Surgical site infection in diabetic and non-diabetic patients undergoing laparoscopic cholecystectomy

Objective: To compare the frequency of surgical site infections in patients with type II diabetes undergoing laparoscopic cholecystectomy as compared with non-diabetic patients

Study Design: Cohort study

Place and Duration of Study: Surgical Unit 2, Services Hospital, Lahore, from May to October 2012

Methodology: Patients were divided into two groups of 60 each, undergoing laparoscopic cholecystectomy. Group A comprised non-diabetic patients and group B comprised type II diabetic patients. Patients were followed postoperatively upto one month for the development of SSIs. Proportion of patients with surgical site infections or otherwise was compared between the groups using chi-square test with significance of p < 0.05

Results: In group A, 35 patients were above the age of 40 years. In group B, 38 patients were above the age of 40 years. Four patients in group A developed a surgical site infection. Seven patients in group B developed SSIs [p = 0.07]

Conclusion: Presence of diabetes mellitus did not significantly affect the onset of surgical site infection in patients undergoing laparoscopic cholecystectomy

Comparison of open mesh hernioplasty verses laparoscopic intraperitoneal onlay mesh for ventral hernias

Objective: compare the outcome of laparoscopic intraperitoneal on lay mesh [IPOM] with open mesh repair in ventral hernias

Material and Methods: seventy patients were divided into two groups of 35 each. Group A= I POM repair and Group B = Mesh hernioplasty

Results: the mean+/-SD age was in group A 44.54+/-7.06 years and 46.40+/-7.14 in group B. Twelve [34%] patients were male in group A, 14 [40%] patients were in group Band 23 [66%] patients were female in group A and 21 [60%] were female in group B with male to female ratio 1: 1.91. There were only 3 [8%] patients had postoperative pain in group A and 10 [28%] patients were in group B [p<0.05] which is statistically significant. In comparison postoperative early surgical site infection in both groups, there was no patient on 3rd postoperative day in both groups. On 10th postoperative day 1 [3%] patient had surgical site infection in group A and 6 [17%] patients had postoperative early surgical site infection in group B [p<0.05] which is statistically significant

Conclusion: laparoscopic approach appears to be as effective, safe, feasible, and cosmetically good procedure. It has fewer rates of early surgical site infection and postoperative pain. Laparoscopic repair is good alternative to the open repair in the treatment of ventral hernias

Comparison of laparoscopic total extraperitoneal repair with Lichtenstein repair in inguinal hernia

Objective: To compare the laparoscopic inguinal hernia repair with Lichtenstein repair in terms of hospital stay and postoperative pain

Study design: Randomized clinical trial

Place and Duration of study: Department of Surgery Services Hospital Lahore, from September 2013 to May 2014

Methodology: Inguinal hernia patients were admitted electively. They were randomly assigned into groups A and B. The group A patients were treated with laparoscopic total extraperitoneal repair [TEP] and group B patients underwent Lichtenstein's repair. Patients were evaluated for 24 hours discharge rate and postoperative pain

Results: A total of 100 patients were included with 50 patients in each group. Group A patients had short hospital stay [discharged within 24 hours - 68.08%] as compared to group B [31.91% -p <0.001]. From 2[nd] to 6[th] postoperative week group A patients had significantly less postoperative pain as compared to group B [p <0.05]

Conclusion: Laparoscopic TEP repair was safe with early hospital discharge and less postoperative pain

Harmonic Scalpel versus electrocautery in axillary dissection in Carcinoma Breast

Objective: To compare the results between harmonics scalpel and electrocautery use in axillary dissection for carcinoma breast

Study Design: Randomized controlled trial

Place and Duration of Study: Department of Surgery, Services Hospital, Lahore, from December 2013 to June 2014

Methodology: Eighty patients fulfilling the inclusion criteria were selected and equally divided in two groups. Axillary dissection for carcinoma breast was performed by using the harmonic scalpel in one group and by using electrocautery in the other group. Total mean axillary drain output and frequency of axillary numbness were noted in both groups and compared

Results: All the patients were females with mean age of 53.52 +/- 9.8. Mean axillary drain output in harmonic scalpel group was 167.75 +/- 43.90 as compared to 310.00 +/- 60.09 in electrocautery group while only 12.5% of patients were positive for axillary numbness in harmonic scalpel group as compared to 100% of patients who were positive for electrocautery group

Conclusion: Use of harmonic scalpel in axillary dissection resulted in decreased total mean axillary drain output and lowered frequency of axillary numbness when compared to utilizing electrocautery

Mesh fixation vs. non-fixation in total extra peritoneal mesh hernioplasty

To compare mesh fixation with non-fixation and its effect on outcome. The interventional prospective study was conducted at the National Hospital and Medical Centre, Lahore from January 2007 to December 2008. After the two-year intervention period, the patients were followed up for 5 years. The selected patients were divided into two groups. In group 1, mesh fixation was performed with metal non-absorbable tackers and in group II no fixation of mesh was performed. Patients were followed up at 6, 12, 24 and 60 months. Of the 63 patients in the study, 32[50.7%] were in group I and 31[49.2% in group II. The Mean pain score in group I was 4.7 +/- 0.683 and 4.1 +/- 0.860 in group II [p< 0.001]. Urinary retention was more common in group 1 [p>0.05], while recurrence was more common in group II [p>0.05]. Pain was significantly less in the non-fixation group, while urinary retention and recurrence were not significantly increased. Non-fixation is a viable option for total extraperitoneal mesh hernioplasty and should be preferred over mesh fixation

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

Laparoscopic splenectomy

Patients undergoing laparoscopic splenectomy were observed for their postoperative recovery and development of complications. It was a retrospective analysis done at Services Hospital and National Hospital and Medical Center, Lahore, from January 2010 to December 2012. A total of 13 patients underwent laparoscopic splenectomy and were included in the study. Patients were followed for their postoperative recovery and development of any complications. The median age of patients was 19 years ranging from 13 to 69 years. Accessory spleens were removed in 3 patients. Mean operating time was 158 minutes. One operation had to be converted to open because of uncontrolled hemorrhage. Six patients experienced postoperative complications including unexplained hyperpyrexia [n=2], pleural effusion [n=4] and prolonged pain > 48 hours [n=1]. No deaths or infections were seen. Seven out of 8 patients with idiopathic thrombocytopenic purpura developed a positive immediate response to the splenectomy, defined as a platelet count greater than 100 x 10[9]/L after the surgery, which was maintained without medical therapy. Mean hospital stay was 5.5 days. Average time to return to activity was 15 days. All patients were followed for 6 months and no follow-up complications were noted

Laparoscopic repair of peptic ulcer perforation: our initial experience

Objective: to evaluate our experience of laparoscopic peptic ulcer repair at National Hospital, Lahore over a one-year period

Material and Methods: a prospective case series study. The National Hospital and Medical Centre, Lahore. Four patients operated from January 2013 to December 2013. Post-operative pain, average hospital stay. Intra-operative and postoperative complications and outcome

Results: average operating time was 95 minutes, Average hospital stay 3.75 days. No intraoperative or operative postoperative complications documented so far

Conclusion: laparoscopic perforated duodenal ulcer repair is an excellent surgical option in selected patients without any added risk of complications

Role of modified alvarado score in diagnosing acute appendicitis in emergency setup

The objective of the study was to evaluate the diagnostic accuracy of modified Alvarado score on patients presenting in surgical emergency with suspicion of acute appendicitis. We studied the Alvarado score of 200 patients in 11 months period who presented to the emergency department with right iliac fossa pain. We decided to design this study with the aim of investigating whether the Alvarado Score can be used by emergency doctors as a criteria for diagnosing acute appendicitis. We compared the Alvarado Score with the operative findings and grade of appendicitis. A total of two hundred patients were studied. We found that patients who had a score of less than 5 had a normal appendix, but at the same time 17% had acute appendicitis. While if, Alvarado Score >5, 59% had acute appendicitis and 1% have normal appendix. Thus the Alvarado Score is both specific and sensitive in diagnosis of acute appendicitis. It is concluded that Alvarado score is a free and easy to use tool and is very helpful in diagnosing acute appendicitis and decreasing the incidence of negative appendectomies

Conservative breast surgery in our setup

Background: Breast conservative surgery [BCS] has been time tested in terms of outcome for early stage carcinoma breast. The disease free period and 5 year survival is almost similar to that of modified radical mastectomy. The benefits remains in terms of breast preservation and avoiding the psychological trauma of mastectomy in females especially the younger age group. This study focuses on 50 patients undergoing breast conservative surgery. Hence discussing the outcome in terms of local recurrence and need for adjuvant therapy

Materials and Method: A total of 50 female patients were operated on between July 2002 and August 2010. Following surgery patients underwent adjuvant therapy with chest wall radiation and hormonal therapy depending upon receptor status. Patients were followed up on 1,6, 12 months and later on yearly basis

Results: Mean age of the patients was 45.04 yrs and mean diameter of the tumor was 3.21cm [SD=+/- 0.923]. Preoperative biopsy was +ve in 92% and ve in 8% patients. Mammograms of all the patients showed malignant changes. Five patients required neoadjuvant chemotherapy for downsizing the tumor from stage 3 to stage 2. Receptor status was +ve in 14 and ve in 36 patients. Local recurrence was present in 10 %[5] patients at follow up. Mean follow up was 48.5 months

Conclusion: BCS is an excellent tool for early stage breast carcinoma when combined with axillary clearance and whole breast irradiation. The benefits are same in terms of outcome and survival as those of formal mastectomies, with less disfigurement. There is however need for patient education as well as strict adherence to multidisciplinary approach in treatment of this overwhelming problem

Sleeve gastrectomy, the most feasible surgical weight loss procedure for morbidly obese patients in pakistan: early results

Background: The laparoscopic sleeve gastrectomy is a new tool in the surgical treatment of the morbidly obese patients which is now increasingly used as a primary surgical procedure for the morbid obesity as it has comparable weight loss to laparoscopic adjustable gastric banding and better safety profile than the Gastric Bypass with no malabsorption. We describe initial results of laparoscopic sleeve gastrectomy for morbid obesity in two academic centers of Pakistan

Materials and Method: Prospective data was collected on consecutive morbidly obese patients undergoing laparoscopic sleeve gastrectomy, and evaluated retrospectively

Results: Twenty one consecutive patients underwent laparoscopic sleeve gastrectomy from October 2008 to August 2010 with follow up ranging from 2 to 15 months. The 8 men and 13 women had an average age of 42.1 years [range 2152 years] and an average body mass index [BMI] of 49.6 kg/m2 [range 35.272.2 kg/m2]. No operation required conversion to laparotomy. Mean length of stay was 2.1 days [range 110 days]. There was no death in the 30 days postoperatively. One patient was admitted with pain abdomen after 10 days of operation with portal pyemia but settled conservatively. Other complications included one suspected clinical leak but no radiological leak. Patient got settled with conservative management in one week. Two patients had repeated vomiting off and on for one month and inability to take water which resolved spontaneously. At 1 -year follow-up all patients had lost an average of 52.0% excess body weight

Conclusion: Laparoscopic sleeve gastrectomy has much to offer for the morbidly obese. We present data showing weight loss rivaling gastric banding and bypass and acceptably low complications

Factors influencing the outcome of surgical management of lower limb ischemia

The objective of this study is to determine factors influencing the outcome of surgical management of lower limb ischemia. It was a cross-sectional analytical study conducted in surgical Unit 4, services hospital, Lahore from 18[th] September to 17[th] March 2007. Fifty patients of lower limb ischemia were included in the study. Appropriate surgical procedure was performed after complete pre-operative evaluation. Risk factors identified and clinical variables were statistically evaluated. Time is single most important factor in acute and in chronic ischemia. Diabetes mellitus, hypertension hyperlipidemia, smoking are factors which influence outcome

Comparison of two suturing techniques: interrupted mass closure and continuous with polypropylene in laparotomy wound

Wound dehiscence is an acute wound failure. It commonly presents about one week after surgery and may be preceded by a serosanguinuous discharge. Wound dehiscence is an important cause of postoperative morbidity and mortality. To compare the early postoperative complications of closure of laparotomy wound by interrupted mass closure and continuous mass closure techniques. Sixty patients were included in this study and divided in two groups; group A and group B. Closure of laparotomy wound with monofilament polyprophylene No.1 suture by interrupted mass closure technique for group A and continuous mass closure technique with same suture material in group B was done. In group A, 2 patients developed wound infection and 1 patient was found with wound dehiscence, while in group B, 3 patients suffered wound infection and 2 patients developed wound dehiscence. The closure of laparotomy wound by interrupted mass closure technique with polypropylene No.1 is better closure technique with low rate of wound infection and wound dehiscence as compared to continuous suturing technique with same suture material

Comparison of two surgical techniques: simple ligation and ligation with invagination of appendicular stump in appendicectomy for acute appendicitis

Appendicitis is an important differential diagnosis in patients with right lower quadrant pain. Acute appendicitis is the common emergency encountered round the globe. It is the cause of an acute surgical abdomen, and it remains one of the most challengeing diagnoses in the emergency department. Appendicectomy is the accepted therapy for acute appendicitis. To compare the technique of simple ligation and ligation with burial of the stump during appendicectomy for acute appendicits. Eighty cases of acute appendicitis were analysed for this study. They were randomly allocated to the two surgical procedures such as simple ligation [group I] and ligation with invagination [Group II] of appendicular stump in appendicectomy. The clinical variables were statistically evaluated. The frequency of postoperative ileus was more in group II [22.5%, and 5%] during first 48 and 72 hours respectively as compared to group I, p<0.05]. Postoperative wound infection was noticed in 15% patients in group I and 22.5% patients in group II [p>0.05]. Simple ligation of stump during appendicectomy is a better and safe procedure as compare to the invagination of stump because there is less incidence of postoperative complications such as postoperative paralytic ileus and wound infection

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

Laparoscopic anatomy of the patterns of union of cystic duct to the common hepatic duct

This study was carried out to determine the various patterns of union of cystic duct to the common bile duct and to find and document the most common patterns. Design: An observational study. Place and Duration of Study: Mayo and National Hospital, Lahore. Subjects and The study is based upon laparoscopic dissection of 600 patients done between December 1995 to December 2000. These dissections were carried out as a part of laparoscopic cholecystectomies performed on these patients. The pattern of union of cystic duct with the common hepatic duct was studied and anomalies documented. It was noted that the original pattern of the union on the right lateral side is seen only in 32% cases, whereas an overwhelming majority i.e. 68% does not follow the known anatomic patterns. The patterns seen in the study were grouped into three different types. It was evident from this study that the common pattern described by the text books does not represent the true picture and indeed a lot of variations exist in this area

Appendectomy and reproductive health, the role of a general surgeon in preventing infertility in the young female: a preliminary report

One of the most important and frequent cause of infertility in young females is lower abdominal surgery prior to marital life. This leads to adhesion formation in the pelvis followed by kinking and blocking of fallopion tubes. A management plan was designed and implemented for unmarried girls needing surgical treatment of acute appendicitis. A total of 112 such patients were operated on; 14 have reported back after their marriage informing that there have been no problems in conceiving

Central venous catheterization by open technique

A modified technique of central venous catheterization is presented. Central venous catheterization was done in 50 patients from December 1986 to july 1992 for the purpose of total parenteral nutrition. 32 patients were male and 18 were female. The only complication which occurred was wound sepsis in 2 cases