrasonography. It was a prospective non-randomized comparative trial without blinding. A quasi-experimental study. A significantly [p < 0.05] greater number of patients treated with a combination of diclofenac and hyoscine achieved pain relief after 30 minutes as compared to those treated with diclofenac alone. No significant difference was found between the treatment groups after 60 minutes of drug administration. The combination of diclofenac and hyoscine gave a faster pain relief as compared to diclofenac alone in patients of ureteric colic

Circumcision - a comparative study

This quasi-experimental study was conducted in department of surgery in Military Hospital Rawalpindi from September 2003 to January 2004 with the aim to compare the results of one of the most commonly performed surgical procedure, circumcision, by open and bone-cutter method in terms of complications such as trauma to glans, bleeding and infection alongwith cosmetic outcome. Total 200 patients were selected from Out Patients Department on the basis of non-probability convenient sampling. After careful history taking and physical examination, patients fulfilling the criteria were identified into two equal groups, one underwent open method circumcision and the other bone cutter circumcision. Parents were instructed to follow up in the surgical OPD after seven days for assessment and earlier in case of any complication. There was insignificant different in terms of bleeding, superficial infection, cosmetic appearance and trauma to glans [P-value > 0.05]. Both methods proved to be safe and effective techniques with reproducible results but it is important to emphasize that trauma to glans; a well known and catastrophic complication is more common with bone cutter circumcision especially in the hands of an inexperienced operator

Tissue repair for inguinal hernia: should they be deleted from literature?

This is a pilot study to evaluate the status of herniorrhaphy procedures in the modern day surgery. Mar 1995 to Mar 2005 Military hospitals Descriptive and Analytical All entitled patients were included in this study and only those non-entitled patients were included who came for regular follow up. All the patients were booked at first admission and their record was maintained. They were subjected to herniorrhaphy by a modified Bassini's procedure. They were called for follow up at 3 months, 6 months then annually for 2 years. A total of 210 patients were operated for inguinal hernia by tissue repair over the period of study. Out of these 164 patients were operated by pure tissue repair, of which 148 were followed up completely and were included in the study. The average age was 50.16 +/- 19.12 years. The mean operation time was 20 +/- 5.84 minutes. Mean Hospital stay was 3 +/- 0.6 days. Recurrence was noted in 1 [0.68%] patient in a follow up period of 2 +/- 0.46 years. Tissue repairs hold good even today in the deserving patients and should be undertaken without hesitation where necessary. We should not hesitate in deciding for easier and cheaper alternatives when available

Effect of topical glyceryl trinitrate on the management of acute anal fissure

To find out the effect of topical glyceryl trinitrate on the symptoms and signs of acute anal fissure. Seventy-five patients were treated with 0.2% topical glyceryl trinitrate twice daily as local application in the anal canal with the help of cotton pledget, which was soaked in the ointment for four weeks and their symptomatology, and healing of anal fissure was assessed weekly. The study was carried out at a surgical unit of Combined Military Hospital Rawalpindi for six months from June 2004 to December 2004. Out of 75 patients, 42 had complete healing of anal fissure while six had partial healing. Thus the healing rate was 64% observed in our study. 0.2% Glyceryl trinitrate ointment is an effective way of treating acute anal fissure

Comparison o frequency of postoperative wound infection with the use of scapel/diathermy during electiv cholecystectomy

To determine frequency of postoperative wound infection with the use of scalpel /diathermy during elective cholecystectomy. Cross sectional [comparative] study. Surgical department unit IV, Military Hospital Rawalpindi and PNS Shifa Karachi, from September 2004 to March 2005. All patients [female and male] presenting with symptomatic gall stones who underwent open cholecystectomy through standard right upper transverse incision were included in the study. Patients were divided into two groups. Group A included 30 patients who underwent open cholecystectomy with scalpel and group B included 30 patients who underwent open cholecystectomy with diathermy. All patients who were having any co-morbid conditions like, diabetes mellitus, immuno-compromised state, pre existing infection at the site of skin incision and previous surgery were excluded. It was observed that out of 60 patients only 3 patients developed post operative wound infection In group A out of 30 patients with scalpel cutting only 1 patient developed wound infection which is 3.3% while in group B out of 30 patients with diathermy cutting only two patients developed wound infection which is 6.6%. Various other observations were found that males who developed cholelithiasis were 8.33% and females were 91.66%. Age distribution was minimum 27 years, maximum 75 years and mean age was 48.8 years. This study concluded that ratio of wound infection with scalpel cutting is less as compared to diathermic cutting and we can protect the patient from wound infection with the use of scalpel

Orthopaedic management of earthquake victims in a tertiary care teaching hospital - CMH Rawalpindi

This study is based on the orthopaedic management of casualties coming from earthquake area after 8[th] October 2005. 03 Months. All the patients requiring orthopaedic managements were subjected to major and minor operations including internal fixation, external fixation and conservative approach. A total 811 major orthopaedic operations were performed by all three orthopaedic teams at CMH Rawalpindi. 192 patients underwent soft procedures and 35 fasciotomies were carried out. 466 fixations were carried out including internal and external and rests were other procedures. It is concluded that proper triage, initial management of wounds and selection of implant playa major role for better .outcome in case of disaster casualties

Anaesthetic management of mass casualties-what should be the drug of choice?

Based on the experience of earthquake 8[th] October 2005 choice of best anaesthetic management for mass casualties was determined. Patients were subjected to all types of anaesthesia and then best out of these came out to be ketamine. One month. A total of 180 patients were anaesthetized by different methods during one month after earthquake. Out of 120 patients 80 received general, 74 ketamine, 22 spinal and 4 regional anaesthesia. 41% who received ketamine anaesthesia showed uneventful recovery without any complication. It is concluded that ketamine alone can be used very safely in case of mass casualties as also recommended in literature

Recurrent acute / chronic appendicitis an independent clinical entity

A multicenter descriptive study was carried out at CMH Abbottabad and PAF Hospital Sargodha. [Both hospitals are secondary referral centers] to determine whether chronic and recurrent appendicitis really exist in our population or not. Duration of study was from Feb 1996 to May 2001. All patients who underwent appendicectomy were included in the study and were divided into two groups, Group A with first episode of appendicitis and Group B with 2 or more episodes of abdominal pain. The patients were followed up for the relief of symptoms and this was assessed against the histological evidence of appendicitis. A total of 525 patients were included in the study out of which 67 had recurrent abdominal pain that was relieved after appendicectomy. The no of patients operated for recurrent abdominal pain fell with each passing year at both centers. However the annual number of patients undergoing appendicectomy remained same throughout the study period at both centers. It is concluded that in the evaluation of a patient with abdominal pain, a history of prior similar episodes of pain should never dissuade one from considering the diagnosis of recurrent acute appendicitis or chronic appendicitis