Mini laparoscopic cholecystectomy: a better outcome

The outcomes after traditional laparoscopic cholecystectomy [LC; one 10 mm port, one 12 mm port and two 5 mm ports] and mini laparoscopic cholecystectomy [MLC; three 3mm ports and one 12mm port] for gall stone disease were compared. The study was a randomized, single blind trial comparing LC with MLC. The randomization period was from February 2003 to December 2004. Two groups of patients underwent the surgery, 48 underwent LC and 47 underwent MLC. Patients were randomized by means of a blind envelop system just before surgery. The groups were matched for age, sex and preoperative characteristics. Median [range] operating times for LC and MLC were similar 45 [20- 120] and 50[20-170] mm. respectively. Intraoperative and postoperative complication rates, the time for the patient to resume walking, eating and passing stools, and median hospital stay were the same in the two groups. The level of post operative pain was lower in the MLC group at 1 h, 3h, 6h, 12h and 24h. Patients who had MLC received fewer injections of analgesic [p=0.036] and more patients in this group expressed satisfaction with the cosmetic result [p= 0.001]. MLC took a similar time to perform and caused less postoperative pain than the standard laparoscopic procedure. Reducing the port size further enhanced the advantages of laparoscopic over open cholecystectomy

Ambulatory hemorrhoidectomy

Hemorrhoidectomy is eligible for day case surgery, but the presences of postoperative pain and! or urinary retention interfere with this concept. This study aimed to use local anesthesia with posterior perineal block [PPB] technique to perform hemorrhoidectomy with comfort and to decrease the postoperative pain and urinary retention allowing early patient discharge. Sixty patients with 3rd or 4th degree hemorrhoids were randomized into two groups. The first group; 20 patients [15 men and 5 women, mean age 40.7 +/- 9.27] received general anesthesia [control group]. The second group; 40 patients [31 men and 9 women, mean age 42.4. +/- 8.83] received PPB with 50 ml ropivacaine 0.5%. Milligan - Morgan hemorrhoidectomy was then undertaken for all patients. There were no local or systemic toxicity for ropivacaine. In the PPB group, the intraoperative analgesia was adequate in 87.5% patients. The postoperative pain was assessed at 30 minute, 2, 4, 8, 12 and 24 hours using visual analog scale WAS]. At all time pain was less in the patients who had received PPB. The rate of urinary retention was 5% [2 patients] in PPB group while it reaches 25% [5 patients] in the control group. Thirty eight patients [95%] in the PPB group and 10 patients [50%] in the control group were discharged on the day of surgery. By the six postoperative weeks all hemorrhoidectomy wounds were healed. PPB technique is safe and provide adequate anesthesia to perform hemorrhoidectomy associated with decreased postoperative pain, urinary retention as well as postoperative analgesic requirements

simple method for treatment of pilonidal sinus

The multiplicity of treatment options available for pilonidal disease reflects the general controversy concerning its management. Sometimes there is no need for the more complex and time consuming procedures namely local flaps. In this study a simple technique consists of excision of the sinus[es] with primary closure after insertion of suction drain for irrigation with antiseptic solution was carried out. A total of 39 patients, 32 [82%] were males and 7 [18%] were females aged between 18-39 years; median 28.5 years with chronic pilonidal sinus[es] were included in the study. After methylene blue staining of the quiescent pilonidal sinus[es], an elliptical incision followed by excision of the sinus was carried out. After haemostasis by diathermy knife a suction drain 12 FG was brought out from the right and left side of the upper end of the wound. The wound is then closed in one or two layers. All patients had been discharged on the day of surgery or maximally the next day. Irrigation of the wound with 4-5ml of betadin solution followed by 4-5m1 of normal saline at 2nd, 4th and 6th day postoperatively at out patient clinic was done. Both limbs of suction drain were shortened 2-3cm at day 7 and removed with stitches at 10th day. Postoperatively, one patient had erythema which improved after change of the antibiotic and there were no deep wound sepsis, haematoma, seroma or necrosis of the wound edges. All wounds healed by primary intension and there was no recurrence during the follow up period [6-24 months]. This, simple procedure of pilonidal sinus excision, primary closure and application of suction-irrigation drain leads to satisfactory outcome with low morbidity rate

cutting seton technique for management of high perianal fistula

Seton technique have been used for treatment of high perianal fistula for thousands of years with successful results. This prospective study reports the results of the cutting seton technique in addition to distal fistulotomy for treatment of high perianal fistula. Twenty two patients, 17 [77.3%] males and 5 [22.7%] females, aged between 20 and 57 years [median 35.5 years] presented with high perianal fistula included in this study. While the patients in the lithotomy position, injection of methylene blue followed by probing was done, care was taken not to do false passage. Subcutaneous track was bayed open till anal sphincter complex, the anoderm and the mucosa overlying the fistula was incised, 2 Nylon No 1 sutures were passed through the fistula and tied over the sphincter complex. The ties were tightened every two weeks in outpatient clinic postoperatively. Thirteen [65%] patients had a normal postoperative continence but 7 patients [35%] had postoperative incontinence [4 patients [20%] incontinent for gases, 2 patients [10%] incontinent for liquid stool and one patient [5%] incontinent for solid stool]. Six patients had been completely recovered and one had permanent incontinence. All fistulae were healed from 10 to 20 weeks [median 14 weeks]. There were two fistulae recurrence during the study period, one was treated successfully by the same procedure

Role of surgery for chronic groin pain by inguinal neurectomy

Inguinal nerve entrapment is a debilitating post operative problem. Fifty patients were treated for inguinal nerve entrapment including 26 men and 24 women with an average age of 45 +/- 14 years Most patients had inguinal hernia repairs or Pfannenstiel incisions. Mesh was found in 27% of patients. Symptoms included pain [100%] radiation of pain to the thigh and/or genital area [59%], and postural pain [59%]. Diagnosis was made by physical examination, postural maneuvering, and inguinal nerve block. Proximal nerve resection was followed by polyester ligature and absolute alcohol application to prevent neuromas. Eight percent of patients had minor complications. Total pain relief was attained in 72% of patients, partial relief in 25%, and no relief in 3%. Two patients complained of numbness postoperatively. Multifactorial analysis showed recurrent hernia repair as a significant predictive factor

surgical options for graves' disease

Sixty consecutive patients [12 men and 48 women with mean age +/- SD 31.92 +/- 11.11 years] undergoing surgical treatment for Graves' disease were randomized to have either total thyroidectomy [TT, n = 30] or subtotal thyroidectomy [ST, n = 30]. There were no mortality, postoperative bleeding or thyrotoxic crisis. There were no permanent recurrent laryngeal nerve [RLN] palsy or hypocalcemia in either groups. Temporary unilateral RLN palsy occurred in one ST patient and in three TT patients. Temporary hypocalcemia occurred in 33 out of 60 patients; 20 patients in TT and 13 patients in ST. So, TT does not present more complications with respect to ST, but it avoids the worsening of thyroid immoral autoimmunity and the relapse of hyperthyroidism. Thus, it could represent the treatment of choice for graves' disease

Changes in the serum gastrin levels in patients with colorectal cancer

A total of 16 patients [5 men and 11 women with a mean age of 49.3 years] with established diagnosis of colorectal cancer [group 1] and 10 patients [5 men and 5 women with a mean age of 36.2 years] with different types of hernia [group 2] taken as controls was studied. Blood samples for the estimation of serum gastrin were taken both fasting and postprandial before and after resection of the tumor in group one. The results showed that the fasting [mean +/- SD 59.63 +/- 18.78 pgm/ml] and postprandial [mean +/- SD 94.65 +/- 33.25 pgm/ml] serum gastrin levels in group 1 before resection were significantly higher when compared with group 2, fasting [mean +/- SD 40.68 +/- 8.51 pgm/ml] and postprandial [mean +/- SD 59.02 +/- 16.42 pgm/ml]. In conclusion, the presence of colorectal cancer was associated with endogenous hypergastrinemia, which was resolved after resection of the tumor. Substances which decreased the level of circulating gastrin could be as useful in regulating tumor growth as gastrin receptor antagonists

better management of chonic pilonidal disease by local flaps

The multiplicity of treatment options available for pilonidal disease reflects the general controversy concerning its management. Recurrence unfortunately plagues all forms of therapy, though it is evident that the lowest rates have been reported for procedures involving local flaps. A total of 30 patients with postanal pilonidal sinus were studied. Twenty patients [17 male and 3 female; mean age 25 years] presented by primary pilonidal sinus repaired using transposition rhomboid flap, and 10 patients [9 male and one female; mean age 28 years] presented by complex or recurrent pilonidal sinus repaired using V-Y fasciocutaneous advancement flap. Results shows, uneventful healing occurred in 23 patients within 10 days. Three cases developed transient minor wound dehiscence [one patient [5%] in rhomboid flap and two patients [20%] in V-Y flap] and 4 cases developed superficial wound infection [3 patients [15%] in rhomboid flap and one patient [10%] in V-Y flap]. The maximal inpatient hospital stay was 5 days and the patients returned to their former jobs within 2 weeks postoperatively. There were no recurrence during the follow up period of 6 - 24 months. Both methods are easy to learn and teach, and this study confirms that both methods for reconstruction allows tissue approximation without tension leading to excellent longterm results, minimal discomfort and disability for the patient, early postoperative mobilization and functional rehabilitation and a shorter period of hospital stay

Changes in the lower oesophageal sphincter after oesophageal transection for the treatment of oesophageal varices

Obviously oesophageal transection interfere with the delicate anti-reflux mechanism and it is not surprising that some patients also complain of heartburn after operation. Fourty patients [35male [87.5%] and 5 female [12.5%], mean age 35 years] with portal hypertension and oesophageal varices were treated by splenectomy, gastro-esophageal devascularisation and oesophageal transection. Pre - and post-transection manometry was done for evaluation of changes in the lower oesophageal sphincter [LOS] pressure, length and function. The results revealed, a significant reduction in the lower oesophageal sphincter pressure [LOSP] following transection [mean 14.2 mmHg] than preoperatively [mean 21.8 mm Hg] The total lower oesophageal sphincter length [LOSL] was shortened postoperatively [mean, 2.5 cm] compared to the preoperative length [mean, 3.7cm]. The percentage of lower oesophageal sphincter relaxation [LOSR] although insignficant, it was lower postoperatively [mean, 8 0.3%] than preoperative measures [mean, 93.2%]. The stage is therefore set for reflux of gastric contents and these patients should be placed on anti-reflux medication routinely. Whether the additional technical difficulty of doing an anti-reflux procedure with the oesophageal transection in patients with portal hypertension is warranted requires