Rate and reasons of conversion of laparoscopic cholecystectomy to open cholecystectomy? A prospective analysis of 450 consecutive laparoscopic cholecystectomies

Objective: To assess the rate and causes of conversion of laparoscopic to open cholecystectomy [OC] in 450 patients who underwent laparoscopic cholecystectomy [LC] by the same surgeon in tertiary care teaching hospitals

Study Design: Descriptive study

Place and Duration of Study: The study was conducted initially at Pakistan Navalship [PNS] Shifa, Karachi and later at Combined Military Hospital, Lahore from November 2009 to June 2013

Material and Methods: All the patients of both genders and of any age group, undergoing LC for gall bladder pathology whether acute or chronic, acalculous or calculous were included in this study by convenient sampling. The exclusion criteria were choledocholithiasis, malignancy, and patients who willingly opted for open cholecystectomy. All the patients were operated by the same experienced laparoscopic surgeon. The number and sizes of the ports varied from patient to patient and was on the choice of the operating surgeon. A detailed proforma was filled which included the demographic data of the patients, indications for cholecystectomy, histories of previous abdominal surgery, their comorbidities [if any], operating time, intraoperative findings, complications, post-operative hospital stay and rate and reasons for conversion to open cholecystectomy [if required]

Results: Out of 450 consecutive patients for whom LC was attempted by a single surgeon, 7 patients [1.6%] were converted to OC. There were 380 female and 70 male patients [F: M ratio 5.4:1]. Their mean age was 44.6 +/- 13.5 years, ranging from 9-82 years. All patients who required conversion to OC were females. The mean operating time was 38.9 +/- 16.2 minutes [range 15-120 minutes]. The reasons for conversion included cystic artery bleeding2, liver bed bleeding1, common hepatic duct injury1, cholecystoduodenal fistula1, severe adhesions caused by tissue inflammation and fibrosis of Calot's triangle1 and cystic duct avulsion1

Conclusion: The overall rate of conversion to OC was 1.6%. Laparoscopic cholecystectomy is a safe procedure with very little chances of conversion to open even in acute cases, when performed by an experienced surgeon

Comparison of direct trocar insertion with other techniques for laparoscopy

Objective: To assess the safety of direct trocar insertion [DTI] before creating pneumoperitoneum in laparoscopic procedures

Study Design: An observational study

Place and Duration of Study: Combined Military Hospital [CMH] Kohat, Pakistan from November 2013 to January 2015

Methodology: All the cases undergoing laparoscopy at the study centre in the above duration were included in the study after approval from the Hospital Ethical Committee and informed written consent. Out of the 200 cases, DTI was successfully used to establish peritoneal access in 190 cases, while open Hassen's technique [OL] was used in ten cases. Body mass index [BMI] of all the patients was calculated before surgery. All the cases were performed under general anaesthesia with adequate relaxation. A 10 mm permanent re-useable sharp metallic trocar was inserted through umbilical scar after lifting the abdominal wall using towel clamps. Studied variables included age, gender, BMI, operations, history of previous surgery, number of attempts for DTI and complications

Results: Mean age of the patients in DTI group was 46.58 +/- 13.94 years, while 48.70 +/- 10.08 years in OL group. Female to male ratio in DTI group was 1.43:1; and 2.33:1 in OL group. Increase in BMI had a relation with number of unsuccessful attempts of DTI, so obesity was the main reason of failure of DTI

Conclusion: DTI is a safe and effective method of peritoneal access for laparoscopy with very low failure rate related to BMI and minimal complications

Knowledge and practices of basic life support amongst the ambulatory staff in Karachi

To assess the Knowledge and Practice of Basic Life Support in the ambulatory staff services in Karachi. Cross Sectional Study This study was conducted at Sindh Medical University [JSMU] from March 1st to October 30[th], 2011. Sample size of 283 was drawn using non- probability purposive sampling, ambulance staff members belonging to 10 ambulance services in the city, mainly Aman Foundation, Edhi, Chippa, Khidmat-e-Khalq Foundation were interviewed through structured questionnaire. The data was collected and analyzed on SPSS version 17. Out of the 283 ambulatory staff members, 72.5% of the staff had no knowledge of Basic Life Support, 27.4% had knowledge. 14% answered correctly about the position in which a heart attack patient should be placed, 90% answered wrongly about patient whose clavicle had been fractured. 72% of the ambulatory staff actually checked oxygen flow in the tank after they had put the mask on the patient, 65% of the staff had removed the helmet of accident patients.64.8% had no idea about the respiratory rate, pulse count of an adult, 76.2% didn't know about the complications of an Intravenous installation. The study proved major lapses in knowledge and practices in Basic Life Support for ambulatory staff. Implementation of first aid's protocol are fully neglected, yielding an ambulance service that might let the patients suffer undue circumstances and also directly affects major indicators of primary health care

role of L- arginine in lithium induced nephrotoxicity in albino rats a morphological study

To observe the protective role of L-Arginine on kidney from toxic effects of Lithium carbonate in Albino rats. A prospective experimental study. The study was conducted at Department of Anatomy, Basic Medical Sciences Institute, Jinnah Postgraduate centre Karachi from July 2007 to November 2007. Forty five adult albino rats of either sex were taken and were taken and divided into three groups as A, B and C which were further divided in to three subgroups according to the period of treatment they received i.e. two, four and six weeks respectively. Group [A] animals served as control and Group 'B' animals received Lithium carbonate [Neurolith, Adamjee Pharma], 20 mg/kg/day with feed. Group [C] animals received Lithium carbonate 20 mg/kg/day plus L-Arginine [Arginine, General Nutritional Corporation, Pittsburg USA] 300 mg/kg/day with feed. After completion of respective period of treatment, kidneys were removed and fixed in alcoholic formalin and 10% formalin, after processing were embedded in paraffin. 5p thick longitudinal sections were cut and stained with PAS-Haematoxylin and Gomori's calcium phosphate method for study of cell morphology. PAS-Haematoxylin stained sections of group [A] revealed normal renal cortical histology. Gomori's calcium phosphate method stained tissue revealed normal activity of alkaline phosphates. Group [B] revealed altered renal histology with damage to the proximal tubules on PAS-Haematoxylin stained sections. Gomori's calcium phosphate method stained sections revealed decreased activity of Alkaline phosphatase in proximal tubules. Group [C] revealed normal cortical architecture except very mild alteration to brush border in subgroup [C3]. Gomori's calcium phosphate method stained sections revealed normal activity of Alkaline phosphatase. The present study suggests that even in therapeutic dose lithium carbonate causes damage to the proximal tubules in albino rats and L-Arginine minimizes the toxic effects of lithium carbonate

effectiveness of elastic rubber band ligation technique in cases of internal haemorrhoids

To study the effectiveness of the elastic rubber band ligation technique in cases of internal haemorrhoids. A prospective study. This study was conducted at Jinnah postgraduate medical center Karachi during 2007-2008. a total of 70 patients of varying degrees haemorrhoids of either sex were taken randomly. In 20 out of the 70 cases open Haemorrhoidectomy was performed by low ligation and excision [after due preparation of the patients] and in 50 cases elastic rubber band technique was performed. Tablet Bisacodyl 4-6 tablets stat were given to the patients at night before the procedure. No anesthesia was used. This procedure was performed in Left lateral position or in knee-elbow/jack-knife position. Patients with elastic rubber band ligation method were discharged at the same day [average stay was only for the procedure], with minimum complains, and post operative complications were found negligible [Pain 28, haemorrhage 6%, discomfort 14%]. In contrast average stay in the cases of Haemorrhoidectomy was 5- 26 days and complications ranged between pain and haemorrhage [95%], discharge [15%], retention of urine [10%] and faecal incontinence [15%]. No case of faecal incontinence and retention of urine was observed in cases of elastic rubber band ligation technique. Elastic rubber band ligation as an Out Patient procedure, is effective, economical easily performable, with minimum complications and is without hazards of anaesthesia

Percutaneous tracheostomy in critically ill patients: 24 months experience at a tertiary care hospital in United Arab Emirates

We assessed the safety and complications related to percutaneous tracheostomy [PCT] without bronchoscopic guidance in our intensive care unit [ICU]. The prospective data over a period of 24 months were collected for patients who underwent PCT. Major, minor and long-term complications were recorded. The parameters recorded were: age, gender, Glasgow Coma Scale / [GCS] score on the day of tracheostomy, acute physiology and chronic health evaluation II [APACHE] score, and predicted mortality based on score on admission and on the day of procedure, total number of days in the hospital before the final outcome, number of successful decannulations and mortality. The patients were stratified in two groups of survivors and nonsurvivors. A total of 117 patients underwent PCT. Overall mean GCS and APACHE-II scores before PCT were 7 +/- 3 and 16 +/- 5, respectively. The only significant difference was APACHE-II score and the predicted mortality based on APACHE-II score on the day of PCT, which was higher amounts the nonsurvivors [P=0.008 and P=0.006]. All 57 [495] survivors were successfully decannulated with mean post tracheostomy days of 24 +/- 15. The major complication observed was three episodes of major bleeding. Only six patients had an episode of desaturation during the procedure and there were three episodes of accidental puncturing of endotracheal [ET] tube pressure cuff. During subsequent follow-up in hospital, six patients developed stoaml cellulitis. PCT without bronchoscopic guidance can be performed safely by carefully selecting patients and having an experienced team High APACHE score on the day of procedure may lead to poor outcome

Prophylactic use of laxative for constipation in critically ill patients

This study was designed to evaluate the use of laxative prophylaxis for constipation in intensive care unit [ICU] and the impact of early versus late bowel movement on patient's outcome. The study was a prospective, randomized controlled trial in critically ill ventilated adult patients, who were expected to stay on ventilator for >72 h. Control group did not receive any intervention for bowel movement for the first 72 h, whereas interventional group received prophylactic dose of lactulose 20 cc enterally every 12 h for the first 72 h. The parameters measured during the study were admission diagnosis, age, gender, comorbid conditions, admission Simplified Acute Physiologic Score [SAPS II], sedative and narcotic agents with doses and duration, timing and tolerance of nutrition, daily assessment of bowel movement, total use of prokinetic, doses of suppositories, and enema for first bowel movement, total number of days on ventilator, weaning failures, extubation or tracheostomy, ICU length of stay, and death or discharge. A total of 100 patients were enrolled, 50 patients in each control and interventional group. Mean age was 38.8 years, and both groups had male predominance. Mean SAPS II score for both was 35. Mean dose of Fentanyl [323.8 +/- 108.89 mcg/h in control and 345.83 +/- 94.43 mcg/h in interventional group] and mean dose of Midazolam [11.1 +/- 4.04 mg/h in control and 12.4 +/- 3.19 mg/h in interventional group]. There were only two [4%] patients in control, while nine [18%] patients in interventional group who had bowel movement in <72 h [P < 0.05]. Mean ventilator days were 16.19, and 17.36 days in control and interventional groups, respectively. Subgroup analysis showed that the patients who moved bowel in <5 days in both groups had mean ventilator days of 18.5, whereas it was 15.88 days for the patients who moved bowel after 5 days in both groups [P< 0.05]. Mean ICU days for control was 21.15 +/- 10.44 and 20.77 +/- 8.33 days for interventional group. Forty-eight [96%] patients in each group were discharged from the ICU. Two [4%] patients died in ICU in each group. Laxative prophylaxis can be used successfully to prevent constipation in ICU patients. Late bowel movement >5 days is associated with less ventilator days, compared to early <5 days bowel movement

Whole lung lavage with intermittent double lung ventilation. A modified technique for managing pulmonary alveolar proteninosis

Whole lung lavage is still the most effective treatment for pulmonary alveolar proteinosis. We report a 21-year-old male diagnosed with pulmonary alveolar proteinosis by open lung biopsy and who underwent whole lung lavage with a modified technique. He showed significant improvement in clinical and functional parameters. The technique of intermittent double lung ventilation during lavage procedure keeps the oxygen saturation in acceptable limits in patients at risk for severe hypoxemia and allows the procedure to be completed in a single setting

Lichtenstein repair versus darning repair in direct inguinal hernia

To compare the merits of Lichtenstein repair with Darning repair in Army soldiers having direct inguinal hernia. Study Design and A comparative, interventional clinical study in 100 cases, carried out in Combined Military Hospital, Malir, Karachi and Pakistan Air Force Hospital Faisal Base, Karachi from March 2002 to March 2004. During the study period, serving soldiers reporting to the surgical outdoor department of both hospitals were selected according to the inclusion criteria and randomly assigned to either group A [Lichtenstein repair] or group B [Darning repair]. Written informed consent was obtained from all the patients before induction in the study groups. 50 patients each were assigned to both the groups. Thorough clinical examination and laboratory profile was done to assess pro operative fitness for general anesthesia. The parameters used to assess the results were duration of stay in hospital, patient comfort and fitness, complications and recurrence. After the respective procedure, as per the group of the patients, they were followed up on day 7, 1 month, 3 months, 6 months and 1 year. On each visit thorough history and clinical examination was done to assess the condition of the patient. Physical efficiency requirements for serving soldiers were also assessed and complications noted. Overall 58% patients presented with right inguinal hernia and 39% with a left, while 3% patients had bilateral hernia. The overall incidence of postoperative complications was 10.4%. Scrotal hematoma occurred in 3% in group A and 6% in group B. The wound infection occurred in 1% of patients in group A and 3% in group B. 10% of group A and 15% of group B had postoperative pain, which required oral NSAIDS for 4-7 days. 2% patients of group B and none of group A developed urinary retention post operatively. The incidence of complications and recurrence is lower in Lichtenstein repair as compared to Darning repair, therefore, we recommend Lichtenstein hernial repair for direct inguinal hernia