Laparoscopic cholecystectomy in acute gall bladder

To look for the feasibility and results of laparoscopic cholecystectomy in acutely inflamed gall bladder, gangrenous cholecystitis and empyema gall bladder. It was a prospective observational case series. As an institutional policy early laparoscopic cholecystectomy was performed in all the patients with diagnosis of acute cholecystitis. The incidence of gangrenous cholecystitis and empyema gall bladder was noted and laparoscopic intervention was preferred in all these patients. The demographic profile, clinical records, operative details, complications and follow up details were prospectively gathered on a performa. Early laparoscopic cholecystectomy was performed in 142 patients. 103 patients had simple acute cholecystitis, 13 patients had empyema gall bladder and 26 patients had gangrenous cholecystitis. The incidence of comorbids such as diabetes mellitus, hypertension and ischemia heart diseases was 28.1%, 61.5 and 80.75 in patients with simple acute cholecystitis, empyema gall bladder and gangrenous cholecystitis respectively. Male gender was predominating in patients with complicated cholecystitis. The open conversion rate was 3.88% in simple acute cholecystitis, 15.38% in empyema gall bladder and gangrenous cholecystitis combined. There were 2 major complications in patients with simple acute cholecystitis and 2 major complications in patients with gangrenous cholecystitis. There was one mortality in a patient with simple acute cholecystitis. Laparoscopic cholecystectomy is a safe and effective option in acute gall bladder. Based on our experience we recommend an early laparoscopic gall bladder removal, provided expertise and gadgets are available

effects of CO2 pneumoperitoneum on end tidal CO[2] [ETCO[2]], arterial blood pressure and heart rate during laparoscopic cholecystectomy under general anaesthesia

To analyze the effects of CO2 pneumoperitoneum at 13 to 15 mmHg infra-abdominal pressure on end tidal CO2 [ETCO2], arterial blood pressure and heart rate during laparoscopic cholecystectomy under general anaesthesia with controlled mechanical ventilation. Prospective Descriptive Study. The study was conducted at the department of anaesthesia Fauji Foundation Hospital Rawalpindi from August 2005 to September 2006. Fifty consecutive ASA grade-1 patients, 47 females, 3 males and aged 35-65 years undergoing laparoscopic cholecystectomy were included in the study. All patients received a standardized balanced anaesthetic in which 0.7 - 1% isoflurane was used during maintenance. Ventilation was controlled and minute volume was kept at 100 ml/kg/min. Pneumoperitoneum was created with CO2 at a flow rate of 10 liter/min and 13 to 15 mmHg infra abdominal pressure was maintained during the operation. End tidal CO2 [ETCO2], heart rate and non invasive systolic, diastolic and mean arterial blood pressure was recorded immediately before infra abdominal C02 insufflation and then after 5 minutes interval during the period of CO2 pneumoperitoneum. Study period started immediately before infra-abdominal CO2 insufflation till about 60 minutes of surgical procedure. The end tidal CO2 [ETCO2] levels progressively increased to reach a plateau 36mmHg 20 minutes after the beginning of infra abdominal CO2 insufflation. The end tidal CO2 [ETCO2] levels increased to 21% of base line [from 30 to 36 mmHg] during CO2 pneumoperitoneum for laparoscopic cholecystectomy under controlled mechanical ventilation at minute volume 100 ml/kg/min. The systolic, diastolic and mean arterial blood pressure increased to 12% to 17% of the baseline during CO2 pneumoperitoneum at 13-15 mmHg infra abdominal pressure. There was no significant change in heart rate. CO2 pneumoperitoneum produces rise in end tidal CO2 [ETCO2] levels and hemodynamic alterations proportional to the increased infra abdominal pressure during laparoscopic surgery under general anaesthesia with controlled mechanical ventilation

Control of cystic artery in laparoscopic cholecystectomy: to clip or to use monopolar electrocautery

The purpose of this study was to compare monopolar electrocautery with clip application for securing hemostasis of cystic artery in patients undergoing laparoscopic cholecystectomy. A comparative study was performed on data collected during a 6-years period [2005-2011] from 600 patients who underwent laparoscopic cholecystectomy. In 306 cases assigned to group 1, the cystic artery was clipped while in 294 cases assigned to group 2, the cystic artery was coagulated with monopolar electrocautery. In group 1, the cystic artery was single in 91%, branched in 6% and absent in 3% cases while in group 2, the cystic artery was single in all cases. The cystic artery was of normal size in 82%, short in 7%, long in 8% and absent in 3% cases in group 1 while in group 2, it was normal in size in 88%, short in 3% and long in 9% cases. The cystic artery was originating from the right hepatic artery in 97% cases and from the superior mesenteric artery in 3% cases in group 1. In group 2, the cystic artery was originating from the right hepatic artery in 97% cases and not visualized in 3% cases. In group 1, only 3 patients had an intra-operative hemorrhage while in group 2, 3 of the patients had bleeding. The post operative recovery was also similar in both groups with 83% and 81% patients going home on the next day. There was no difference in the outcome of patients whether clips or monopolar electrocautery was used for hemostasis of cystic artery in laparoscopic cholecystectomy

Mediastinal tuberculosis presenting with sternal osteomyelitis and discharging sinus

Involvement of the mediastinum and sternal bone leading to osteomyelitis is a very rare presentation of tuberculosis even in countries where tuberculosis is endemic like Pakistan. Frank presentation as discharging sinus is even more uncommon. We describe a case where a patient presented with constitutional symptoms of fever, loss of appetite, significant weight loss and an erythematous tender lesion over the sternum with a discharging sinus without any features of pulmonary tuberculosis. The case was initially not diagnosed by routine laboratory tests and the lesion was just considered as a boil until presented to tertiary care hospital as discharging sinus. Plain Radiographs showed lytic lesion on the inner aspect of sternum and histopathology of the aspirate from the lesion confirmed the presence of epithelioid granulomas and acid fast bacilli on staining. Patient responded very well to 12 months of antituberculosis treatment

Ductal variations in the Calot's triangle seen on laparoscopic cholecystectomy

To describe the frequency and pattern of ductal variations seen in the Calot's triangle on laparoscopic cholecystectomy. Descriptive study. This study was conducted in the Surgical Unit 1, Fauji Foundation Hospital, Rawalpindi from December 13, 20008 to February 22, 2011. 200 patients with a diagnosis of biliary colic, cholelithiasis, acute cholecystitis, empyema gall bladder and mucocele gall bladder were included in this study. Patients with age less than 15 years were excluded. Careful dissection of the Calot's triangle was carried out. The anatomical variations of the cystic duct and other anomalous variations in the region were noted and data analyzed on SPSS 10. The age range was 19 to 88 years with a mean of 48 years. The majority [88%] of the patients presented with a clinical diagnosis of biliary colic. The cystic duct was of normal size in 88%, short in 7%, and long in 5% of the cases. The cystic duct terminated laterally into the common hepatic duct in 94% of the cases, anteriorly into the common hepatic duct in 5% and posteriorly into the common hepatic duct in 1% of the cases. Each Calot's triangle differs from the other. Ductal variations are the hallmark of this region and their knowledge is mandatory for a safe laparoscopic cholecystectomy

Vascular variations in the calot's traingle seen on laparoscopic cholecystectomy

To describe the frequency and pattern of vascular variations seen in the Calot's triangle on laparoscopic cholecystectomy. Descriptive study. From December, 2008 to February, 2011. Surgical Unit 1, Fauji Foundation Hospital, Rawalpindi. Two hundred patients with a diagnosis of biliary colic, cholelithiasis, acute cholecystitis, empyema gall bladder and mucocele gall bladder were included. Patients with age less than 15 years were excluded. Careful dissection of the Calot's triangle was carried out. The anatomical variations of the cystic artery and other anomalous variations in the region were noted and data analyzed on SPSS 10. The age range was 19 to 88 years with a mean of 48 years. The majority [88%] of the patients presented with a clinical diagnosis of biliary colic. The cystic artery was single in 91%, branched in 6% and absent in 3% cases. The cystic artery was supero-medial to the cystic duct in 88%, anterior in 6%, and posterior in 3% of the cases. Other arterial variations included Calot's arteries [2%], Moynihan's Hump [3%] and gall bladder arterial supply from liver bed [3%]. Each Calot's triangle differs from the other. Vascular variations are the hallmark of this region and their knowledge is mandatory for a safe laparoscopic cholecystectomy

Laparoscopic ureterolithotomy: an experience of 15 cases

To review our experience of laparoscopic ureterolithotomy and revisit its indications in the current era of minimally invasive urologic surgery. A descriptive study. The study was conducted at the department of Urology, Foundation University Medical College and Fauji Foundation Hospital, Rawalpindi from January 2007 to December 2009. We performed laparoscopic ureterolithotomies on fifteen patients for large [1.5-2.5 cm], impacted upper and middle ureteric calculi. In 10 patients laparoscopic ureterolithotomy was adopted as a primary procedure, four patients had stones resistant to Extracorporeal Shockwave Lithotripsy [ESWL], while one patient had failed ureterorenoscopy [URS]. An extraperitoneal approach was selected in all the patients. There were 11 patients with upper ureteric calculi and four with midureteric calculi, the procedure was successful in 14 cases. One patient required conversion to open ureterolithotomy. The average operating time was 50 minutes. The average hospital stay was 2.5 days. There was no major complication. One patient had persistent drain for four days. IVU at three months follow-up was normal in all cases. Laparoscopic ureterolithotomy in selected cases is a good minimally invasive procedure. Large, impacted, hard calculi which are resistant to ESWL and difficult to fragment endoscopically without flexible ureteroscopes and holmium laser can be managed by this technique

Emergency thyroidectomy in infected thyroid cyst due to spontaneous gas forming organisms

We are reporting a case of a young female, who presented to emergency room with sudden increase in thyroid swelling, high fever and acute respiratory distress. Clinical diagnosis of spontaneous infection of thyroid cyst was made. Operative finding was infection of thyroid cyst with gas formation. Systemic antibiotics and operative intervention by subtotal thyroidectomy led to recovery of the patient

[General health and its association with sleep quality in two groups of nurses with and without shift working in educational centers of Iran University of Medical Sciences [IUMS]]

The health condition of nurses as caregivers influences the quality of care received by patients. To reach the maximum performance, nurses themselves need be health. Nurses, because of the nature of their career confront many types of stresses in their work environment and they are among people that are prone sleep disorder because of working in morning, evening, night and especially, rotation shifts. The aim of this study is comparison of the general health and sleep quality of nurses in two groups of without shift and with shift working in IUMS- 2006. It was a descriptive - analytical study. The setting was hospitals affiliated to IUMS. Five hundreds and twenty nurses were recruited using stratified random sampling. To survey the general health and sleep quality of nurses General Health Questionnaire - 28 and Pitsberg Sleep Quality Index tools were used. Chi - Square test indicatod that there was a significant difference between general health of without shift and with shift workers, so that general health of without shift workers was better than rotation shift ones. The sleep quality of without shift nurses was also better than rotation shift ones [r=0.692, P<0.001]. There was a direct correlation between general health state and sleep quality [P<0.001]. Based of the finding of this study, appropriate and efficient managmant and careful planning of working shifts is suggest to reduce sleep disturbances in nurses. Promotion of nurse's quality of sleep can promote their general health and eventually promotes the quality care of patients

Recurrent goiter: is it preventable?

To determine the different factors responsible for the recurrence of goiter after surgery. Department of Surgery, Fauji Foundation Hospital, Rawalpindi from January 1998 to December 2005. All patients with recurrent goiter irrespective of place of first surgery were included. The patients with recurrent goiters due to thyroid malignancies were excluded. Sixty-four patients were included during study period from January 1998 to December 2005. 34.38% were in 4[th] and 25% of patients reported in 3[rd] and 5[th] decade each. Among them 96.9% were females and 3.1% males. 46.88% patients noticed recurrence after 4-6 years and 28.13% after 6-7 years of surgery. 75% of patients had not used thyroxin at all and 25% used for some duration after surgery. None of the patients gave the history of continuous use of suppressive dose of thyroxin postoperatively. During surgery it was observed that the site of recurrence was 25% whole one lobe, 18.75% from both lobes or at multiple places, 12.5% from pyramidal lobe and 9.37% from superior pole. Adequate thyroxin prophylaxis, correct indications for primary surgery, adequate surgery and removal of all palpable nodules reduce the risk of recurrent goiter

comparison of open vesicolithotomy and cystolitholapaxy

To compare Vesicolithotomy with Transurethral optical cystolitholapaxy. Comparative Observational study. Study was conducted at Department of Surgery, Fauji Foundation Hospital Rawalpindi, from October 2002 to April 2005. Study comprises of 40 patients, which were divided into two equal groups of twenty each. All patients having stones less than 30 mm in size were included. Group-I patients were treated with open vesicolithotomy and Group-II patients with transurethral optical cystolitholapaxy. All 40 patients were between age of 16 -76 years [mean age 52 years and 54.5 years in Group-I and II respectively] and female to male ratio were 1:2.3. Average hospital stay was long [7.33 days] in Group-I. 2.5% patients had UTI postoperatively in both groups and transient haematuria [5%], urethral trauma [5%] and recurrent stone formation [5%] was noted in Group-II patients. Transurethral optical cystolitholapaxy is a better way of managing Vesical stones because it is minimally invasive with short hospital stay. Complications noticed with this procedure are minor and can be reduced by experienced surgeon

Seroprevalence of Hepatitis B and C among the healthy blood donors at Fauji Foundation Hospital, Rawalpindi

To find out the seroprevalence of Hepatitis B and C virus among the healthy blood donors at Fauji Foundation Hospital, Rawalpindi. A prospective observational study. From April 2005 to September 2005 at Fauji Foundation Hospital, Rawalpindi. All healthy blood donors reporting to blood bank were screened for Hepatitis B and C. Total number of 1428 donors were screened, among them 97.05% were males. Prevalence of Hepatitis B was 2.45% with a male predominance of 2.38%. Seroprevalence of Hepatitis C was 2.52% with male predominance of 2.52%. Prevalence of Hepatitis B and C is not uncommon in our country. Transfusion of contaminated blood is one of the important cause of its spread. To control its further spread public awareness and health education programs and selection of healthy blood donors should be done

Recurrent laryngeal nerve injury: an experience with 310 thyroidectomies

Thyroid surgery has been associated with complications ranging from nerve injury to death. Improvements in techniques have reduced the mortality rate to minimum. Morbidity, however, remains a significant concern. This study was designed to determine the prevalence of recurrent laryngeal nerve [RLN] injury and duration of recovery following transient recurrent laryngeal nerve injury, during thyroid surgery. This prospective, observational study was carried out in the Surgical Department of Fauji Foundation Hospital, Rawalpindi, from January 2000 to December 2005. All patients undergoing Thyroid surgery were included. 310 patients, predominantly female [97.09%], were operated. Majority were euthyroid [90.33%]. 3.22% patients had recurrent laryngeal nerve injury. Amongst them, 87.5% had transient and 12.5% had permanent nerve lesion. Majority of the patients [87.5%] showed signs of recovery within 12 weeks after surgery. Injury was observed more in huge goiters [3.57% transient and 1.42% permanent], total thyroidectomy [7.69% transient and 3.84% permanent] and during lobectomy and total thyroidectomy [6.25% respectively for transient and permanent nerve injury. Thyroid surgery should be done by experienced surgeon and care should be taken especially in huge goiters and patients undergoing total thyroidectomy

To ligate or not the inferior thyroid artery to avoid hypocalcaemia after thyroid surgery

Hypocalcaemia is a well recognized complication of thyroid surgery. We have compared the prevalence of hypocalcaemia in our patients following ligation and non-ligation of the inferior thyroid artery [ITA] during thyroid surgery. A prospective observational study was done from January 2000 to December 2004, at Fauji Foundation Hospital, Rawalpindi. All patients undergoing subtotal or total thyroidectomy were placed in two groups at random. Group I had ITA ligated whereas in Group II, ITA was not ligated. 310 patients were operated, majority of them being female [97.10%]. Transient hypocalcaemia was observed in 4.29% patients in Group I and 3.4% patients in Group II. Permanent hypocalcaemia was observed in 1.84% and 1.36% patients in Group I and Group II, respectively. Results were statistically insignificant [p value > 0.5%]. There is no significant difference in post-operative hypocalcaemia whether or not the ITA is ligated

Evaluation of knowledge and practices of foot care in patients with chronic type 2 diabetes mellitus

To evaluate the knowledge and practices of foot care in patients with diabetes mellitus and to stress upon the importance of such knowledge and practices in decreasing morbidity associated with diabetic foot disease. One hundred patients of either sex from three tertiary care hospitals with a 5 year history of Diabetes Mellitus were selected in this study and were asked to fill out a questionnaire about their knowledge and practices about daily foot inspection, foot cleaning, appropriate nail care, and use of footwear in the form of shoe material, open or closed forepart and nature of heel. Out of 100 patients [36 males and 64 females], 34% patients inspected their feet daily and 78% of the respondents knew about care of callosities, minor injuries and cuts, 52% of patients didn't know about correct technique of cutting nails. Eight [22.2%] male and 28 [43.8%] female patients were using open shoes while 24 [66.7%] male and 38 [59.4%] female patients had shoes with narrow forepart. Ten [27.8%] males were using shoes made of hard material as compared to 20 [31.3%] of female patients. Twenty two [34.4%] of our female diabetic patients were using shoes with high heel. Only 68% of the patients were on regular follow up. This simple quality initiative concludes the notion that patients with diabetes who are at risk for the development of diabetic foot ulcers should receive ongoing foot-specific patient education

Complications of thyroid surgery: a five year experience at fauji foundation hosp., Rawalpindi

To determine the prevalence of complications after thyroid surgery and to compare our results with those in the international literature. This prospective observational study was conducted from April 2000 to March 2005. Department of Surgery, Fauji Foundation Hospital, Rawalpindi. 310 patients who underwent thyroid surgery were included. The data of all these patients was collected and analysed. Majority of the patients were females [97.09%] and only 8.06% were hyperthyroid pre-operatively, the rest being euthyroid. Subtotal thyroidectomy was done in 63.23%, while 10.96% patients underwent near total thyroidectomy. Complications were noted in 16.45% patients. Amongst them 5.48% developed hypocalecmia, 3.22% recurrent laryngeal nerve palsy, 2.90% seroma formation and 0.96% post-operative bleeding. Successful outcome of thyroid surgery depends on improving surgical training and skills