Mesh hernioplasty: surgeons' training ground?

To clinically evaluate the outcome of Inguinal Hernioplasty in terms haematoma, wound infection and recurrence, with special reference to surgery done by trainee surgeons. Case control study with prospective data collection, conducted from Sep. 2005 to August 2006. Surgical Unit two, Civil Hospital, Karacho. All male patients above 30 years of age with Inguinal hernia were included in the study. Patients presenting in emergency and those with age less than 30 years were excluded, as they did not undergo Mesh Hernioplasty. Patients with symptoms like chronic cough and constipation, and those with conditions like anaemia, diabetes and hypertension were optimized before surgery. Anaesthesia fitness was taken after necessary investigations. Patients were mostly operated under Regional [Spinal] anaesthesia. Two doses of a first generation cephalosporin or co-amoxiclav were used as a prophylactic antibiotic. Data was collected on a pre-designed proforma; record was also duplicated on the computer in the SPSS Version 10. Out patient follow-up was done for 6 months as a minimum. A total of 75 males with 78 inguinal hernias were operated during the study period; three patients had bilateral hernia. Sixty five percent of our patients had hernia on the right side and 31% on the left side, while 4% were bilateral. The ages of the patients ranged from 30 to 81 years; majority [72%] were under the age of 60 years. Sixty percent of the patients were manual workers. Sixty nine [88.5%] inguinal hernias were reducible and 9 [11.5%] irreducible; 6[7.7%] were recurrent. Trainee surgeons did 70% of the operations. Haematoma occurred in five cases, seroma in nine, urinary retention in four, wound infection in four and recurrence in one case. No mortality occurred during the study. In our set-up Mesh Hernioplasty has proven to be effective with low complication and recurrence rates. It is easily learnt by trainee surgeons. Early ambulation should be the aim. Cost of the mesh is a minor stumbling block, but the long term benefits of this hernia repair makes it the benchmark for all

Audit of a general surgical unit: reed for self evaluation

To find out the pattern of admissions and the outcome of patients in a general surgical unit of a major teaching hospital. Observational, descriptive study covering the year 2006 with retrospective data collection. Surgical Unit three, Dow Medical College and Civil Hospital Karachi. All patients admitted to the unit during 2006 either through Out-patient Department or Emergency Department or transferred/referred from other units/departments. Detailed data regarding the patients was collected and analyzed. A total of 779 patients, 492 males and 287 females, were admitted during the study period; 489 from the Out-patients Department [OPD] and 276 from the Emergency [Casualty] Dept., while 14 were transferred from other departments as they had general surgical problems. Inguinal hernias accounted for the highest number of admissions i.e. 15.5% followed by Acute Appendicitis [11 9%] and Chronic Cholecystitis [10.7%]. Trauma constituted 11.2% of the total admissions, including 46 [5.5%] cases of gunshot injuries. There is a dire need of local studies on the topic of Surgical Audit because for proper and better health care planning of the country, a knowledge of the current pattern of admissions and diseases spectrum are essential

Post operative wound infection: a surgeon's dilemma

Keeping in view the prevalence of wound infection in our set up, this study was designed to evaluate the frequency, clinical presentation, common risk factors and different organisms involved in cases of clean and cleancontaminated surgery. Observational descriptive study from March 2005 to February 2006. Surgical Unit III, Civil Hospital, Karachi. One hundred patients who underwent clean and clean-contaminated surgery. Biodata of the patients together with their clinical features, diagnosis, type of surgery performed and the development of any complications including wound infection was noted and the data analyzed. Out of the 100 patients [52 males and 48 females] in the study, 69 belonged to the clean surgery group and 31 to the clean-contaminated surgery group. The overall incidence of surgical site infection [SSI] in the study was 11%; 5[7.2%] cases in the clean surgical group and 6[19.4%] cases in the clean-contaminated group developed infection. Patients in the age group 51-60 years were infected more than those in the younger age groups. The incidence of wound infection was more in male patients [11.5%] as compared to female patients [10.4%]. Obesity was also a main cause of SSI as evident from the fact that patients with more than 60kg/m2 were infected more [20%] as compared to 30-40kg/m2 [7.1%]. Surgical site infection was found more in patients with extended pre-operative hospital stay. Anaemia, smoking, diabetes mellitus, prolonged surgery, operations by junior surgeons and operations late in the list were also associated with more surgical site infection. The usual time of presentation of SSI was within three weeks following surgery and most patients presented with wound abscess and cellulitis, while two patients had wound dehiscence. The common organisms involved in the SSI were Staphylococcus aureus, E. coli, Streptococcus pyogenes and Pseudomonas group. Meticulous surgical technique, proper sterilization, judicious use of antibiotics, improvement of operation theatre and ward environments, control of malnutrition and obesity, treatment of infective foci and diseases like diabetes, and avoidance of smoking helps control the morbidity of surgical wound infections

Utilization of blood in elective cholecystectomy

To evaluate Blood Ordering and Transfusion ratios for elective cholecystectomy. All patients who underwent elective cholocystectomy in Surgical Unit III, Civil Hospital, Karachi from December 2005 to November 2006 were included in this study. Blood units cross matched and units transfused intra-operative and post-operatively were recorded apart from patient demography and hepatitis profile. A total of 132 patients underwent elective open cholecystectomy during the study period. Total 181 blood units arranged, among these only nine units of blood were transfused. This means only only 4.9% of blood was utilized while 95.1% of blood was not utilized. Cross-match to transfusion ratio=20.11, Transfusion probability=6.8 and Transfusion index=0.06. For elective cholecystectomy, there is no need for routine cross matching of blood. However, one must confirm the availability of blood for Hepatitis B and Hepatitis C reactive patients, and for cases with recurrent acute cholecystitic attacks

Blunt abdominal trauma; does clinical evaluation suffice?

To correlate preoperative clinical diagnosis with per-operative findings in cases of Blunt Abdominal Trauma. Observational study with prospective data collection from Jan. 2004 to Dec. 2005. Surgical Unit III of Civil Hospital, Karachi. All patients over 12 years of age who underwent surgery for admitted with Blunt Abdominal Trauma. The patients were resuscitated and prepared for surgery: starting. blood transfusion in haemodynamically unstable patients, passage of nasogastric tube, bladder catheterization and doing appropriate investigations where conditions permitted. Pulse, Blood pressure, Temperature, Respiratory rate, Oxygen saturation and Urinary output monitoring started. As soon as possible surgical exploration was carried out through a midline incision under general anaesthesia. The surgical procedures performed depended upon the laprotomy findings. The data collection was done on a standard performa. During the two-year study period 25 patients, 21 males and 4 females, aged 16-52 years [mean 27 years] were admitted with Blunt Abdominal Trauma. At the time of presentation in the Casualty Dept. most of the patients [64%] were in a state of circulatory shock. Road Traffic Accident [RTA] was the commonest cause of Blunt Abdominal Trauma in our study, accounting for 16 [64%] patients, followed by fall from height in six [25%] and assault in three [12%] cases. A clinical diagnosis of splenic injury was made in 11 [44%] cases, liver injury in eight [32%],intestinal perforation in five [20%] and bladder injury in one [4%] case. Our pre-operative clinical diagnosis correlated with the operative findings in 22 [88%] cases. However in three [12%] cases, the operative findings did not correlate with clinical diagnosis. An early examination of Blunt Abdominal Trauma patients, enables the surgeon to reach a correct working diagnosis in the majority of cases

Morbidity and mortality following colostomy in penetrating colonic injuries

To study the complications and mortality associated with colostomy in penetrating colonic injuries; besides gathering additional information regarding the mechanism, pattern and the type of colonic injuries. Retrospective study from Jan. 1997 to Dec. 2005. Surgical Unit III, Abbasi Shaheed Hospital, Karachi. All patients with penetrating colonic injuries who underwent colostomy as a mode of treatment. The data of the above mentioned patients was collected from records and analyzed. A total of 83 patients, majority being young [78.3% <40 years] and males [91.5%], underwent colostomy for penetrating colonic injuries. In most [89%] of the patients the mechanism of trauma was gunshot injury. The over-all morbidity was 28.9%, while the colostomy related complications were 8.4%. The mortality in this series was 2.4%. Colostomy is a safe and effective method of treating patients with penetrating colonic injuries

Amyand's hernia: appendix within an inguinal hernia

Hernia containing the vermiform appendix is known as the Amyand's hernia. It is a rare condition that occurs in about one percent of the cases of inguinal hernia. This is the report of a case of Amyand's hernia in a 24 years old male patient. As the appendix was not inflamed, hence it was not removed and replaced in the abdominal cavity. The indirect inguinal hernia was repaired with darning

Outcome Of Ileostomy in cases of small bowel perforation

To find out the outcome of ileostomy in cases of small bowel perforation.Prospective, descriptive study carried out over a period of two years.Civil Hospital,Karachi.All patients presenting with small gut perforations except children and duodenal ulcer perforation cases. The patients were evaluated clinically and investigations including CP and ESR, RBS, Urea, Creatinine and Electrolytes, Widal Test, X-ray Chest and Abdomen [erect] done. All patients were operated in emergency OT via a right paramedian incision and findings noted. Ileostomy, either loop or end, was performed in all cases after primary closure of the perforation or resection of the gut. Out of the 40 patients seen during the study period, there were 33 [82.5%] males and 7 [17.5%] females. The age of the patients ranged from 15 to 75 years. The causes of small gut perforation were typhoid perforation 135%], followed by trauma [30%], non-specific inflammation [30%] and tubercluosis [5%]. Abdominal pain, vomiting constipation and high grade fever were common symptoms, while generalized tenderness, rigidity and obliteration of liver dullness were the main clinical findings. Wide differences were observed in haemoglobin levels,:total leukocyte counts, urea, creatinine and electolytes. In most patients the perforation was single and at the anti-mesenteric border 'with minimal to moderate peritoneal soilage. Multiple perforations and gross peritoneal soilage was present inpatients who presented late. Common complications seen during hospitalization and in the follow-up period were -ound sepsis, peristomal skin excoriation, chest infection and prolonged ileus. Other complications included deostomy retraction, faecal fistula, intra-abdominal abscesses and burst abdomen. Inspite of late presentation in same cases, the overall mortality was low [7.5%], major causes of mortality were septicaemia and uncontrolled faecal fistula. Hospital stay varied between seven to twenty eight days.Creation of a stoma [ileostomy], especially in-patients with typhoid and tuberculous perforations, reduced mortality and morbidity dramatically. Such immuno-compromised patients instead of having primary Pewction and anastomosis had an alternative approach of faecal diversion, which has altered the outlook completely

Bilateral Carcinoma breast

Carcinoma of the Breast is the commonest carcinoma in the females; the incidence being one woman out of every 11 women. The disease can also develop bilaterally, rarely. In this report we are presenting the case of a bilateral carcinoma breast in a female aged 35 years

Postoperative analgesic effect of diclofenac suppository versus diclofenac I.M. injection

All surgical procedures, whether minor or major, are followed by some degree of pain and discomfor[1]. Many drugs, including narcotics and non-narcotics, have been employed by different techniques to overcome this problem[2]. Diclofenac sodium, a non-steroidal anti-inflammatory drug, is commonly used via oral, intra-muscular or rectal route to produce analgesia in the post-operative period. This randomised clinical trial was conducted on 100 patients in Surgical Unit III of Civil Hospital, Karachi to compare the efficacy, safety and analgesic duration of diclofenac suppository versus its intramuscular administration. The results show that the average duration of pain free interval was greater in the Suppository Group [12.90 hours] than in the Injection Group [11.85 hours] and the duration of pain free mobilization was shorter in the Suppository Group [15.54 hours] than the Injection Group [18.32 hours]. There were no side effects amongst patients of the Suppository Group and they were also discharged earlier. However, no significant difference was observed in the quality of analgesia. It is, therefore, concluded that diclofenac sodium in suppository form is an effective, safe, practical and better way of providing post-operative analgesia than the intra-muscular injection. Besides it is also cost effective as a single dose of diclofenac suppository costs less than the injection

Giant multinodular goiter

This is the case report of a 24 years old female that presented with a huge multinodular goiter, a rare occurrence these days. The goiter extended from the mandible above, to the front and back of the sternum below. She underwent sub-total thyroidectomy with successful outcome and no post-operative complications

External hernias in women

A retrospective study carried out at Surgical Unit II of Peoples Medical College, Nawabshah, revealed that over a span of 8 years 112 women presented with external hernia accounting for 11.58% of all hernias and 4.09% of all female admissions. Of these 29 [25.89%] had incisional hernia, 29 [25.89%] - paraumbilical, 17 [15.18%] - umbilical, 14 [12.5%] - epigastric, 14 [12.5%] - inguinal and 9 [8.04%] femoral hernia. Majority of cases were seen between 21-50 years of age. There is a genuine need for mass education as most women with hernia report late when some complication has occurred

Observations on the epidemiology of benign prostatic hypertrophy at Nawabshah

In a retrospective study carried out at Surgical Unit II of Medical College Hospital, Nawabshar between 1980 to 1987 there were 661 patients of benign prostatic hypertrophy. These constituted 21% of all urological cases and about 6% of total admissions. Majority of cases i.e. 40% were seen in the fifties. About 11% cases had urinary calculi and 8% hernias in addition to BPH. Sixty two percent cases underwent transvesical prostatectomy with a perioperative mortality of 3.9%. The overall mortality in this series was 3.6%

Biliary ascariasis

Out of 38 patients who were operated for obstructive jaundice during a 4 years period Ascaris lumbricoid was found in the bile ducts of 3 patients. In one patient who responded to conservative management, there was strong evidence that the obstructive jaundice was due to the presence of round worm in the bile duct. This makes a total of 4 cases of biliary ascariasis in 39 patients of obstructive jaundice, a high prevalence rate of 10.26%

Colosotomy closure

This study was carried out in Surgical Unit II of Abbasi Shaheed Hospital, Karachi from August 1992 to Feb. 1997. It describes the results of colostomy in 48 patients who had colostomy for gunshot injuries of the abdomen. All patients were males most of them [43] were below 40 years of age. All colostomies were closed 3 months after they were made by consultants. Special attention was given to meticulous bowel preparation prior to closure which was made intraperitoneally in two layers. Average hospital stay of the patients was 10 days with a morbidity of 8.33% and no mortality

Bilateral ovarian hydatid cysts, with impending surface rupture of a hepatic cyst

A very rare and interesting cases of Hydatid Cyst in both the ovaries, the first ever to be reported, from Pakistan, is being presented. The patients also had an impending rupture of an infected Hepatic Cyst on the surface, another rare feature