Comparison of hernioplasty under local anesthesia v/s spinal anesthesia.

Background: Hernia is a common surgical problem which requires good surgical skill as well as good knowledge about anatomy and various repair of hernia. Hernia is a protrusion of a viscous of part of viscous through a normal or abnormal opening in the wall of its containing cavity. Inguinal hernioplasty can be done under general anesthesia, spinal/epidural and local anesthesia. The choice of anesthesia depends upon a variety of factors viz patient's acceptance, surgeon’s wishes, safety feasibility and cost etc. Recently there has been revival in the use of local anesthetic technique for hernioplasty. Aim: To study comparison of local anesthesia v/s spinal anesthesia for per-operative and post- operative outcome measures. Material and methods: We have done comparative study of total 100 patients (50 patients under local anesthesia and 50 patients under spinal anesthesia), with follow up period of 60 days. The present study included male patients of uncomplicated inguinal hernia with ASA grade 1 to 3. Patients were selected without bias of type (Direct/Indirect) and extent. All patients were explained about both the methods of anesthesia for hernioplasty, those who willing for local anesthesia were selected for this group and similarly spinal anesthesia group selected (total 100,50 in each group). Results: All patients were explained about both the methods of anesthesia for hernioplasty, those who willing for local anesthesia were selected for this group and similarly spinal anesthesia group selected (Total 100, 50 in each group). In local anesthesia group 7(14%) patients had intra- operative discomfort in form of pain. 64% of patients of local had mild pain and 38% had moderate pain. None of the patients belonged to serve pain group. In spinal anesthesia, 6% of patient had serve pain, 22% patients had mild pain and 72% patients had moderate degree of pain. Local anesthesia was associated with less post-operative complication, in our study no patient devlope complication like nausea, vomiting, urinary retention, or headache. Conclusion: hernioplasty under local anesthesia was an acceptable alternative to spinal anesthesia for hernioplasty especially with regard to operative condition, patient’s surgeon’s satisfaction, post- operative pain relief, complications and cost efectiveness.

Study of management of 25 cases of fistula- in-ano.

Background: Fistula-in-ano forms a good majority of treatable benign lesions of the rectum and anal canal. 90% or so of these cases are end results of crypto glandular infections. Despite the easy of diagnosis, establishing a cure is problematic on two accounts. Firstly, many patients tend to let their ailment nag them rather than being subject to examination, mostly owing to the site of this disease. The more important second factor is that a significant percent of these diseases persist or recur when the right modality of surgery is not adopted or when the post-operative care is inadequate. Aim and objectives: To know the usefulnessof investigative procedures in early and accurate diagnosis of fistula in ano. To study the efficacy of different modalities of surgical approach with reference to post-operative hospital stay and complication like pain, bleeding and sphincter incontinence and outcome in respect to persistence /recurrence of fistulae. Material and methods: A total of 25 patients with clinically diagnosed fistula in ano were included in the study. Clinical history was obtained in all the patients. Clinical examination including per rectal examination and proctoscopy was done in all the patients. All the patients were processed by routine investigations, ECG, ches X -ray etc. prior to surgery. Patients were followed up to a period of 1 year. Results: 6 patients i.e. 24% had similar illness out of them two previously operated for fistula with recurrence, and four patients with similar illness and resolved without treatment. In this study, 72% of patients had low level of fistula and another 28% of patients had an internal opening situated above the ano rectal ring. Patients with low level fistula were treated with fistulotomy and fistulectomy and patients with high level fistula were treated with seton placement. In this study 60 % of patients underwent fistulotomy, 12 % of patients fistulectomy and another 28% seton placement. Patients with low level fistula were treated with fistulotomy and fistulectomy and patients with high level fistula were treated with seton placement. Conclusion: Fistula-in-ano is an important, commonest disease due to crypto glandular infection (anal glands) and has a complication of ano rectal abscess. It is curable disease by the treatment of surgery and higher antibiotics, local antibiotics with good post-operative wound management, like sits bath for twice a day without closing the wound.

A study of 50 cases in different modalities of treatment of chronic pancreatitis.

Background: Chronic pancreatitis was defined by features consistent with irreversible pancreatic inflammation, i.e., clinical, structural or functional abnormality of the pancreas. The presence of pancreatic calculi or ductal irregularity/parenchymal atrophy was determined at imaging using ultrasonography, CT scan, MRI, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS). Material and methods: The profile of 50 patients with chronic pancreatitis seen in the Genral Surgery, Gastro surgery Department of Civil Hospital, Ahmedabad, from May 2007 to September 2009 were included. The diagnosis of chronic pancreatitis was based on clinical, biochemical (serumamylase, serum criteria and anti-diabtic treatment requirement) and imaging. Various treatment modalities like conservative, endotherapy and surgical were evaluated. Results: Out of 50 patients, 33 underwent surgery, 11 underwent endotherapy, 6 underwent external drainage via pigtail catheterization and 14 were kept on medical therapy that later on underwent surgery due to partial or no relief of abdominal pain. The indication for surgery was in these 33 patients and the surgical procedures were performed. 15 (10%) patients had postoperative complications; major among these being wound dehiscence (n=2), pancreatic fistula (n=1), gastrointestinal bleed (n=1) and intra abdominal bleed (n=1). There were four postoperative death (3 post whipple’s and 1 post triple bypass). Conclusion: Idiopathic pancreatitis is the most common form of chronic pancreatitis seen at our hospital, and in general, the majority of these subjects showed a good response to endotherapy and surgery of chronic pancreatitis. Pancreatic endotherapy is effective as short-term intervention, can be used at an early stage and has limited indications.

Study of success rates in endoscopic dacryocystorhinostomy with and without stenting.

Background: The dacryocystorhinostomy (DCR) surgery involves fistulization of the lacrimal sac into the nasal cavity. DCR is currently the main stay of treatment of nasolacrimal duct (NLD) obstruction. It can be performed externally or endoscopically. Aim: To evaluate the success rates of endoscopic DCR with silicone stenting comparing to those with DCR without stenting in patients with epiphora who failed medical treatment. Material and methods: A retrospective study of 39 consecutive patients who underwent primary or revision endoscopic DCR with or without stenting was done at our hospital between January to July 2014. These patients were divided in two groups: Groups - A in which DCR was followed by stenting, Group – B in which no stent placement was done. Results: There were more female patients- 28 (71.79%) than male patients -11 (28.20%). The mean age was 40.44 years. Age range was 14-74 years. Both eyes were almost equally affected. Left eye was affected in 16 patients compared to 17 patients had right eye involvement. 6 patients had bilateral symptoms of which one eye was operated at a time. Revision cases included our own revision of endoscopic DCR without stenting 2 (5.12%) and of endoscopic DCR with stent 1 (2.5%). 4 of these patients had atrophic rhintis, which was preoperatively controlled by appropriate medical treatment. 11 of these patients had deviated nasal septum in which 5 patients had undergone correction simultaneously. In our own revision cases of endoscopic DCR with stent, the cause was synechiae formation as simultaneous septoplasty with stenting was done. Revision cases of endoscopic DCR without stenting the causes were granulations and stoma closure. During revision surgery stenting was done. Conclusion: Endoscopic DCR is a simple, minimally invasive procedure. In our study, we concluded that endoscopic DCR with stent placement had good results. Regular follow up after endoscopic DCR is necessary. Endoscopic DCR with stent has several advantages over classical external approach.

Role of antibiotic prophylaxis in open inguinal hernioplasty – A prospective randomized clinical trial.

Background: Inguinal hernia surgery is the most commonly performed surgery worldwide. Lichtenstein tension free repair using polypropylene mesh is the gold standard procedure for inguinal hernioplasty. Wound infection is the most common complication encountered in an surgical procedure. Antibiotic prophylaxis for open inguinal hernioplasty in minimizing wound infection has been a subject of debate since the beginning of mesh repair. We have conducted a randomized clinical trial in our hospital to analyze the usefulne hernioplasty. Material and methods: 60 patients were included in this prospective randomized control trial. 30 of them received 1 g of Injection Cefataxim half an hour before surgery and remaining 30 received injection Multivitamin infusion. Lichtenstein tension free hernia repair using polypropylene mesh was done. Superficial SSI was diagnosed according to CDC criteria. Results: Totally 5 patients developed SSI (8.33%). Out of the five, (6.67%) were in antibiotic group and remaining 3 (10%) were in placebo group (p = 0.64). Odd’s ratio was 0.6429 (CI=0.0995 to 4.1531). All 5 had only superficial SSI; there was no deep surgical site infection (SSI). 2 patients were managed with dressing alone and remaining 3 with antibotics. After 2 weeks, 2 had wound gapping and at four weeks wound was normal in all patients. 2 out of 5 were above 60 years of age and no SSI occurred >30 years of age (p value = 0.59). Conclusion: Routine use of antibiotics is not necessary in all open inguinal hernioplasty. Antibiotics can be reserved only for patients who are in high risk of SSI. Regularizing the use of antibiotics will have a good cost benefit and decrease the emergence of drug resistant organisms.

Study of prognostic value of various biomarkers (creatinine phosphokinase – MB, C – reactive protein) and admission neutrophil lymphocyte ratio in early outcome of patients with acute myocardial infarction.

Introduction: Coronary artery disease (CAD) continues to be a major cause of morbidity and mortality in developed as well as developing countries. The time course of bio-maker (protein) release during acute myocardial infarction provides diagnostic information which in turn is helpful in evaluating therapeutic interventions. The three easily measurable markers e.g. creatinine phosphokinase - MB (CPK-MB), C-reactive protein (CRP) and neutrophil lymphocyte ratio (N:L) in patients of acute myocardial infarction (AMI) can be used for diagnosis as well as prognosis. Material and methods: Patients of acute myocardial infarction admitted in intensive coronary care unit (ICCU) of a General Hospital were included in the present study. Detailed clinical examination of each patient was done and after initiating oxygen inhalation and pain relieving therapy, following investigations were sent; hemoglobin level, total white blood cell (WBC)count, differential count, CPK -MB, CRP level Observation: Significantly high Cpk- MB levels (>60 IU/L) were observed in 24% of patients who had or later developed complication of MI while only 7% of uncomplicated MI patients had significantly elevated levels of CPK - MB. Similarly more patients in Complicated MI had higher values of CRP and N: L ratio as compared to uncomplicated MI patients. Conclusion: Blood levels of biomarker CPK - MB and inflammation markers CRP and N:L ratio at the time of hospital admission does have a direct correlation with chance of development of complications and/or mortality in early post-infact period. These bio-chemical markers are important not only for diagnosis but also have prognostic values and help in risk stratification and decision making regarding further early therapeutic intervention.

Study of pre-operative and post-operative variables for incisional hernia repair by open and laparoscopic technique.

Background: Incisional hernia is protrusion of part or whole of abdominal viscus through the weakness in layers of anterior wall in the scar of previous operation. The major predisposing factors being post operative wound infection or hematoma. This incidence increases in the presence of adverse factors (local and systemic) such as wound infection, obesity, hypoproteinemia. In all suture repair techniques the tissues are under tension and this increase the risk of ischemia, suture cut out and repair failure. The studies showed that the complication seen in open incisional hernia repair is seroma, hematoma, wound infection, stitch sinus, and recurrence. To overcome this complications and recurrent rates of open incisional hernia repair the Laparoscopic repair of incisional hernia was introduced in the 1990s, which reports (Olmi study) have showed more improvement in recovery time, hospital stay and complication rate. Objective: The purpose of this study was a prospective study which had been carried out, during the period of July 2010 to September 2012 at a tertiary care centre. A total number of 50 cases were studied and were followed up for a period of 6 months. All patients were operated on by the same surgical team, adapting the type of surgical technique depending on the type of hernia. In the selection process of the technique patients were ranndomly allowed to opt for any of the two modalities after analyzing the biological status of the patient but also the associated his/her comorbidities. Patient selection criteria were as below. Inclusion criteria: Wall defect: >3 cm to <8 cm, Post-surgical and gynecological procedure, BMI < 30 kg/m2, Patient willing for surgery. Exclusion criteria: Complicated hernia, BMI >30 kg/m2, Conversion of laparoscopic repair to open repair. Results: Incidence of incisional hernia was maximum in the age group of 31-50 years (66%) with female preponderance (74%). 25 patients had risk factors like chronic cough (5), hypertension (13), diabetes mellitus (5) and difficulty in micturition (2). 27 had previous emergency surgery while 23 had undergone planned surgery. 60% of patients had undergone gynecological procedures, among complications in previous surgical procedure. Mean operative time for laparoscopic incisional hernia repair was 2 hour 45 minutes and for open hernia it was 2 hour 05 minutes. 46% of patients had duration of return to work (6-10 days) in laparoscopic surgery, 40% of patients had duration of return to work (11-15 days) in open surgery (mean 16 ),4% in laparoscopic surgery (mean 10.24days), 10% of patients had duration of Return to work (16-20 days) in open surgery. Conclusion: An optimal technique for mesh placement has not yet been determined and is still a subject of debate among surgeons. Laparoscopic techniques seem to have many benefits, including decreased length of hospital stay, decreased postoperative pain, and reduce the time to return to work and normal activities, but require long learning curve and are still not very accessible to all surgeons, especially in our country.

Comparative study of local calcium channel blocker application and lateral internal sphincterotomy in the treatment of chronic anal fissure: study of 50 cases.

Background: The treatment of chronic anal fissure has changed greatly during the past two decades with ongoing research directed at lowering the internal anal sphincter tone and avoiding the risk of fecal continence disturbance. Glycerin trinitrate, topical calcium channel blockers and anal dilators and botulinum toxin injection alone are all known to be able to lower the internal anal sphincter tone but results have been disappointing in curing chronic anal fissure, often marginally better than to placebo. The surgical treatment in the form of lateral internal sphincterotomy is the gold standard for chronic anal fissure. Aims & Objective: The aim of this prospective study was to assess the efficacy of medical treatment in form of topical calcium channel blocker and surgery in the management of chronic anal fissure. The objective is to compare the efficacy with regard to complete healing, recurrence, incontinence and other complications after treatment with topical calcium channel blocker and lateral anal sphincterotomy. Material and Methods: From October 2010 to October 2012, 50 patients with typical chronic anal fissure completed the study. 25 patients were initially treated with topical calcium channel blocker for 8 weeks and rests 25 were treated with lateral anal sphincterotomy. During the follow-up healing rates, symptoms, incontinence scores, and therapy adverse effects were recorded. Results: Overall healing rates were 60% after 8 weeks therapy with topical calcium channel blocker. Whereas overall healing after lateral internal sphincterotomy group was 88% with no recurrence. Conclusion: Lateral internal sphincterotomy is far more effective than medical treatment, with significantly increased healing rates while avoiding risk of incontinence.

Effects of blood transfusion on gastrointestinal anastomosis – Our experience in 52 patients.

Background: Patients, operative technique and instrumental factors, all affect the intestinal anastomosis outcome. Preoperative, intraoperative and postoperative blood transfusion influences the very common surgical procedure. Blood transfusion is discriminated from other risk factors in that; its intentionally added risk factor. Aims & Objective: The effect of intra-operative and post-operative blood transfusion on elective gastrointestinal anastomosis mainly evaluated by following factors; (1) surgical site complications (2) anastomosis leak (3) faecal fistula and (4) death. Material and Methods: To evaluate the effect of blood transfusion (Intraoperative and Postoperative) in outcome of Gastrointestinal anastomosis at Government General Hospital. Data collected from fifty two patients who underwent elective gastro intestinal anastomosis at our hospital. Results: The total number of patients was 52, 28male and 24 female. Mean age was 43 years, 17.3% were underwent small bowel anastomosis, 83.7% were underwent large bowel anastomosis, and 15.38% were transfused intraoperative and 26.92% were transfused postoperatively. Regardless other risk factors the incidence of surgical site infection was significantly high in transfused patients (25%), also there was a high rate of other complications in transfused patients. Conclusion: Intraoperative and post-operative blood transfusion is a good predictor for development of complications in elective intestinal anastomosis. There were some limitations in this study, as other risk factors might change the outcome and the effect of blood amount wasn’t considered, so more precise studies have to be done to give more support to our results.

The surgical approach in huge scrotal lymphedema.

Giant Scrotal Lymphoedema is a rare disease. Such Scrotal elephantiasis presents multiple problems both to the patient as well as the treating clinician obstruction, aplasia, or hypoplasia of the lymphatic vessels. The most common cause worldwide is lymphatic Filariasis. A case where the resected scrotal tissue weighed 30kg which is one of the largest so far mentioned in literatures. The lymphedema was progressive over 15 year’s duration and the testes were not palpable with the penis deeply buried. There is no effective medical treatment for filariasis. There are different surgical methods for scrotal filariasis in the literature. In this case, the patient was treated by Modified Charles procedure. Once fibrosis sets in resectional therapy will be needed in most cases. Successful reduction scrotoplasty with acceptable cosmetic results can be obtained in giant scrotal lymphedemas weighing as large as 30kg as in this case.

Recent trends in peptic perforation.

Background: The peptic perforation is one of the commonest abdominal surgical emergencies. Common causes are H.pylori, increased inadvertent use of NSAIDS, smoking and stress of modern life. During last few years there has been great revolution in availability of the newer broad spectrum antibiotics, better understanding of disease, effective resuscitation, prompt surgery under modern anaesthesia techniques, and intensive care unit resulted in reducing the mortality. Aims & Objective: To study the recent trends in peptic perforation. Material and Methods: This prospective study was carried out in the department of surgery during period from 1st May 2009 to 30th November 2011. All were indoor patients with diagnosis of peptic perforation in stomach and/or duodenum excluding other sites. Each patient was study in detail with relevant clinical history, examination, laboratory investigations and management. The study comprised of total 50 patients operated for peptic perforation by various modalities. Results: The middle age group was commonest. Smoking, alcohol and stress were common etiological factors. The perforation was common in anterior surface of the first part of duodenum. Wound infection and bronchopneumonia were common post-operative complications. Conclusion: The duration of perforation more than 24 hours and size of the perforation more than 1 cm has increase morbidity & mortality. Early diagnosis and prompt management of shock & septicaemia is important for better prognosis of patients. The simple closure with omentopexy of peptic perforation still remains the first choice as a treatment. H-pylori eradication treatment is mandatory after simple closure of the perforation to prevent recurrence of ulcer.

Recent trends in interstitial lung disease: Study of 25 cases .

Background: Interstitial lung disease accounts for more than 200 etiology. There has been worldwide increase in diagnosis of interstitial lung disease because of the help of recent advance diagnostic tools. Aims & Objective: to study age & sex distribution, to correlate symptoms & pulmonary function, role of HRCT as etiology diagnosis particular in interstitial pulmonary fibrosis, to study ECG & 2D ECHO changes and to study pulmonary function test pattern. Material and Methods: This was the study of 25 cases of interstitial lung disease in which various parameters like DLCO, PFT, 2D ECHO, ECG, identification of etiology, assessment of prognosis & role of immunosuppressant, steroids were studied. The exclusion criteria was age < 12 years. Results: The age distribution was highest in age group of 50-70 years. Occupational interstitial lung disease was more common in male while the connective tissue disorders are common in female which lead to more incidence of interstitial lung disease. Pulmonary function test is very helpful for prognosis. The patient with high pulmonary artery pressure had worst prognosis. HRCT is a useful tool for diagnosis of IPF without biopsy. Conclusion: Interstitial lung disease with moderate to severe pulmonary artery hypertension leads to poor prognosis. HRCT is very useful non-invasive diagnostic tool for interstitial lung disease.

Use of topical skin adhesive (2-octyl cyanoacrylate) following circumcision surgery.

Introduction: circumcision is a commonly performed surgery. Surgeons have become increasingly interested in the use of adhesive bonds. Recent advances have been made in the use of tissue glue in the circumcision. In this study, we used 2-octyl cyanoacrylate for closing circumcision wounds and we have reported our experience. Material & Methods: this was a prospective non-comparative preliminary clinical study involving 30 patients where 2-octyl cyanoacrylate was used as a tissue adhesive for wound closure after formal circumcision at surgery department, Smt S.C.L. Municipal General Hospital from May 2008 to Nov 2010. Result: in this study, the mean time taken for skin closure by 2-octyl cyanoacrylate is much faster in last year of study. There is significant less pain. There is 10% (3 cases) of complications are observed. The wound cosmesis score on 90th post-operative day is optimal except in one patient of wound separation. Conclusion: the comparison with criterions of time taken foe skin closure, the post-operative pain, the cosmetic appearance of adhesive glue proves that 2-octyl cyanoacrylate skin closure is significantly better than the traditional skin suturing skin closure.

The surgical management of diabetic foot.

Diabetes has proved itself a silent killer disease. Today in the world maximum numbers of the patients are suffering from this disease, and moreover they are passing through the associations of the complications too. In present study 50 cases of diabetic foot surgically managed has been studied at teaching institute in department of surgery. The limb was preserved in 35 out of 50 cases. 15 out of 50 cases despite of proper medical management and repeated debridement had to undergo local amputation-B\K amputation-A/K amputation. This was done to save the patients. It is concluded that we should be able to save 100% limbs in diabetic foot and no amputations provided.

Comparative study between open V/S laparoscopic cholecystectomy.

Gall stones are one of the major causes of morbidity and mortality all over the world. Differences in primary outcomes like mortality and complication proportions (particularly bile duct injuries) are important reasons to choose one of the two operative techniques open or laproscopic Cholecystectomy. The study consists of 100 patients with a diagnosis of calculus cholecystitis that underwent Cholecystectomy. Laparoscopic cholecystectomy is a considerable advancement in the treatment of gall bladder disease .technically the dissection of the cystic artery and cystic duct is very precise and bleeding is easily controlled with less per operative blood loss.LC is associated with less chances of wound infection and there is no risk of wound dehiscence. The only disadvantage of the laparoscopic Cholecystectomy over the open procedure is the duration of operating time which is significantly longer. In cardiac patient or in those patient where general anesthesia’s contra indicated, open Cholecystectomy can be carried out in regional anesthesia and in such patient when duet o co2 inflation cardiac arrhythmia can be provoked open Cholecystectomy is better option.