Arcuate line variations: are they important for TEP surgeons?

Objectives: Wide anatomic variations in Arcuate line have been recently reported by a few clinical investigators using modern technology of laparoscopy, but received little attention of laparoscopic hernia surgeons as well as anatomists, and hence the present study

Setting: J. N. Medical College Hospital, Aligarh Muslim University, Aligarh, India

Design: Prospective study

Subjects: Twenty-five male patients with uncomplicated primary inguinal hernia [Unilateral 20 and Bilateral 5]

Intervention: Intra-operative measurement and documentation with video recording

Method of analysis: Data computation in terms of Mean +/- SD

Results: Thirty total extraperitoneal [TEP] hernioplasties were performed in 25 male patients with uncomplicated primary inguinal hernia [Unilateral 20 and Bilateral 5] with a mean age of 49.72 +/- 17.56 years [range 18 - 80]. Arcuate line was observed during 26 operations and found absent in four instances; well-defined in 24 and ill-defined in six; single in 28 and double in two instances. Mean distance from umbilicus to Arcuate line was 5.65 +/- SD 1.7 cm [Range 3.5 - 11.5]. In presence of Arcuate line variations [absence/multiple and too high/too low], significantly increased difficulties were experienced during surgery in terms of endoscopic vision, ease of procedure and operating time, along with a higher incidence of intraoperative peritoneal rent, surgical emphysema and postoperative seroma

Conclusions: Arcuate line variations were observed in 40% of cases, and they were associated with an increased level of surgical difficulties and a higher rate of peritoneal injuries. TEP surgeons are advised to keenly observe these variations, preferably under high definition endovision, for a smooth and safe surgery

Low tension breast hydatid cyst-A case report

Features of low tension in breast hydatid cyst and symptoms secondary to cyst dying and disintegration are unique and not yet reported in the literature. An young woman of 30 years complained about pain and vague swelling in the right breast during follow-up with albendazole therapy following second laparotomy for post-surgical residual cavity of hydatid cyst in the left lobe of the liver. Breast ultrasound was diagnostic. Segmental breast excision revealed a large dead hydatid cyst. Postoperative course was uneventful. Breast hydatid cyst may become symptomatic and hypotensive after start of albendazole therapy

Prolonged mechanical ventilation causing tracheoesophageal fistula

Tracheo esophageal fistula [TEF] is a congenital or acquired communication between the trachea and esophagus. These fistulae can often lead to fatal complications. Prolonged intubation with high compliance endotracheal tube cuffs used to prevent gas leak and also pulmonary aspiration may cause tracheal damageand lead to tracheoesophageal fistulae

We report a case of a young man developing a TEF after being intubated for multiple injuries with the intent to highlight this rare cause of severe complication and even death

Feasibility and outcome of proximal catheter lleostomy - a pilot study

Loop ileostomy has high complication rates and causes much patient inconvenience. This study was carried out to evaluate the feasibility and outcome of a proximal catheter ileostomy in place of loop ileostomy in patients treated by intestinal repair and/or resection-anastomosis. Prospective study. Setting: J. N. Medical College Hospital, Aligarh Muslim University, Aligarh, India. From November 2006 to November 2009, in all patients treated surgically by primary repair and/or resection-anastomosis of small and/or large bowel, we constructed a catheter ileostomy when a defunctioning proximal protective loop ileostomy was considered advisable. Catheter ileostomy was constructed in the fashion of catheter jejunostomy, with postoperative saline irrigation. Catheter ileostomy was performed in 20 patients in the 3-year period. The mean age of the subjects was 28.6 years and the male: female ratio was 1.86:1. Four patients died of septicemia and multiple organ failure unrelated to catheter ileostomy in the immediate postoperative period. Catheter ileostomy started functioning within 48 hours of the operation, and twice-daily irrigation was found sufficient in 81.25% of the surviving patients. Only one patient developed peritubal leak with mild skin excoriation that cleared within 5 days. Another patient with Koch's abdomen underwent conversion to loop colostomy on re-exploration for postoperative adhesive obstruction. There was no instance of intestinal leak. Ileostomy wounds closed spontaneously within 7-14 days of catheter removal, and none required formal closure. Hospital stay ranged from 12-35 days [mean: 23 days]. Catheter ileostomy is effective in protecting intestinal anastomosis/ repair; there is minimal morbidity and no catheter-related leak/mortality, and we recommend the procedure

Specific evoked motor response for supraclavicular brachial block

To assess and evaluate the accuracy of individual types of evoked motor responses [EMRs] for prediction of successful surgical anesthesia following peripheral nerve stimulator [PNS] assisted supraclavicular block. A prospective study was carried out over a period of one and half years from August 2004 to January 2006, at J. N. Medical College, Aligarh Muslim University, Aligarh, India, in 60 patients who underwent various elective operative procedures on the upper limb. Any of the EMR, such as forearm flexion or extension, carpal flexion, or extension, prono-supination, or finger flexion, at a definite current of 0.25 mA for 2 ms was taken as an end point for prediction of successful block, and a local anesthetic solution [0.375% Bupivacaine, 30 ml] was administered at that level. Complete surgical anesthesia was observed in those cases where EMR included: flexion of only second and third fingers [n=15/15] or flexion of all 4 fingers with thumb opposition [n=14/14] or uncommon flexion of all 4 fingers without movement of any other joint of the upper limb [n=2/2], suggesting a sensitivity of 100%. However, thumb opposition to the tip of the flexed little finger revealed a success rate of only 83% [n=5/6], and other EMRs were followed by high rates of inadequate surgical anesthesia or total failure. Specific EMR of flexion of second and third fingers, or all the 4 fingers are reliable predictors of complete surgical anesthesia following PNS assisted single injection supraclavicular nerve block with no incidence of pneumothorax and nerve damage

Tracheostomy tube: an unusual foreign body in trachea

A rare case of aspiration of the vertical flange of the tracheostomy tube into the trachea, is reported. The literature on the subject is briefly reviewed