Should we routinely expose recurrent laryngeal nerve[s] during thyroid surgery?

To compare the frequency of recurrent laryngeal nerve[s] [RLNs] palsy after various thyroid procedures with and without identification of recurrent laryngeal nerve during the operation. Randomized controlled trial. Department of Surgery, Military Hospital, Rawalpindi, from August 2008 to April 2010. Patients undergoing indirect laryngoscopy with normal vocal cords and those with carcinoma and re-do surgery having normal vocal cord were included in the study. Patients with hoarseness of voice, abnormal vocal cord movements and with solitary nodule in the isthmus were excluded. These patients were randomly divided into 2 groups of 50 each using random number tables. RLN was identified by exposing the inferior thyroid artery and traced along its entire course in group-A. Whereas, in group-B, nerves were not identified during the operations. Immediate postoperative direct laryngoscopy was performed by a surgeon with the help of an anaesthesiologist for the assessment of vocal cords. Patients with persistent hoarseness of voice were followed-up with indirect laryngoscopy at 3 and 6 months. Temporary unilateral recurrent laryngeal nerve palsies occurred in 2 [4%] patients in group-A where the voice and cord movements returned to normal in 6 months. In group-B, it occurred in 8 [16%] patients, 2 bilateral [4%] injuries requiring tracheostomy and 6 unilateral injuries [12%]. Among the 2 bilateral recurrent laryngeal nerve injuries, the tracheostomy was removed in one case after 6 months with persistent hoarseness of voice but no respiratory difficulty during routine activities. Tracheostomy was permanent in the other case. Among the 6 cases of unilateral nerve injuries, the voice improved considerably in 4 cases within 6 months but in 2 cases hoarseness persisted even after 6 months. Frequency of recurrent laryngeal nerve palsies was significantly lower in group-A as compared to group-B [p = 0.046]. For safe thyroid surgery, recurrent laryngeal nerve[s] should be routinely exposed in its entire course

Short-term outcome after polypropylene darn and lichtenstein's hernioplasty: a randomized prospective study

To evaluate and compare the short term outcome of polypropylene darning with Lichtenstein's Hernioplasty for primary inguinal hernia. Randomized control trail. The study was conducted in CMH Sialkot, CMH Jhelum and PAF Hospital Mianwali from October 2000 to March 2005. A study of 270 patients with primary inguinal hernias was conducted in different hospitals. Group I [n=132] underwent darning with polypropylene while Group II [n=140] was subjected to Liechtenstein's operation. It was a simple randomization using random number tables. Patients above 18 and below 75 years age were included in the study and those with gross obesity basal metabolic rate [BMR] >35; chronic obstructive pulmonary diseases [COPD] and other chronic ailments were excluded from study. The patients were randomized and placed in either of the groups. Both the procedures were evaluated post-operatively for pain, inflammatory response [by measuring C-reactive protein [CRP] levels in blood], operation time, cost of procedure and various complications. All patients were discharged after 48 hours and were called again after 7 days for removal of stitches and then after 14 days for any post op evaluation. Patients were then examined after 3 months and then yearly for 3 years. Any complication in the intervening period, or thereafter, was also reported by the patient. There is insignificant difference in short-term outcome of both the procedure in terms of recurrence rate and other complications. The recurrence rate was 2.27% in group I while it was 2.14% in group II. Other complications like hematoma/ seroma formation, infection, ischemic orchitis, hydrocele, ingynodynia and post-operative pain did not show significant difference in both the groups. Total cost of biomaterial in Lichtenstein's operation exceeds Rs 1800 as compare to Rs 200 for darning. Darning with polypropylene is still cost effective and comparable with Lichtenstein's operation when dealing with a large majority of patients with primary inguinal hernia in our setup. Improving the technique and better patient selection can further decrease the recurrence rate

Spontaneous nephrocutaneous fistula in tuberculous pyelonephritis

A rare case of spontaneous nephrocutaneous fistula with renal tuberculosis is presented here. A 70 years old male with neglected stones in right kidney was investigated for discharging sinus right lumbar region of three months duration. Excretory urography revealed non-functioning right kidney and an impacted stone right upper ureter and a small stone in renal pelvis. The patient was successfully treated by nephroureterectomy and excision of the fistulous track followed by anti-tuberculous treatment. Histopathology of the specimen revealed renal tuberculosis. Though the incidence of various forms of tuberculosis is very high in this part of the world, presence of nephrocutaneous fistula is still uncommon

Polytrauma: epidmiology and prognosis versus trauma score

To study the epidemiology of trauma and prognostic significance of various trauma score systems. A multi-center descriptive study. The study was conducted from July 1995 to March 2005 comprising almost 10 years in services hospitals of Lahore, Malir, Sialkot, and Mianwali. 271 patients of various age groups were studied. Cases were grouped as burns, head injuries and multisystem injuries and were managed according to Advance Trauma Life Support [ALTS] and parameters of various trauma scores recorded and compared with outcome. Probability of survival as calculated by TRISS methodology has better prognostic significance than various trauma score systems alone. The study revealed low specificity in all types of injuries showing late deaths and unexpected complications. Revised Trauma Score and TRISS methodology were more accurate in multiple injuries than in burn and head injuries. Revised Trauma Score [RTS] is useful t ool as triage and prognostic indicator for multiple injuries but not in cases of burns and head injuries. We need to develop our own norms and coefficients for TRISS methodology and unexpected outcome should be minimized by sound clinical judgment. Moreover, we need radical improvement in burn care and neuro-surgical facilities in our country