Single incision laparoscopic cholecystectomy with conventional instruments and ports: initial experience at tertiary care public sector Hospital

Objective: To find out safety and feasibility of single incision laparoscopic cholecystectomy [SLIC] using conventional instruments

Methods: This study was conducted at surgical department of LUMHS Jamshoro Pakistan from Jan: 2014 to Dec: 2015. All cases of symptomatic cholelithiasis that consented for laparoscopic surgery were included. The exclusion criteria were acute cholecystitis, acute gall stone pancreatitis, common bile duct stones and patients with co-morbid. A midline 3cm incision made supraumbilically and 10mm port placed. Two 5mm ports placed on either side of umbilicus slightly superior and laterally in order to triangulate. A 2/0 prolene suture placed through the infundibulum of the gall bladder to achieve retraction. The rest of the procedure is like standard 4 ports laparoscopic cholecystectomy

Results: Total no of cases were 50. The age ranged from 30-59 years [mean 35.20 years +/- 4.886.] There were 43[86%] females and 07[14%] males. The mean operating time was 80 minutes [range 50-120 +/- 16.020]. Four [8%] cases were converted to standard four ports laparoscopic cholecystectomy due to bleeding and difficult dissection in Calot's triangle. Minimal blood loss was observed during the procedure with no postoperative complications. The range of hospital stay was 1-2 days [mean 1.08 +/- 0.274]

Conclusion: SILC is a safe and feasible procedure with conventional laparoscopic instruments without additional cost of single port and articulated instruments. The cosmetic results are excellent with minimal increase in the operating time

Validity of surgical bypass in un-resectable pancreatic cancer

To evaluate the efficacy of surgical bypass as a palliative procedure in patients with pancreatic cancer. This prospective descriptive analytical study was conducted at Liaquat University of Medical and Health Sciences, Jamshoro, Sind, Pakistan from January 2005 to December 2010. All patients with obstructed jaundice and gastric outlet obstruction, later on diagnosed as pancreatic cancer are included in the study. LFT'S, Blood CP, Ultrasound abdomen, CT scan abdomen, and x-ray chest were performed in all patients. Surgical treatment was planned after assessing the resectability of the tumor. The variables studied included presentation, procedure performed, post operative complications and follow up after discharge from the hospital. The Chi square test is applied and data were statistically analyzed on SPSS v17. Forty three patients with a mean age of 62.09 +/- 6.782, with advance carcinoma of head of pancreas were operated and bypass surgical palliation was done. The morbidity, mortality and efficacy of various surgical bypass operations are evaluated. Bilio-gastric bypass still offers a reasonably safe and effective method of billiary decompression and duodenal obstruction caused by inoperable pancreatic cancer

evaluation of Milligan-Morgan and Ferguson procedures for haemorrhoidectomy at Liaquat university hospital Jamshoro, Hyderabad, Pakistan

To compare the outcome of Milligan-Morgan [MMH] and ferguson [fH] techniques for haemorrhoidectomy with regard to postoperative pain, control of bleeding, early mobilization of patients and wound healing. In this prospective, randomized clinical study conducted between January 2005 to December 2008, 213 patients with late 2[nd] degree; third or fourth degree hemorrhoids were assigned to two groups. One hundred ten patients in group A were operated by an open method and 103 patients in group B were operated by closed method. Age ranged from 22-70 years with mean age of 45.5 years. peak incidence was between 41-50 years. Out of 213 patients, 170 [79.81%] were male and 43 [20.18%] were females. The mean +/- SD operating time was significantly more in group B [31.3 +/- 4.8 min] than group A [25.2 +/- 5.6]. The duration of hospitalization and duration off from work was more in group A than the group B. Wound healing was quicker in group B than the group A. Post operative pain scores were significantly low in the Group A than Group B during first 24 hours and at first bowel movements. Reactionary hemorrhage occurred in 4 [3.63%] patients of group A, no patient in group B developed this complication. Retention of urine was seen in 13 [11.81%] patients in group A and 4 [3.88%] in group B. No patient in group A developed anal stenosis, while 3 [2.91%] patients in group B developed anal stenosis. Wound infection was one [0.9%] in group A and two [1.9%] in group B. Two [3.63%] patients in group A came with recurrent hemorrhoids and in group B, only one [0.97%] patient reported recurrence. The closed technique is more beneficial with respect to postoperative pain, control of bleeding, early mobilization of patients and wound healing

Reasons and morbidity of conversions in laparoscopic cholecystectomy

To identify variables and morbidity that lead to conversion to open surgery in laparoscopic cholecystectomy [LC] patients. Descriptive case series. Surgical Department of Liaquat University Hospital Jamshoro, from June 2005 to May 2008. All patients with symptomatic cholelithiasis were included. Patients with previous abdominal surgery, gall stone cholangitis and pancreatitis were excluded. A total of 619 patients [68 males and 551 females] underwent laparoscopic cholecystectomy. Forty [6.46%] patients were converted to open surgery. Regarding preoperative variables males had higher conversion rate of 72.5%[p <0.0001]. Mean age of the converted group was 55.2 +/- 2.5 year and mean age of laparoscopic group was 42.6 +/- 3.8 year [p 0.0003]. Conversion was more in patients with acute cholecystitis [p value <0.0001]. Obscured anatomy of Calot's triangle [45%] and equipment failure [15%] were major reasons for conversion. Operative complications leading to conversion were bile duct injury [5%], haemorrhage [7.5%], duodenal injury [1%], colonic injury [1%] and common bile duct stones [5%]. Patients in conversion group had higher rate of postoperative morbidity. This included wound infection [10.0%], fever [12.5%], bile leakage [5%] and intra abdominal collection [5%]. It increased the hospital stay to 4.3 +/- 0.3 days which for the laparoscopic group was 1.6 +/- 0.1 day [p <0.0001]. Possibility of conversion can be predicted pre-operatively with variables like male gender, old age, acute cholecystitis and during surgery by obscured anatomy at Calot's triangle

comparative study of the results of the anal fissurectomy and lateral internal sphincterotomy for chronic anal fissure

To compare the results of surgical treatment of chronic anal fissure resistant to conservative management, after anal fissurectomy or lateral internal sphincterectomy. One hundred forty five patients with chronic anal fissure failed to heal with medical treatment admitted in the Department of Surgery Unit II Liaquat University Hospital Jamshoro Sindh Pakistan, from January 2007 to June 2009 were studied. Patients were divided into two groups, 67 patients underwent Fissurectomy [F], and 78 patients underwent open lateral internal sphinterotomy [LIS]. We assessed the patients after median follow up of 12 months, for persistence of symptoms [pain, bleeding], complications and recurrence. All patients become symptoms free within 10 days of surgery. Urinary retention was noted in 3[2.06%] patients, 2[2.98%] in fissurectomy [F] and 1[1.28%] in lateral internal sphincterectomy [LIS] group. Incontinence to flatus was noted in 2[2.98%] patients of 'F' group and 1[1.28%] patient of 'LIS' group. Faecal soiling was noted only in 1[1.49%] patient of 'F' group. Recurrence occurred in 3[4.41%] patients of 'F' group, no recurrence seen in 'LIS' group. Wounds healed within six weeks. Sixty two [91.17%] patients of 'F' and 77[98.71] patients of 'LIS' group were satisfied with treatment. In the treatment of chronic anal fissure lateral internal sphincterectomy is the best surgical technique with very few complications and better patient satisfaction

Open versus close pneumoperitoneum: a pursuit for safer technique

Pneumoperitoneum is a prerequisite in all laparoscopic procedures. This is a very vital step and is still a matter of concern and a subject of further evaluation. Two basic methods commonly used with some modification are closed [veress needle] and open [Hasson] techniques and none of technique has proved to be better than other. We carried out this study to compare the two techniques in terms of access related complications and time consumed during creation of pneumoperitoneum and closure of port wounds. A comparative randomized prospective study was conducted in department of surgery. 475 patients were finally evaluated, 223 were randomized for open [Hasson] while 232 for closed [veress] technique. In open technique slight modification was used by making incision at junction of umbilical stalk and linea alba, while standard veress needle technique was used in closed group. Operative and post operative complications were recorded and analyzed. Mean time required to create pnemoperitoneum was significantly less with open group [6.61 +/- 3.89 minutes] compared to closed group [8.18 +/- 3.39 minutes]. Time required to close port wounds was also significantly less with open group as compared to closed group [7.41 +/- 1.87 versus 10 +/- 2.44 minutes]. No mortality and major complication regarding vascular and solid organ injury was recorded in both groups. Failure of procedure was observed in 4 cases [1.72%] in closed group and one case [0.44%] in open group. Bowel injury was recorded in two cases in closed group however it was not significant statistically. Other minor injuries were not significant on comparing both groups. Open technique is safe and quicker. We recommend this method in all cases of laparoscopy requiring access into abdominal cavity

Breast lumps in adolescent and young female: are all benign?

Objective: To analyze the pattern of presentation and pathology of breast lump in adolescents and young female patients

Methods: Medical records of female patients below 30 years presenting with palpable breast lump at Liaquat University Hospital during August 2008 to July 2009 were retrospectively reviewed. Patients having acute mastitis, inflammatory carcinoma and recurrent malignant or benign lesions were excluded from study

Results: A total of 214 patients were included in study. Mean age was 22.11 years. Approximately 46% of the patients were at the age 20 or less. Most common mode of presentation was painless lump in 61.22% followed by pain and lump in 20.56%.The histopathology of resected specimen showed that fibroadenoma was the most common lump while benign phylloides was the least common. Carcinoma breast was identified in 25 cases, of which 3 cases were at age 20 or less. The commonest histopathology was infiltrating duct cell carcinoma [60%], followed by lobular carcinoma [16%], scirrhous carcinoma [12%] and medullary carcinoma in 8 %. The Paget's disease was found in 4%

Conclusion: We found an increased frequency of breast cancer in comparatively younger age. These findings suggest that any female patient with palpable breast lump should preferably be managed by surgeon with special interest and training in breast diseases

Laparoscopic cholecystectomy without the use of drain in selected cases

Objective: To observe the effects of omitting the routine drainage after laparoscopic cholecystectomy, with respect to hospital stay, morbidity, and mortality

Methodology:This comparative observational study was carried out in the Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, from January 2009 to December 2009. During study period 100 consecutive cases of cholelithiasis, underwent laparoscopic cholecystectomy. The patients were divided in two groups; group A without drain and group B with drain. The effects of omitting the drain, regarding hospital stay, morbidity, and mortality were observed

Results: This study consists of 100 patients [male 22 and females78] with male female ratio of 1:3.54 and mean age of 37.86 years. Post operative hospital stay in patients without drain was 2.1 days as compared to 3.58 days for those with drain [p-value 0.000]. Moreover the use of drain has also been found to be associated with significant drain site pain / discomfort. There was no mortality in any group

Conclusion: We have observed that routine placement of drain after laparoscopic cholecystectomy, not only prolongs the post-operative hospital stay; it also leads to drain site pain / discomfort

Identification of recurrent laryngeal nerve during thyroidectomy decreases the risk of nerve injury

To determine the effect of Recurrent Laryngeal Nerve [RLN] exposure on the incidence of nerve injury, and compare the injury rate with that when nerve is not exposed during thyroid surgery. This prospective observational study was carried out in department of general surgery, at Liaquat University of Medical and Health Sciences, Jamshoro, from January 2005 to December 2006. A total of 120 patients were included, with 24 males and 96 females [male: female of 1: 4]. Mean age of our patients was 30.85 years [range 14-68 years]. The different surgical procedures, performed on thyroid gland included total thyroidectomy 23, near total thyroidectomy 58, subtotal thyroidectomy 28, and hemi-thyroidectomy 11. The RLN was exposed in 60 patients, in other group of 60 patients thyroidectomy was carried out without exposing RLN, and incidence of nerve injury was compared between two groups. RLN identification decreased the nerve injury incidence from 5% to 1.6%. When recurrent laryngeal nerve is not identified during thyroid surgery the chance to incur damage to RLN is statistically significant [Chi square at 1df 0.000] We believe that RLN identification during thyroidectomy would be the best approach to avoid nerve injury

Changing practice of rectal cancer surgery in Pakistan

To describe the presentation and pathology of rectal cancer, and to evaluate the local experience after total mesorectal excision at a tertiary care hospital in Pakistan. A retrospective study of two hundred cases of carcinoma rectum that had undergone total mesorectal excision at Liaquat University Hospital Jamshoro Pakistan was carried out from January 1998 to December 2007.The cases were admitted through outpatient and emergency departments. The demographic details of each patient and variables such as clinical presentation, tumor location, Dukes staging, TNM staging, operations and complications were recorded on proformas. Each patient was followed up at two months for one year, every four months for three years and annually thereafter. Male to female ratio being almost equal 1.6:1, Age ranged from 14-70 years. Site of tumor at upper one third 25%, middle one third 30% and lower one third 45%. Majority of patients [more than 62%] were in Dukes B Group. There were no postoperative deaths, complications occurred in a total of 59 [29.5%] patients, which were mostly colostomy related [13.0%]. The abdominal wound infection 5%, anastomotic dehiscence 1.0%, urinary tract infection 5%, and impotence occurred in 1.5%. In 20% patients' local recurrence was detected. Total mesorectal excision is a safe and feasible technique for rectal cancer surgery with acceptable perioperative morbidity and adequate local disease control

Gynaecomastia: management in a developing country

Gynaecomastia is a benign enlargement of male breast. It is common in the general population, resulting from various pathophysiological mechanisms. The aim of this study was to describe the presentation and outcome of treatment for gynaecomastia at a University Hospital in Pakistan. A three year retrospective study was carried out of one hundred men with gynaecomastia. Patients were evaluated in detail clinically and by appropriate investigations. They were counseled and kept on hormonal therapy for three months. Surgery was considered for patients with long standing gynaecomastia, failed medical therapy and for cosmetic reasons. Post operative complications and patient's satisfaction was assessed. Most [90%] cases were idiopathic. Other causes were liver cirrhosis in 4 cases, testicular tumour in two, thyrotoxicosis in one and drug induced [use of cimetidine and Kushta] in two. Carcinoma of the breast was diagnosed in one patient. Most of the patients had bilateral, non tender lump in the breast. Three cases of idiopathic gynaecomastia resolved on danazol. Eighty-eight cases underwent surgical treatment. The mean age of patients who underwent surgery [n=88] was 30.5 +/- 9.59 years. Most of the patients belonged to 21-30 years age group. Major indications for surgery were failure of medical treatment [45.5%] and cosmetic reasons [34.0%]. Mean operating time for subcutaneous mastectomy was 42.2 +/- 3.70 [36-48] minutes. Mean hospital stay after subcutaneous mastectomy was 5.2+2.44 [2-10] days. The only postoperative complication noted was wound infection [24%]. Seventy -two [81.8%] were satisfied with the results of their surgical treatment. Gynaecomastia is the common condition affecting male breasts and most common cause of gynaecomastia is idiopathic. Secondary gynaecomastia may regress in size by treating the primary cause. Idiopathic gynaecomastia do not respond to danazol so they needed surgical treatment. Subcutaneous mastectomy through a periareolar skin incision is a valid procedure for treatment for gynaecomastia and provides satisfactory cosmetic and provides satisfactory cosmetic results

Management of giant inguinal hernia

Objectives: to determine the frequency and evaluate the clinical presentation and management policies of giant inguinal hernia

Design: descriptive study

Place and duration of study: this study was conducted in the department of surgery at Liaquat University of Medical and health Sciences Jamshoro / Hyderabad and Rajputana Hospital Hyderabad from October 2000 to September 2002 [two years]

Material and methods: male patients of all ages with giant inguinal hernia diagnosed clinically were included in the study. A uniform system of history taking, physical examination, investigations and treatment was adopted for all patients and information was recorded on predesigned proforma

Results: all 30 patients were male with age ranging from 50 to 70 years. Average age being 54.33 +/- 5.62. Most of the patients 60% were farmers by occupation and having right sided giant inguinal hernia. Ninty percent of patients presented as an uncomplicated case with complaints of giant inguinoscrotal swelling causing difficulty in walking, sitting and difficulty in voiding. Only 3 cases [10%] were admitted with features of intestinal obstruction. Out of 30 cases, 14 [46.66%] underwent basini repair while 8 [26.66%] underwent repair with mesh and orchidectomy. Right hemicolectomy including resection of half portion of ileum with orchidectomy and mesh repair was done in 8[26.66%] patients. Two patients of 70 years died due to cardiorespiratory failure while one patient died because of renal failure. Clinically maximum number of patients [46.66%] belonged to MHL grade-I while only one patient belonged to MHL grade-IV. Postoperative complications, hematoma in 5 patients[41.6% cases] and wound infection in 4 patients [33.33%] were the most common complications followed by chest infection developed in 3 [10%]. Twenty cases [66.66%] had hospital stay of 7 to 9 days while others were discharged late due to postoperative complications

Conclusion: the frequency of giant inguinal hernia is more among patients of old age, labour class and from rural areas. It is common in our population because of ignorance of hernia, living in remote areas and unawareness of complications of the disease

Volvulus of caecum

This case report describes volvulus of caecum in a young boy of 18 years, who presented with symptoms of acute abdomen. The condition was diagnosed at laparotomy and the patient was treated with right hemicolectomy

Superiority of laparoscopic appendectomy over open appendectomy: the hyderabad experience

To compare the out come of laparoscopic and open appendicectomies in terms of operative time, analgesic requirement, postoperative complications, hospital stay, return to normal activity and condition of scar. This prospective study was carried out in Department of Surgery, Liaquat University Hospital Hyderabad/ Jamshoro from September 1997 to August 2000. One hundred consecutive patients of age ranging from 15-45 years with features suggestive of acute appendicitis were equally divided into laparoscopic appendectomy [LA] and open appendectomy [OA] groups, after taking informed consent. LA was done with the help of three trocar/cannulae creating pneumoperitoneum with CO2 whereas OA was performed by Lanz incision. The data were analyzed by Student t-test and Chi square tests using SPSS version 10. The operating times in OA and LA were 20-70 minutes [mean 30] and 25-95 minutes [mean 55] respectively. Increased doses of analgesics, antibiotics and antiemetics were required in OA, as compared to LA. The mean postoperative hospital stay in LA group was 1.4 days [range 1-3 days] whereas it was in OA group, it was 3.5 days [range 2-6 days]. 2 LA is safe and has major benefits like less postoperative pain, decreased wound infection, early hospital discharged, early return to work and a better cosmetic scar than OA

audit of renal cell carcinoma at Hyderabad

To audit the patients of Renal Cell Carcinoma treated in Surgical Unit-IV, Liaquat University Hospital Jamshoro, Hyderabad. Prospective interventional study conducted from Jan. 2000 to Dec. 2004. Department of Surgery, Liaquat Medical University Hospital, Jamshoro. All patients who presented with Renal Cell Carcinoma during the study period. The history and examination findings of all these patients was recorded. Complete blood picture, urine analysis, liver function tests, ultrasound abdomen, IVU and CT scan was done in all the cases. Staging was done according to the TNM classification and surgery performed in fit patients. A total of 39 cases of Renal Cell Carcinoma were seen during the study period, with a male to female ratio of 3.3:1 and a mean age of 46 years. Most [61.53%] patients presented with a mass in the abdomen; 51.28% were in Stage-II and 25. 64% in stage-III. Thirty four [87.18%] cases were operated, the rest being unfit. Radical nephrectomy was done in 51.28% cases, simple nepherectomy in 10.26%, debulking surgery in 20.51% and biopsy only in 5.13% cases. Three [8.8%] patients died due to postoperative complications. Radical surgery is the curative treatment for Renal Cell Carcinoma. Cases should be diagnosed early in order to decrease the morbidity and mortality of the disease

Carcinoma stomach. a thrapeutic challenge

A five year retrospective study was carried out in Surgical Unit - IV Liaquat Medical College Hospital Jamshoro. The cases of carcinoma stomach admitted from January 1993 to December, 1997 were included in the study to determine the clinical presentation and treatment of gastric cancer. Duration of symptoms were less than six months in 70 percent cases. Abdominal pain [60 percent], vomiting [54 percent], peptic ulcer symptoms [50 percent], GIT bleeding [36], dysphagia [36 percent] weight loss [40 percent] palpable mass [48 percent], ascites [34.3 percent] and hepatomegaly [42.8 percent] were the main clinical presentations. Out of 50 cases 35 were operated, 15 being unfit for the operation. Out of 35 cases no procedure could be performed in 15 cases due to advanced stage of disease. Palliative gastrectomy was performed in 10 and curative surgery in another 10 cases. Duodenal leakage [14.3 percent], bleeding [11.43 percent], wound infection [8.5 percent], UTI [17.14 percent] and small bowel obstruction [2.83 percent] were major complications. Upper GIT endoscopy for early diagnosis of carcinoma of stomach is essential especially before starting treatment for peptic ulcer symptoms

comparative study of sutured versus stapled gastrointestinal anastomosis

A prospective study was carried out at Surgical Unit IV, Liaquat Medical College Hospital, Jamshoro to compare hand sutured with stapled anastomosis from April 1994 to March 1998. Of the total 91 patients in the study, 58 were hand sutured while 33 underwent stapler anastomosis. Patients were divided into seven categories according to the type of anastomosis viz. oesophagogastric [9 sutured, 13 stapled], small intestinal [22 sutured, one stapled], ilcocolic [12 sutured, 3 stapled], colonic [8 sutured, 14 stapled], colorectal [3 sutured, 6 stapled], ileoanal [2 sutured, 3 stapled], and coloanal [2 sutured, 3 stapled]. The occurrence of anastomotic leak was 13.79% in sutured and 9.09% in stapled group whereas stricture formation was 3.72% in sutured and 12.12% in stapled anastomosis. The incidence of wound infection was 1.34% in sutured and 6.6% in stapled group, while reactionary haemorrhage was 3.72% in sutured and 6.6% in stapled anastomosis. The mortality was 10.39% in sutured and 9.09% in stapled group. It was concluded that in stapler anastomosis a lot of time is saved, hospital stay is short, and morbidity and mortality is decreased

Carcinoma of gall bladder

To determine the incidence, clinical presentation and management of Carcinoma of gall bladder. Design: A prospective study of 20 cases of histologically proved Carcinoma gall bladder found in 230 cases of gall bladder disease operated from January 1993 to December 1994. Settings: Surgical department Liaquate Medical College Hospital, Jamshoro, Hyderabad. Subjects: Twenty cases of Carcinoma of gall bladder. Main outcome measures: Clinical features, investigations, management and follow up of the patients. The mean age of patients was 50 years and female to male ratio was 4 to 1. Clinical presentation was 90% had pain right hypochondrium, 50% had lump right hypochondrium and 20% had jaundice. Investigation were not helpful in the diagnosis. Fourteen cases underwent cholecystectomy, 1 partial cholecystectomy and 5 cases had biopsy only. All cases died within 6 months expect incidentally found carcinoma gall bladder. Early cancer is asymptomatic and investigations are not helpful in the diagnosis. The advanced cancer is incurable and long term survival can be expected in incidentally found carcinoma of gall bladder