Demographical evaluation of laparoscopic versus open appendectomy at tertiary care teaching hospital

Objective: To document the demographical evaluation of laparoscopic versus open appendectomy at tertiary care teaching hospital

Patients and methods: This is comparative study was carried out in Surgical Unit-II, Liaquat University Hospital Jamshoro, Sindh, Pakistan from 21[st] November 2012 to 3[rd] February 2016 after the approval from Ethical review committee. During period of the study sixty patients admitted through the outpatient department, as well as from casualty department of Liaquat University Hospital Jamshoro / Hyderabad were enrolled. Results were prepared with the help of tables and graphs. Data was analyzed through SPSS software

Results: Out of 60 patients, 40 were males [66.66%] and 20 females [33.33%]; with male to female ratio of 2:1. The mean age for both groups was 26.78 years, ranging from 10 to 70 years. Symptoms of patients in both groups were almost identical comprising of pain in right iliac fossa in 59 [98.33%], pain starting around umbilicus in 45 [75%], nausea in 50[83.33%], vomiting 35[58.33%], anorexia in 25 [41.66%], fever in 22[36.66%] and altered bowel habits in 20[33.33%]

Conclusion: The laparoscopic appendectomy has significant advantages over open appendectomy with respect to length of hospital stay, discharge from hospital, and postoperative in-hospital complications and morbidity

Cystic duct anomalies and their surgical implications in patients undergoing laparoscopic cholecystectomy

Background: During cholecystectomy, to avoid common bile duct injury or other per operative complication, the knowledge of cystic cyst anomalies is imperative. This study aimed to highlight cystic duct anomalies identified during laparoscopic cholecystectomy and report their implications

Methods: This prospective study was conducted at Liaquat University of Medical and Health Sciences, Jamshoro over a period of six years [2009-2014] in the department of Surgery. Over this specified period a total of 775 patients underwent cholecystectomy and were included in this study

Results: Among 775 patients who underwent laparoscopic cholecystectomy, abnormal confluence was found in 7.22%, short cystic duct in 26.78%, long cystic duct in 17.86% and double cystic duct in 12.50%. Surgical problems encountered due to these variations were cystic duct avulsion, common bile duct injury, bleeding and bile leak

Conclusion: During laparoscopic cholecystectomy, unidentified anatomical variations of cystic duct may cause drastic complications including ductal injuries which significantly increase morbidity and may raise mortality

Xanthogranulomatous cholecystitis [XGC] - A diagnostic dilemma

INTRODUCTION: Xanthogranulomatous cholecystitis [XGC] is an unusual form of chronic cholecystitis characterised by marked thickening of the gallbladder wall and accumulation of lipid laden macrophages. It is frequently misdiagnosed preoperatively with gallbladder carcinoma. The aim of this study was to assess the preoperative clinical and radiological characteristics, operative findings and histological features of patients with XGC based on the experience of a single institution. In addition a literature search was performed to identify previously reported cases

PATIENTS AND METHODS: This retrospective study was conducted from January 2009 to December 2014. 1,989 consecutive patients who underwent elective cholecystectomy at the Surgical Unit-I, Liaquat University Hospital, Jamshoro, Pakistan were included in this study. Seventeen patients were identified to have XGC on histopathology

RESULTS: Seventeen [0.8%] cases of XGC were identified in 1,989 cholecystectomy specimens performed. The female to male ratio was 7.5:1. The average age in our series was 51.6 [range from 18 to 77 years]. Two [11.7%] cases, suspected of malignancy during preoperative work-up, were reported as XGC on histopathology

CONCLUSION: Preoperative differentiation between XGC and carcinoma of the gallbladder remains challenging due to similarities in clinical presentation, radiological and operative findings

In view of this there should be a low threshold for conversion from a laparoscopic to an open procedure

Single dose versus 24 - hours antibiotic prophylaxis against surgical site infections

OBJECTIVE: To observe the effect of single dose antibiotic is it as efficient as a 24-hour regimen in preventing SSIs in adults undergoing clean, clean contaminated and contaminated elective surgical procedures

STUDY DESIGN: Random, prospective SETTING AND DURATION: Department of general Surgery, Liaquat University Hospital, Jamshoro, Pakistan from May 2011 to April 2012

PATIENTS AND METHODS: A total of 208 patients undergoing general surgical operations were included in the study. The patients were randomly divided into two groups

The single-dose group received 2 grams of ceftriaxone intravenously, whereas the 24-hour group received 2 grams of ceftriaxone intravenously at the time of induction of anaesthesia, followed by 1 g at 8 and 16 hours postoperatively

RESULTS: The administration of ceftriaxone in a single dose regimen was associated with higher rate of SSIs compared with rates for patients receiving the 24-hour regimen [9.6% vs. 6.7%]

CONCLUSION: Multiple doses of prophylactic antibiotics over 24 hours should be used instead of single doses in surgical prophylaxis in clean-contaminated and contaminated procedures

Laparoscopic cholecystectomy in acute gallstone pancreatitis in index hospital admission: Feasibility and safety

Acute gallstone pancreatitis is quite common throughout the globe. Conventionally definitive cholecystectomy has been delayed in index hospital admission. Since the last decade timing of cholecystectomy is gradually shifting towards the earlier phase of disease and currently gallstone pancreatitis is being evaluated as a further indication for laparoscopic cholecystectomy. There is also great concern regarding compliance of patients for definitive surgery due to poverty, ignorance and illiteracy in developing countries. The aim of this study was to assess the feasibility and safety of laparoscopic cholecystectomy as a definitive treatment in patients with mild and resolving gall stone pancreatitis. This was a prospective study from July 2009 to June 2012. Patients were diagnosed by clinical examination, biochemical tests, ultrasonography and contrast enhanced CT. Patients with mild form of the disease [Ranson Score <3] and who showed clinical improvement were offered laparoscopic cholecystectomy in index hospital admission. Those who were unfit for surgery were referred for endoscopic sphincterotomy. Common bile duct stones were excluded preoperatively. A total of 38 patients were admitted with acute gallstone pancreatitis in the study period. The mean age of patients was 46.3 years with male to female ratio of 11727. 22 [57.8%] patients were selected for laparoscopic cholecystectomy and procedure was completed successfully. Ten [26.3%] patients were referred for ERCP and endoscopic sphincterotomy and 11 [28.9%] were managed by conservative treatment and went without any definitive treatment. Mean duration of time from onset of symptoms and laparoscopic cholecystectomy was 7 days [range 4-10]. Mean duration of operative time was 45 minutes and hospital stay was 7 days. There was no operative mortality. No major intra-operative or post-operative complication was recorded, two patients [9%] had minor complications. Laparoscopic cholecystectomy can be safely performed in selected cases of mild gallstone pancreatitis in order to prevent further attacks of acute pancreatitis and Other consequences Of d6l3y8[] treatment. Furthermore it resolves the problem of noncompliance of patients in third world countries where many patients are lost for definitive treatment

Role of laparoscopy in peritonitis

Laparoscopy has gained clinical acceptance in many subspecialties in the last decade. The conventional open surgery for peritonitis carries significant morbidity and mortality. The present study was done to extend and evaluate benefits of minimally invasive surgery in this subset of patients. This was a prospective study spanning over a period of four years. All those patients diagnosed as having peritonitis on clinical assessment and preoperative investigations and those who were stable enough haemodynamically were included in this study. After initial resuscitation for few hours, they underwent diagnostic and therapeutic laparoscopy to identify the cause of peritonitis and to confirm the pathology. All cases were done under general anesthesia, using three standard ports at appropriate sites according to pathology. Patients were treated by different procedures either laparoscopically or with laparoscopic assistance after diagnosis. Operative and post operative data was collected and analyzed. Ninety two cases of peritonitis underwent diagnostic and therapeutic laparoscopy. Mean age of patient was 46.5 years. 24 patients were diagnosed as perforated duodenal, in 14 [58.3%] patients laparoscopic suture repair was done and in 8 [33.3%] small upper midline incision was given and perforation was repaired. Out of 32 patients having perforated appendix, 25 [78.1%] patients laparoscopic appendectomy was done while in 7 [21.8%] perforation was dealt by laparoscopic assistance. Out of 14 patients of ileal perforation 6 [42.8%] with minimal contamination laparoscopic suture was applied, while in 8 [57.1%], perforated loop was brought out by making small window and perforation was closed. All 22 patients with pelvic sepsis needed only aspiration of pus and peritoneal lavage. Only one patient died post operatively and 2 [2.1%] patients developed fistula. 6 [6.5%] patients developed port site infection. Laparoscopic management is feasible, safe and effective surgical option for patients with peritonitis due to different abdominal emergencies in properly selected cases with higher diagnostic yield and a faster postoperative recovery

Biliary bypass surgery - Analysis of indications and outcome of different procedures

This study reports the indications and outcome of various biliary bypass surgical procedures from a single centre over a period of 10 years. This is a prospective observational study conducted over a period of 10 years [January 2001-december 2010]. A total of 1500 patients were included, who underwent pancreatico-biliary surgery due to common bile duct [CBD] stones, congenital anomalies of biliary tree, unoperable pancreatico-biliary malignancies, CBD strictures and cases who developed iatrogenic biliary injuries during cholecystectomy [both open and laproscopic] during this period of time. The patients who required biliary bypass surgery were further analysed for indications and outcome. Out of 1500 patients 83 [5.53%] required biliary bypass surgical procedures. The CBD stones were observed as the most common indication [25.3%], followed by CBD injuries after open [10.84%] or laproscopic-cholecystectomy [14.46%], carcinoma head of pancreas [12.05%] and CBD obstruction [14.46%] either due to CBD strictures or unknown distal obstruction. Roux-en-Y-hepatico-jejunostomy [26.51%] was the most frequently performed procedure, followed by choledochoduodenostomy and Roux-en-Y choledocho-jejunostomy [i.e. 25.3% and 12.05% respectively]. Roux-en-Y biliary bypass procedure was observed to be associated with better outcome in terms of rate of complications as well duration of hospital stay. Biliary bypass surgical procedures are the better options to restore the continuity of biliary system in patients with iatrogenic biliary tree injuries and un-operable pancreatico-biliary malignancy. Roux-en-Y biliary bypass procedure is safe and problem solving method in these cases

Laparoscopic management of hydatid cysts of the liver at a tertiary care hospital

To evaluate the feasibility and safety of laparoscopy in the management of hydatid cysts. All consecutive patients diagnosed with liver hydatid disease were offered laparoscopic management. We performed select conservative procedures using standard laparoscopic instruments after sterilization of the cysts with 20% hypertonic saline. Deroofing, evacuation and partial cystectomy were performed. Omentoplasty was performed, and a drain was placed in the cyst cavity. A total of 63 patients [M:F=48:15] with 75 cysts were managed successfully by laparoscopy. The mean age +/- SD of the patients was 38.59 +/- 11.46 years old. The mean operative time +/- SD was 88.24 +/- 23.52 minutes [range: 52-145 minutes]. The mean size of the cysts was 9.2 cm [range: 5.8-16.5cm]. The mean hospital stay +/- SD was 3.49 +/- 1.16 days [range: 1-7 days]. There was no disease or procedure related mortality. Recurrence of a cyst was observed in 3 [4.76%] cases. Open surgery had to be performed on four patients. There were no major complications; minor biliary leaks were observed in 7 cases and cavity infections in 5 cases. The mean follow-up +/- SD in 51 patients was recorded as 28.9 +/- 31 months. Laparoscopic treatment of hydatid cysts of the liver is safe and effective, with low morbidity and a low recurrence rate in uncomplicated cysts. Despite some of its limitations, the procedure is a good alternative to open surgery in select cases.

Post laparoscopic cholecystectomy exploration: an audit

This study was conducted to analyse the different causes and factors for exploration and their management after laparoscopic cholecystectomy in 1000 cases of cholelithiasis. This is a prospective study conducted in the department of surgery Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan, from January 2003 to December 2010. Thousand cases of cholelithiasis were operated for laparoscopic cholecystectomy in eight years and were observed for their recovery and complications postoperatively. Those patients who developed major problems were assessed clinically and by different investigations like LFT, Ultrasound, CT scan and HIDA scan to find out the cause. They were operated once absolute indication of exploration was made. All patients were included in study after getting informed consent for first operation as well as for Re-do surgery if any one required exploration. Out of 1000 cases, 58 patients [5.8%] developed unidentified complications during laparoscopic cholecystectomy who required surgery for one or other reason. The problems which required exploration were bleeding in 2.2%, biliary leak in 1.9% and obstructive jaundice in 1.0% of cases as main reasons. The cases were managed by various open surgical procedures depending upon the pathology found on exploration. Laparoscopic cholecystectomy though proved as gold standard for cholelithiasis but still is not free of complications and can land up into major problems for patients who had either difficult cholecystectomy or over looked congenital anomalies of biliary tree

Factors responsible for prolonged postoperative hospital stay after laparoscopic cholecystectomy

To identify various factors which prolong post-operative hospital stay after laparoscopic cholecystectomy. This is an observational prospective study conducted at a teaching hospital over a period of five years [Jan 2005-Dec 2010] and includes 580 patients of symptomatic cholelithiasis, admitted and treated by laparoscopic surgery. All patients were observed from 1st postoperative day to date of discharge and different operative, postoperative and patient related variables were recorded on a proforma which were found responsible for an unduly prolonged post-operative stay in the hospital. The duration decided for short stay was 48 hours and duration more than that was considered as prolonged stay. Out of 580 patients, 187 [32.24%] had prolonged stay extending from 3-28 days. Majority of patients presented in 4[th] and 5[th] decade [60.52%] with pain in right hypochondrium [58.79%] and pain in right hypochondrium combined with pain in epigastrium [27.6%] as main clinical features. Twenty eight variables were identified comprising of 10 patients related [15.86%], 12 surgery related [16.55%] and 6 post-surgery related [16.38%] which contributed to prolong the hospital stay. Patients having co morbid conditions, difficult operative procedure and major postoperative complications were main factors for prolonged stay. The prolonged post-operative hospital stay can be reduced by careful pre-operative assessment, meticulous surgery and proper post-operative management

Laparoscopic cholecystectomy in complicated gallstone disease

Objective: To assess the role of laparoscopic cholecystectomy [LC] in gallstone disease with its complicated problems. Design: Prospective observational study. Setting: Surgical Department of Liaquat University of Medical and Health Sciences, Jamshoro and Private Hospitals of Hyderabad, Sindh-Pakistan; from May 2001 to April 2005

Methods: The patients were categorized as cases of complicated gallstone disease on the basis of clinical assessment, investigations especially ultrasound abdomen and operative findings noted during laparoscopic cholecystectomy. All patients were explained for advantages and disadvantages of early LC with their difficult disease problem and willing taken for study. Sampling strategy was convenient. The patients with uncomplicated gallstones, obstructive jaundice, acute pancreatitis and carcinoma of gall bladder were excluded from this series

Results: 120 out of 400 patients presented with one of the known complication of cholelithiasis such as chronic cholecystitis 50%, acute cholecystitis 12.5%, empyma 18.33%, mucocele 10% and fibrosed gall bladder in 9.17% of cases as assessed on clinical examination, ultrasound and laparoscopic findings. Majority [75%] of cases were having adhesions around gall bladder and 25% without adhesions. Problems encountered during LC were difficult separation of tight adhesions around gallbladder [50.0%], grasping and holding of thick walled and distended gallbladder [41.67%], dissection and identification of structures in Calot's triangle [29.17%], haemorrhage from main cystic artery and gall bladder bed 20.83% and delivery of large and thick wall gallbladder in 25% of cases. Intra operative complications seen during procedure were haemorrhage in 20.83% cases, perforation of gallbladder by instrumentation in 12.5% and avulsion of cyctic duct in 1.67% of cases. Two patients [1.67%] were converted to open cholecystectomy due to bleeding. Postoperatively 12.5% of patients developed biliary leak, out of which 3 cases [2.5%] were due to actual common bile duct injury, 2.5% of cases developed port-site sepsis as main postoperative complications. Cases with bile duct injury were re-explored and managed accordingly. Hospital stay varied from 2-7 days but majority of patients were discharged [70.83%], within 2-3 days, no mortality was seen in this series

Conclusion: Laparoscopic cholecystectomy like uncomplicated biliary stone disease is equally effective procedure for complicated cholelithiasis. Its applicability is almost 95% in experienced hands

Laparoscopic cholecystectomy in the elderly patients. An experience at Liaquat University Hospital Jamshoro

Advancing age with its associated co-morbidities increases the likelihood of postoperative complications as well as conversion rate during laparoscopic cholecystectomy. Recent studies have also questioned efficacy of this procedure in geriatric patients. The present study assesses the safety and applicability of laparoscopic cholecystectomy in geriatric patients. The objective of the present study was to asses safety and applicability of laparoscopic cholecystectomy in the elderly patients of 65 years and above. This is a prospective analysis of 173 patients, over 65 years of age, who underwent laparoscopic cholecystectomy from December 2002 to November 2006 at Liaquat University Hospital, Jamshoro. Patients presenting with complicated and uncomplicated gallstone disease were included in the study population and all of them were operated laparoscopically. The data included demographic details, co-morbidities, underlying biliary pathology, indications for surgery, operative and postoperative complications, morbidity and mortality, and hospital stay. The statistical analysis of the data performed on SPSS version 10. Laparoscopic cholecystectomy undertaken in 173 elderly patients with a mean age of 69.72 years, out of whom 52 [30.05%] were males and 121 [69.94%] were females. Co-morbid conditions were identified in 53.17% [n=92] patients and included hypertension in 38 patients [21.96%], Diabetes Mellitus in 23 patients [13.29%], COPD in 19 [10.98%] patients, Coronary artery disease in 9 [5.20%] and cardiac arrhythmias in 3 [1.73%] patients. Indications for surgery included simple biliary colic in majority of patients [69.94%] and complicated stone disease in 52 [30.05%] subjects. There were 37 [21.38%] emergency laparoscopic cholecystectomies and 136 [78.61%] patients were operated electively. Mean operative time was 100 minutes with a SD 29.03. Fourteen [8.09%] patients required conversion to OC [Open Cholecystectomy] due to various reasons. Mean hospital stay was 6.28 days. Overall 23 [13.29%] patients developed postoperative complications. One patient died of acute MI on 2nd postoperative day. There is no undue risk in laparoscopic cholecystectomy in the elderly population and the procedure can be regarded as safe as in patients below 65 years of age

Emergency laparoscopic cholecystectomy in acute cholecystitis

To study the presentation and outcome of cases operated for Gynecomazia. A retrospective study spread over four years i.e. June 2002 to May 2006. Different hospitals of Karachi including Civil Hospital. 46 males who were admitted for surgery of Gynecomazia. All patients included in this study were evaluated in detail clinically and by appropriate investigations. They were counselled about the condition, and operated via a peri-areolar or sub-mammary incision, and the outcome noted in terms of healing and complications. Out of the 46 cases, majority [71.74%] presented in the age group 11-20 years with peak incidence around 16 years of age. The main symptom was breast enlargement, though pain or discomfort was also seen in 12 [26.1%] patients. The size of the breasts varied between 4-8 cms, and 34 [73.9%] cases were bilateral. Surgery was done for macromastia in 7, long standing gynecomazia in 11 and cosmetic reasons in 28 cases. Wound infection and hypertrophic scar formation constituted the few complications noted. Gynecomazia is the commonest condition affecting male breasts. In majority of the cases counselling and observation is all that is required for management, as they subside spontaneously or on medication. Surgery is indicated in those cases that do not subside or on patient demand

Clinico-pathological profile of patients with breast diseases at university hospital, Jamshoro

To assess various disorders of breast regarding their frequency, presentation, pathology and management at a University Hospital. A descriptive study. Department of Surgery, Liaquat University Hospital Jamshoro - Sindh from January 1999 to December 2003. One hundred and fifty patients with different breast disorders were studied. All cases were assessed clinically by getting history on a predesigned proforma and diagnosis was confirmed with help of relevant investigations. Patients with various breast diseases were included in the study except those who were having either no definite lump or no breast pathology. The treatment given was according to type of lesion in the form of surgery or conservative. Patients with benign breast diseases were assured and followed up after surgical treatment or kept on hormone therapy where as cases with malignant disease were referred to oncologist for cancer registry purpose and chemo-radiotherapy. Among 150 cases, majority was females with female to male ratio of 24:1. All patients presented with breast lump [100%], followed by pain in the lump [53.33%] as main symptoms. Left breast was involved in 53.33% and right breast in 44.66% of cases. Majority of cases [84.67%] underwent surgery. Histopathology revealed fibro-adenoma in 30.66%, fibrocystic disease in 15.33% and carcinoma in 35.33% cases as main disorders. All six male patients had gynaecomastia. In our set up, frequency of carcinoma of breast is increasing as compared to benign lesions. However, overall benign problems are more frequent than breast cancer

Minicholecystectomy: review of 200 cases

A prospective study of 200 cases of cholelithiasis who underwent minicholecystectomy was conducted at surgical unit-IV of Liaquat Medical College Hospital, Jamshoro and other private hospitals over a period of three years from January 1996 to December 1998. Female patients were 89 percent. Youngest patient was 21 years of age while oldest was of 80 years, mean age being 42 years. Operating time varied between 24 minutes to 70 minutes, with average time 35 minutes. Twelve percent of cases presented with acute cholecystitis and adhesions, 10 percent of cases presented with mucocele and 8 percent with empyma gall bladder. Post-operatively, 22 percent of cases developed complications. Amongst these, 9 percent of cases developed primary hemorrhage, 3 percent of cases bile leakage, 5 percent developed wound sepsis, 4 percent complained of painful scar and bile duct injury developed in 1 percent of cases. All the complications were transient and mortality was zero

Evaluation of morbidity and recurrence in bilateral repair of inguinal hernias

A prospective study of bilateral repair of 100 cases of inguinal hernia was carried out from January, 1996 to January 1998 at Liaquat Medical College Hospital [LMCH], Hyderabad. Age of presentation was between 16 years to 70 years, with mean age 43 years. Common presentation was swelling in groin and dragging pain during walking. Forty percent of patients had -indirect inguinal hernias, 45 percent had direct and 10 percent of cases had direct hernia on one side and indirect on other side. In most of the cases repair was done with Bassini's technique. In 20 percent of cases suprapubic skin crease incision was made and in 80% of cases two separate incisions were made. Hospital stay was between 2 to 14 days with average of 5 days. Post-operative complications were haematoma 8 percent, penile oedema 6 percent, wound sepsis 4 percent, Hydrocele 6 percent and recurrence rate in 4 percent of cases. Mortality was 0%. This study shows little difference in morbidity and recurrence in bilateral repair as compared to stage one side repair in bilateral inguinal hernias