Use of box simulators for improving intraoperative laparoscopic skills: an essential tool for the surgeon in training

To compare the improvement of intraoperative laparoscopic skills by measuring GOALS score between residents who have undergone simulator training with those who have not received any simulator training. A randomized controlled trial. Department of Surgery, Services Hospital, Lahore, from August 2013 to February 2014. Thirty residents belonging to year 1, 2 and 3 were included in the study. They were randomly divided into 2 groups. Both groups had a baseline evaluation with GOALS score while performing dissection of gallbladder from liver bed during laparoscopic cholecystectomy. Group-A underwent formal training on simulators whereas group-B did not receive any formal training on simulators. After 6 months, a repeat evaluation was done again by measuring GOALS score while performing gallbladder dissection. Baseline GOALS scores of both the groups were similar. Group-A baseline score was 7.66 +/- 0.93 and group-B score was 7.46 +/- 1.04 [p = 0.585]. However repeat scores for group-A showed a significant improvement [an increase of 7.16 +/- 1.48 to 14.76 +/- 1.67, p < 0.001] from baseline scores. Residents in group-B improved their scores by 2.30 +/- 0.99 to 9.76 +/- 0.79 [p < 0.001]. When inter group comparison was done the second score of group-A was significantly higher than that of group-B [14.76 +/- 1.67 vs. 9.76 +/- 0.79, p < 0.001]. Inter-rater reliability was moderately significant [Kappa 0.540]. Training on laparoscopic simulators results in significant improvement of intraoperative laparoscopic skills

Malignant Melanoma: presentation as a primary retroperitoneal tumor

This is a case report of an extremely rare primary malignant melanoma presenting in the retroperitoneum of a 30 years old female. She was operated in a District General Hospital with a presumptive diagnosis of hydatid cyst of right lobe of liver. The patient bled profusely on exploration and the surgeon packed the abdomen and referred her to our emergency, where she was received in shock. After resuscitation she was operated on the next available list and was found to have a very vascular, pigmented, retroperitoneal mass measuring 10-x 12-cm lying in front of the infrarenal IVC pushing the duodenum towards the midline. It was completely excised. Histopathology showed it to be a malignant melanoma. Upon subsequent examination and extensive workup, no evidence of a primary malignant melanoma was found. There was no past history of a melanoma which may have regressed spontaneously or excised. After extensive search of literature we could not find another report of a primary retroperitoneal melanoma

Critical factors in determining mortality from penetrating abdominal vascular trauma: the Mayo Hospital experience

Mayo Hospital Lahore is a big and busy trauma center in Pakistan that receives a substantial number of patients with penetrating abdominal trauma. Vascular injuries in these patients are not uncommon. They are difficult to repair and are usually associated with a high mortality. The purpose of this study was to review treatment principles, complications and factors affecting the outcome variables in our setup in these cases, the main outcome variable being survival. Complete medical records of 411 patients with penetrating abdominal injuries, operated in our emergency over a four years period [January 1996 - December 1999], were reviewed. Amongst these 57[13.86%] had significant abdominal vascular injuries. The commonest afflicting agents were firearms [81%]. The overall mortality was 31.5%. The highest mortality was associated with retro-hepatic vena caval injuries [66.6%]. Very high mortality rates were seen in patients who were admitted with un-recordable blood pressure [72.2%] and in patients who had combined arterial and venous injuries i.e. more than one abdominal vascular injury [42.8%]. Mortality seems to be directly related to the site of the vascular injury [high for supra-renal / retro-hepatic vena caval injuries], the presence of shock on admission, free bleeding and the lack of retro-peritoneal tamponade at the time of surgery, and the presence of additional vascular injuries. The major cause of death in our patients was profound shock due to uncontrolled bleeding. Early diagnosis, prompt intervention and effective management could result in improved salvage rates