Inguinal hernioplasty; laparoscopic tep with and without dissection balloon

To compare laparoscopic TEP Inguinal hernioplasty with and without dissection balloon. Observational study. Minimal Invasive Surgical Centre Jamshoro and General Surgical Department at Dow University Hospital, Ojha Campus Karachi. May 2011 and Dec 2012. Twenty [20] male patients with uncomplicated unilateral or bilateral inguinal hernia were prospectively randomized in two groups; group A Commercially available dissection balloon and group B. Telescopic dissection for creating TEP working space. We had 20 male patients for this study. The average age was 43.6 and ranging between 17 to 64 years. Only 2 patients 10% had bilateral groin hernia, 4 patients 40% had direct inguinal hernia in group A and 5 patients 50% had direct hernia in group B. Peritoneum was breached in 5 [50%] patients with telescopic dissection. One patient [10%] with bilateral groin hernia in group B had large tear in peritoneum converted to TAPP while other group normal. The incidence of scrotal edema/seroma was greater in group B then group A. 40% patient in group B developed seroma while 0nly 1 [10%] patient with bilateral groin hernia in group A developed seroma. Pain was scored on VAS at 1 and 4 hours after surgery was higher in group B. The mean operation time was 55 min [45-100] in the group with the balloon and 73 min [50-120] in the group without the balloon [p = 0.004]. TEP laparoscopic inguinal hernia repair is probably the best option amongst the two techniques used in laparoscopic inguinal hernia repair and dissection with balloon is though costly but more helpful in dissection and safer

Role of laparoscopy in peritonitis

Laparoscopy has gained clinical acceptance in many subspecialties in the last decade. The conventional open surgery for peritonitis carries significant morbidity and mortality. The present study was done to extend and evaluate benefits of minimally invasive surgery in this subset of patients. This was a prospective study spanning over a period of four years. All those patients diagnosed as having peritonitis on clinical assessment and preoperative investigations and those who were stable enough haemodynamically were included in this study. After initial resuscitation for few hours, they underwent diagnostic and therapeutic laparoscopy to identify the cause of peritonitis and to confirm the pathology. All cases were done under general anesthesia, using three standard ports at appropriate sites according to pathology. Patients were treated by different procedures either laparoscopically or with laparoscopic assistance after diagnosis. Operative and post operative data was collected and analyzed. Ninety two cases of peritonitis underwent diagnostic and therapeutic laparoscopy. Mean age of patient was 46.5 years. 24 patients were diagnosed as perforated duodenal, in 14 [58.3%] patients laparoscopic suture repair was done and in 8 [33.3%] small upper midline incision was given and perforation was repaired. Out of 32 patients having perforated appendix, 25 [78.1%] patients laparoscopic appendectomy was done while in 7 [21.8%] perforation was dealt by laparoscopic assistance. Out of 14 patients of ileal perforation 6 [42.8%] with minimal contamination laparoscopic suture was applied, while in 8 [57.1%], perforated loop was brought out by making small window and perforation was closed. All 22 patients with pelvic sepsis needed only aspiration of pus and peritoneal lavage. Only one patient died post operatively and 2 [2.1%] patients developed fistula. 6 [6.5%] patients developed port site infection. Laparoscopic management is feasible, safe and effective surgical option for patients with peritonitis due to different abdominal emergencies in properly selected cases with higher diagnostic yield and a faster postoperative recovery

Biliary bypass surgery - Analysis of indications and outcome of different procedures

This study reports the indications and outcome of various biliary bypass surgical procedures from a single centre over a period of 10 years. This is a prospective observational study conducted over a period of 10 years [January 2001-december 2010]. A total of 1500 patients were included, who underwent pancreatico-biliary surgery due to common bile duct [CBD] stones, congenital anomalies of biliary tree, unoperable pancreatico-biliary malignancies, CBD strictures and cases who developed iatrogenic biliary injuries during cholecystectomy [both open and laproscopic] during this period of time. The patients who required biliary bypass surgery were further analysed for indications and outcome. Out of 1500 patients 83 [5.53%] required biliary bypass surgical procedures. The CBD stones were observed as the most common indication [25.3%], followed by CBD injuries after open [10.84%] or laproscopic-cholecystectomy [14.46%], carcinoma head of pancreas [12.05%] and CBD obstruction [14.46%] either due to CBD strictures or unknown distal obstruction. Roux-en-Y-hepatico-jejunostomy [26.51%] was the most frequently performed procedure, followed by choledochoduodenostomy and Roux-en-Y choledocho-jejunostomy [i.e. 25.3% and 12.05% respectively]. Roux-en-Y biliary bypass procedure was observed to be associated with better outcome in terms of rate of complications as well duration of hospital stay. Biliary bypass surgical procedures are the better options to restore the continuity of biliary system in patients with iatrogenic biliary tree injuries and un-operable pancreatico-biliary malignancy. Roux-en-Y biliary bypass procedure is safe and problem solving method in these cases

Laparoscopic management of hydatid cysts of the liver at a tertiary care hospital

To evaluate the feasibility and safety of laparoscopy in the management of hydatid cysts. All consecutive patients diagnosed with liver hydatid disease were offered laparoscopic management. We performed select conservative procedures using standard laparoscopic instruments after sterilization of the cysts with 20% hypertonic saline. Deroofing, evacuation and partial cystectomy were performed. Omentoplasty was performed, and a drain was placed in the cyst cavity. A total of 63 patients [M:F=48:15] with 75 cysts were managed successfully by laparoscopy. The mean age +/- SD of the patients was 38.59 +/- 11.46 years old. The mean operative time +/- SD was 88.24 +/- 23.52 minutes [range: 52-145 minutes]. The mean size of the cysts was 9.2 cm [range: 5.8-16.5cm]. The mean hospital stay +/- SD was 3.49 +/- 1.16 days [range: 1-7 days]. There was no disease or procedure related mortality. Recurrence of a cyst was observed in 3 [4.76%] cases. Open surgery had to be performed on four patients. There were no major complications; minor biliary leaks were observed in 7 cases and cavity infections in 5 cases. The mean follow-up +/- SD in 51 patients was recorded as 28.9 +/- 31 months. Laparoscopic treatment of hydatid cysts of the liver is safe and effective, with low morbidity and a low recurrence rate in uncomplicated cysts. Despite some of its limitations, the procedure is a good alternative to open surgery in select cases.

Post laparoscopic cholecystectomy exploration: an audit

This study was conducted to analyse the different causes and factors for exploration and their management after laparoscopic cholecystectomy in 1000 cases of cholelithiasis. This is a prospective study conducted in the department of surgery Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan, from January 2003 to December 2010. Thousand cases of cholelithiasis were operated for laparoscopic cholecystectomy in eight years and were observed for their recovery and complications postoperatively. Those patients who developed major problems were assessed clinically and by different investigations like LFT, Ultrasound, CT scan and HIDA scan to find out the cause. They were operated once absolute indication of exploration was made. All patients were included in study after getting informed consent for first operation as well as for Re-do surgery if any one required exploration. Out of 1000 cases, 58 patients [5.8%] developed unidentified complications during laparoscopic cholecystectomy who required surgery for one or other reason. The problems which required exploration were bleeding in 2.2%, biliary leak in 1.9% and obstructive jaundice in 1.0% of cases as main reasons. The cases were managed by various open surgical procedures depending upon the pathology found on exploration. Laparoscopic cholecystectomy though proved as gold standard for cholelithiasis but still is not free of complications and can land up into major problems for patients who had either difficult cholecystectomy or over looked congenital anomalies of biliary tree

Haemorrhoids

The objectives of the study are to compare the outcome of the Doppler Guided Haemorrhoidal Artery Ligation and open Haemorrhoidectomy in 2nd and 3rd Degree Haemorrhoids. Comparative study. Study was carried out at the General Surgical Department at Liaquat University Hospital, Jamshoro and private hospital Hyderabad from 2008-2009. Study consisted of 50 patients of diagnosed cases of heamorrhoid. Patients were divided in two groups. In Group A Standard open Haemorrhoidectomy and Group B we used Doppler Guided Haemorrhoidal artery ligation. Detailed history was taken from all the patients with special regard to the bleeding per rectum or some thing coming out during defecation and Clinical examination of anal canal DRE and Proctoscopy was done. In both groups male were 37 [74%] and female 13 [26%] with male: Female Ratio of 2: 8:1. Age ranging from 20 to 60 years in both group, mean ages of patients were 38.28 + 10.355 years. 3rd degree haemorrhoid 31[62%] while 2nd degree 19[38%]. Complications were mild to moderate pain 24[96%] patients in DG -HAL group while moderate to severe pain 23[92%] in excisional heamorrhoidectomy group. Anal stenosis in 2[8%], patients, anal fissure 1 [4%] patients and feacal incontinence 1[4%] patients were observed only in excisional heamorrhoidectomy. Recurrence occurred in one case [4%] in each group. DG-HAL procedure has a low rate of complications, earlier mobilization, implies a shorter hospital stay and offers the patient a more comfortable postoperative period than Excisional heamorrhoidectomy procedure

Comparative study of conventional open versus laparoscopic cholecystectomy for symptomatic cholelithiasis

To compare the results of conventional open with laparoscopic cholecystectomy regarding their operative time and postoperative parameters. This is a comparative study of 400 patients of cholelithiasis operated for either open or Laparoscopic cholecystectomy during five years from January 2004 to December 2008. The cases were compared for operative time and various postoperative parameters in order to assess the advantages and disadvantages of each procedure. The patients were divided into two groups; group OC for open and group LC for laparoscopic cholecystectomy, each comprising of 200 cases. The operative time was longer in OC than LC patients with mean operative time of 54.16 +/- 11.94 minutes in OC and 46.89 +/- 14.83 minutes in LC group [P<0.001]. The overall frequency of postoperative complications was relatively high in OC group 50.5% as compared to LC [37%] including all minor and major problems with combined morbidity of 43.75% [P<0.001]. The mean hospital stay was shorter in LC group as compared to OC group i.e. 3.02 +/- 1.75 [range 1-5] days versus 5.56 +/- 9.8 [range 4-10] days respectively. Return to normal work was also significantly shorter in LC group i.e. 18.06 +/- 5.16days [range 1-4 weeks] as compared to 31.61 +/- 7.6 days [range 3-6 weeks] in OC group with p value <0.001. The laparoscopic cholecystectomy is superior to open cholecystectomy due to short operative time, early mobilization and fast recovery, less postoperative pain and complications, short hospital stay and early return to work

Efficacy of strictureplasty in tuberculous strictures of small intestine

To assess the efficacy of strictureplasty for tuberculous stricture of small intestine. This is a retrospective descriptive study, conducted at Liaquat University Hospital Jamshoro [LUH] during period of 5 years from July 2004 to June 2009. Sixty patients of small intestinal tuberculosis presented with stricture of small intestine and underwent strictureplasty were the subject of this study. The procedure was done conventionally in all cases, in 70% intestine was closed in two layers while in remaining it was done as single layer. Early complications were seen in 23 cases which included anastomotic leakage with fistula formation [9 cases [15%]], burst abdomen [5 cases [8.34%]] and subdiaphragmatic abscess [9 cases [15%]] The late complications observed after mean follow up of two years include intestinal obstruction that necessitated readmission was seen was in 9 cases [15%], however the re-exploration was required in five cases. Incisional hernia was seen in 9 cases [15%].Though the post operative complications are frequent after strictureplasty yet the procedure is safe and simple for tuberculous stricture of small intestine as it requires minimum expertise, less operative time and above all preserve gut's length

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

Factors responsible for prolonged postoperative hospital stay after laparoscopic cholecystectomy

To identify various factors which prolong post-operative hospital stay after laparoscopic cholecystectomy. This is an observational prospective study conducted at a teaching hospital over a period of five years [Jan 2005-Dec 2010] and includes 580 patients of symptomatic cholelithiasis, admitted and treated by laparoscopic surgery. All patients were observed from 1st postoperative day to date of discharge and different operative, postoperative and patient related variables were recorded on a proforma which were found responsible for an unduly prolonged post-operative stay in the hospital. The duration decided for short stay was 48 hours and duration more than that was considered as prolonged stay. Out of 580 patients, 187 [32.24%] had prolonged stay extending from 3-28 days. Majority of patients presented in 4[th] and 5[th] decade [60.52%] with pain in right hypochondrium [58.79%] and pain in right hypochondrium combined with pain in epigastrium [27.6%] as main clinical features. Twenty eight variables were identified comprising of 10 patients related [15.86%], 12 surgery related [16.55%] and 6 post-surgery related [16.38%] which contributed to prolong the hospital stay. Patients having co morbid conditions, difficult operative procedure and major postoperative complications were main factors for prolonged stay. The prolonged post-operative hospital stay can be reduced by careful pre-operative assessment, meticulous surgery and proper post-operative management

Laparoscopic versus inguinal [Ivanissevich] varicocelectomy

To compare the postsurgical outcome of laparoscopic and open inguinal varicocelectomy. Quasi-experimental study. Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, from July 2003 to June 2007. One hundred seven patients underwent either open inguinal or laparoscopic varicocelectomy. Diagnosis was made by clinical examination and color Doppler scan in doubtful cases. Pre-operative semen analysis was done in all patients. Operative time, postoperative analgesic requirement in number of tablets, hospital stay in days, improvement in semen parameters in subfertile subjects, pain on visual analog score, and postoperative complications were recorded and compared between the two groups. There were 50 patients in each group, with age ranging from 12-50 years [26.9 +/- 7.67 in open inguinal and 26.2 +/- 7.08 in laparoscopic group]. Average operative time was 34.8 +/- 7.89 minutes for open inguinal and 43.8 +/- 8.95 minutes for laparoscopic group. The analgesic requirement was 16.3 +/- 1.58 tablets in the open inguinal and 11.3 +/- 2.23 in the laparoscopic group. Postoperative pain was significantly less in the laparoscopic group. There was statistically significant [p < 0.001] improvement in sperm count as well as motility in both groups irrespective of procedure. The open inguinal [Ivanissevich] procedure and laparoscopic varicocelectomy had almost equivalent postoperative outcomes regarding improvement in semen parameters and postoperative complications. Open inguinal procedure had a shorter operating time while laparoscopic varicocelectomy had the advantage of less analgesic requirement and short hospital stay. On the whole, open inguinal [loupe magnified] varicocelectomy is an effective procedure where availability and costs of laparoscopic instruments are barriers

Emergency laparoscopic cholecystectomy in acute cholecystitis

To study the presentation and outcome of cases operated for Gynecomazia. A retrospective study spread over four years i.e. June 2002 to May 2006. Different hospitals of Karachi including Civil Hospital. 46 males who were admitted for surgery of Gynecomazia. All patients included in this study were evaluated in detail clinically and by appropriate investigations. They were counselled about the condition, and operated via a peri-areolar or sub-mammary incision, and the outcome noted in terms of healing and complications. Out of the 46 cases, majority [71.74%] presented in the age group 11-20 years with peak incidence around 16 years of age. The main symptom was breast enlargement, though pain or discomfort was also seen in 12 [26.1%] patients. The size of the breasts varied between 4-8 cms, and 34 [73.9%] cases were bilateral. Surgery was done for macromastia in 7, long standing gynecomazia in 11 and cosmetic reasons in 28 cases. Wound infection and hypertrophic scar formation constituted the few complications noted. Gynecomazia is the commonest condition affecting male breasts. In majority of the cases counselling and observation is all that is required for management, as they subside spontaneously or on medication. Surgery is indicated in those cases that do not subside or on patient demand