Comparison of closed and open methods of pneumoperitonium in laparoscopic cholecystectomy

Pneumoperitonium is the first step in laparoscopic surgery including cholecystectomy. Two commonly used methods to create pneumoperitonium are closed and open technique. Both have advantages and disadvantages. The current study was designed to compare these two techniques in terms of safety and time required to complete the procedure. This was a randomized controlled prospective study conducted at Department of Surgery, Ayub Hospital Complex Abbottabad, from 1[st] June 2007 to 31[st] May 2008. Randomization was done into two groups randomly using sealed envelopes containing the questionnaire. Seventy envelopes were kept in the cupboard, containing 35 proformas for group A and 35 for group B. An envelope was randomly fetched and opened upon selection of the patient after taking the informed consent. Pneumoperitonium was created by closed technique in group A, and by open technique in group B. Time required for successful pneumoperitonium was calculated in each group. Failure to induce pneumoperitonium was determined for each technique. Time required to close the wounds at completion, total operating time and injuries sustained during induction of pneumoperitonium were compared in both techniques. Out of the total 70 patients included in study, 35 were in group A and 35 in group B. Mean time required for successful pneumo'peritonium was 9.17 minutes in group A and 8.11 minutes in group B. Total operating time ranged from 55 minutes to 130 minutes in group A and from 45 minutes to 110 minutes in group B. Mean of total operating time was 78.34 and 67 minutes in group A and B respectively. Mean time needed to close the wound was 9.88 minutes in group A and 4.97 minutes in group B. Failure of technique was noted in three patients in group A while no failure was experienced in group B. In two cases in group A minor complications during creation of pneumoperitonium were observed while in group B no complication occurred. No patient died in the study. We concluded from this study that open technique of pneumoperitonium was, less time consuming and safer than the closed technique

Aspiration and tetracycline sclerotherapy of primary vaginal hydrocoele of testis in adults

Primary Vaginal Hydrocoele of Testis is a common condition which is primarily treated surgically. Many patients with Hydrocoele of testis are either not willing or are unfit for surgery. This study was done to know the safety, efficacy and outcome of tetracycline induced sclerotherapy of Primary Vaginal Hydrocoele of Testis in adults. This quasi experimental study was done in Shahina Jamil Hospital, attached with Frontier Medical College and Ayub Teaching Hospital, Abbottabad from March 2006 to April, 2007. Thirty-seven patients with primary vaginal hydrocoele were included in the study. Aspiration and instillation of Tetracycline was done after spermatic cord block with 2% lignocaine. Procedure time, Peri and Post-procedure complications, number of injections for cure and patients' satisfaction with the procedure were recorded. Patients were discharged home 3 to 4 hours after the procedure and followed up after one week, one month, three months and six months. Direct admission and re-admissions were recorded. The mean age of patients was 47 years. Mean procedure time was 45 minutes. All patients were cured. Mild postprocedure pain occurred in 12 [40%], moderate pain in 14 [46%] patients and severe pain in 4 [13.3%] patients. No patient developed haematoma or local infection. One patient [3.3%] had micturition problem. Two [6.6%] patients had minimal recurrence. One injection was sufficient for cure in all patients. 28 [93%] patients were satisfied while 2 [6.6%] patients were not satisfied with this procedure. No patient was admitted in the hospital after the procedure. Aspiration and injection of tetracycline in Primary vaginal Hydrocoele of Testis in adults is safe, effective and very economical procedure

Re-do orchidopexy in a general surgical unit-reliability of clinical diagnosis and the outcome of surgery

Re-do Orchidopexy is not very common, expertise is limited and the results of clinical examination and ultrasonography are not always reliable. This cross-sectional study was based on medical records of patients under-going re-exploration of inguinal region for a missing testicle after previous groin surgery, and no mention of orchidectomy. All patients were thoroughly examined, investigated with ultrasonography and offered re-exploration. Results were graded as Good, Fair and Poor. Out of 11 boys included in the study, 7 [63.63%] had failed orchidopexy. Another 3 [27.27%] were opened for 2nd stage orchidopexy and 1 [9.09%] had iatrogenic ascent of testis after herniotomy. On clinical examination 4 [36.36%] had a palpable testicle at the superficial ring, 2 [18.18%] were in inguinal canal [1 doubtfull], and no testicle could be palpated in 5 [45.45%]. Ultrasonography picked up 2 testicles [18.18%] at the superficial Inguinal ring, 1 [9.09%] in Inguinal canal and 1 [9.09%] testicle in the abdominal cavity. On reexploration, 10 [90.9%] testicles were found and brought down, 7 [63.63%] being considered of reasonable consistency and size. Another 3 [27.27%] were considered soft or small in size, and in 1 [9.09%]], no testicle was found. In 5 patients [45.45%], the testicle was at superficial ring, in 3 [27.27%] in the inguinal canal, and in 2 [18.18%] in the abdominal cavity. Results were considered good in 6 [54.54%], fair in 3 [27.27%]] and poor in 2 [18.18%]. Groin examination after previous inguinal surgery is tricky. Ultrasonography is also not very reliable. Re-exploration via the inguinal approach is adequate and recommended. Thorough exploration is essential before declaring the testicle absent

Laparoscopic Cholecystectomy: An early experience at Ayub Teaching Hospital Abbottabad

Laparoscopic Cholecystectomy first introduced in 1987, is becoming more and more popular and now it has become gold standard in symptomatic gallstone disease. The current descriptive study is carried out in Department of General Surgery, Ayub Teaching hospital, Abbottabad to evaluate the result of Laparoscopic Cholecystectomy in symptomatic gallstones disease in our set up with special emphasis on complication rate, morbidity and mortality. The data of all patients who underwent Laparoscopic Cholecystectomy form January to December 2007 was entered in standardized proforma and analysed on SPSS 10. Out of 60 patients, 51 [85%] were female and 9 [15%] were males; the age range from 17 to 65 years mean age being 40.30 years, majority were in age 30-40 years group. Two [3.3%] patients had bile leak, 1 [1.3%] patient developed port site wound infection 1 [1.3%] patient developed collection in pouch of Morrison and in 1 [1.3%] patient stone were recovered from the epigastric port site wound. There was no bile duct or colonic injuries. The conversion rate was 5%. There was no mortality. Laparoscopic cholecystectomy is a safe and effective treatment for gall stone disease and is up to the accepted standard in our set up as compared to national and international data

Conservative management of mesh site infection in ventral hernia repair

Mesh Hernioplasty is the preferred surgical procedure for abdominal wall hernias and infection remains one of the most common complications of this technique. In some patients the mesh may need removal to overcome infection, where as others may be salvaged by conservative treatment. This study was conducted to assess the outcome of conservative management for mesh site infection in abdominal wall hernia repairs. This study was carried out in Ayub Teaching Hospital Abbottabad Pakistan from Jan 2006 to Dec 2007. Thirteen consecutive cases were included, who developed mesh site infection after abdominal wall hernia repair. Pus or purulent fluid was sent for culture and sensitivity. All patients were treated by intravenous antibiotics and local wound care. Treatment was taken as successful when there was complete resolution of infection and healing of the wound. There were 7 inguinal [53.84%], 4 para-umbilical [30.76%] and 2 incisional hernias [15.38%]. Eight patients were males [61.53%] and 5 females [38.46%]. Median age of the patients was 40 years [range 28 to 52 years]. Staphylococcus aureus was the most commonly found organism causing infection in 8 patients, [76.9%]. Mean hospital stay was 22 days [range 18-26 days]. All cases were effectively treated conservatively without removing the mesh. Polypropylene mesh was used in all of these cases. Conservative management is likely to be successful in mesh site infection in abdominal wall hernia repairs

Cancelled elective general surgical operations in Ayub teaching hospital

Cancellation of operations in hospitals is a significant problem with far reaching consequences. This study was planned to evaluate reasons for cancellation of elective surgical operation on the day of surgery in Ayub Teaching Hospital, Abbottabad. From July 2006 to June 2007 the medical records of all the patients who had their operations cancelled on the day of surgery in all the three General Surgical units of Ayub Teaching Hospital, Abbottabad were audited prospectively. The number of operation cancelled and reasons for cancellations were documented. 3756 patients were scheduled for surgery during the study period. 2820[75%] patients were operated upon. 936 [25%] operations were cancelled out of which 338[36%] were cancelled due to shortage of time, 296[31.6%] were cancelled due to medical reasons, 152[16.2%] were cancelled due to shortage of beds while 55[5.8%] were cancelled due to shortage of anaesthetists. Three operation lists were lost completely. The Anaesthetist cancelled 43%, Surgeon 39% while 18% of operations were cancelled due organizational reasons. Cancellation of patients on operation lists occupy a substantial population [25%] of cases. Majority of cancellation were due to reasons other than patients medical conditions. Better management could have avoided most of these cancellations

Combined abdominal hysterectomy, cholecystectomy and appendicectomy: a study of 25 cases in Abbottabad

Gallstone disease is common in women. Many patients undergoing abdominal ultrasound for gynaecological diseases are found to have gallstones. This study was done to see the results of combined abdominal hysterectomy, mini-cholecystectomy and appendicectomy in a set up lacking facilities of laparoscopic surgery. This prospective study was conducted in Ayub Teaching Hospital, Iltaf Hospital and Shahina Jamil Trust Hospital of Abbottabad from August 1998 to July 2004. All patients undergoing combined abdominal hysterectomy and mini-cholecystectomy were exclusively studied with reference to following variables. Age, Weight, Parity, Co-morbid conditions, peri-operative and post-operative complications, blood transfusion, hospital stay and mean extra time for mini-cholecystectomy and appendicectomy after abdominal hysterectomy. There were 25 patients in the study group. The ages ranged from 35-50 years. Mean weight was 65 Kg. There were no operative complications. Mild postoperative complications occurred in 7[28%] patients. Mean extra time for cholecystectomy was 25 minutes. Mean hospital stay was 9 days. In selected women, combined abdominal hysterectomy, cholecystectomy and appendicectomy is a safe, feasible and cost effective procedure

audit of patients satisfaction after adult day - case surgery at Ayub teaching hospital, Abbottabad

Day-case surgery has become an important component in the provision of surgical care in the Western countries. This study was done to introduce the concept of day-case surgery and assess the patients' satisfaction after day case general surgery in our set up with vast rural communities lacking medical facilities and no day-case surgery units in the hospitals. All those patients suitable for day-case surgery and who accepted day-case surgery for general surgical procedures in General Surgical 'A' unit of Ayub Teaching Hospital, Abbottabad were interviewed after the operation on follow up visits. Questions were asked about their satisfaction with day-case surgery. If they were not satisfied, the reasons for dissatisfaction were noted. Direct admissions and re-admissions after day-case surgery were recorded. Any complications in the postoperative period were also noted. The patient's preference for a similar procedure as day-case in future was also recorded. There were 122 patients in this study. 60[49%] were operated under general anesthesia and 62[51%] under local anesthesia. Fourty Nine [40%] patients were satisfied while 73[60%] were not satisfied with day-case surgery. Six [5%] patients were admitted directly after day-case surgery while 7[5.7%] patients were admitted after discharge. Complications occurred in 41[33.6%] patients at home. Wound complications and pain were the most common morbidity encountered by the patients. Twenty eight [23%] patients contacted a hospital or a doctor in the early postoperative period. Sixty two [51%] patients would prefer operation as in-patient while 74 [60.6%] would prefer an overnight stay after the operation next time. Conclusions: Patients satisfaction with day-case surgery in Ayub Teaching Hospital is not high. Short-stay surgery would be more appropriate in our set up

Accuracy of surgeon - performed abdominal utrasound for gallstones

Gallstone disease is common in Pakistan. It is primarily diagnosed by ultrasonography, which is traditionally done by radiologists. If surgeons could perform ultrasonography, it would enable early diagnosis in one-stop clinic. This study was done to evaluate the accuracy of surgeon-performed abdominal ultrasonography to detect gallstones. This study was carried out at Surgical A and Surgical C units of Ayub Teaching Hospital, Abbottabad from July. 2000 to December, 2002. One hundred fourty two patients with signs and symptoms of gallstone disease who had ultrasonography performed by a surgeon, trained in ultrasonography were exclusively studied. These patients were referred for further scanning by the radiologists who were unaware of the surgeons interpretation. The results of surgeon and radiologist performed ultrasonography were compared. The interpretation of surgeon-performed ultrasonography was correct in 100 patients and incorrect in 42 patients. There were 100 True Positive. 41 True Negative, One False Negative and Zero False Positive scans yielding 99%, Sensitivity, 100% Specificity and 99.3% Accuracy. Sensitivity of surgeonperformed ultrasonography in detecting gallstones compared to operative findings was 100%,. Conclusions: Abdominal ultrasonography performed by an ultrasonography trained surgeon can detect gallstones as accurately as by a radiologist

Small bowel obstruction in children due to persimmon phytobezoars

To present the clinical picture of small bowel obstruction caused by Persimmon phytobezoars in children of Hazara [Northern Pakistan]. Design: Descriptive case series. Place and Duration of Study: Three general surgical units of Ayub Teaching Hospital, Abbottabad from November 1998 to March 2003. Patients and Nineteen children were managed for small bowel obstruction due to persimmon phytobezoars. The age, gender, season at the time of presentation, history of persimmon ingestion, symptoms, signs, site of obstruction, operative procedure and outcome were analyzed. There were 15 males and 4 females with ages ranging from 4-11 years [mean 7 years]. All presented in winter with a positive history of persimmon ingestion. All had signs and symptoms and evidence of small bowel obstruction on plain abdominal x-rays. At laparotomy, ileum was the commonest site of obstruction. Milking of bezoars into caecum was performed in 17 patients while 2 patients required enterotomy for removal of bezoars. Complications occurred in 4 patients. There was no mortality.Small bowel obstruction in children due to persimmon phytobezoars is uncommon. However, it should be considered pre-operatively as a possible cause of intestinal obstruction in winter in children who have access to the fruit. Laparotomy should be performed for persistent obstruction or signs of strangulation

Rubber band ligation in hemorrhoids

Hemorrhoids is a very common medical condition. A large number of cases can be managed by non-surgical means. The purpose of this study is to evaluate the therapeutic results of rubber band ligation in hemorrhoidal disease. Design: Prospective case series with a minimum follow up of 1 year. Place and Duration of Study: Surgical clinic over a period of 2 years and 7 months from February 1997 to August 1999. Subjects and One hundred patients with 1st, 2nd and 3rd degree symptomatic hemorrhoids had rubber band ligation on outdoor basis in one session. They were examined weekly for one month and every two-month for one year. Subjective and objective symptoms [bleeding and prolapse] were noted. Rectal examination and proctoscopy were done. Therapeutic effect was assessed by symptomatic improvement of bleeding and prolapse and any complication on follow-up. Twenty-two patients had 1st degree, 48, 2nd degree and 30 3rd degree hemorrhoids. Twenty-two [22%] patients presented with bleeding, 46[46%] with prolapse while 32[32%] presented with both bleeding and prolapse. Rubber band ligation cured 72 [72%] patients, improved 10 [10%] and it failed in 8 [8%] patients. After one year follow-up, recurrence of bleeding and prolapse occurred in 10 [10%] patients. Complications were seen in 52 patients, however, no serious and life-threatening complications were seen. Rubber band ligation is a rapid, safe, effective and economical method of treating 1st, 2nd and early 3rd degree hemorrhoids in the outdoors

Spontaneous appendico - cutaneous fitusa

A healthy female aged 16 years presented with a discharging sinus in the right iliac fossa since the last eight months. There was no past history of pain in the right iliac fossa or any other disease. She had consulted several doctors for this disease. Once scrapping of the sinus tract was done by a gynaecologist. On examination, there was a small sinus in the right iliac fossa surrounded by granulation tissue. There was a discharge of thin yellowish-brown pus on pressing the surrounding area. Her hemoglobin was 11 gm%, TLC 6,800 mm3, ESR 7 mm. Blood urea 36 mg/dl, random blood sugar 130 mg/dl. Culture of pus showed E. coli sensitive to amikacin. Abdominal ultrasound and Chest X-rays were normal. Barium enema was also normal. Fistulogram showed the fistula tract leading from skin to the ileo-caecal region. Laparotomy was done through an oblique, elliptical incision in the right iliac fossa including the fistula opening. It was found that the fistula tract was appendix itself with its tip adhered to the anterior abdominal wall. No other intra-abdominal pathologies were found. Appendicectomy and primary closure of the abdomen was done. Appendix and the cutaneous fistula margins were sent for histopathology that showed chronic non-specific inflammation. The patient was discharged for home on seventh postoperative day after removal of skin stitches. At six months follow-up, the patient is doing well

Chylothorax

This is a case report of chylothorax in an adult man. The clinical features were pain in the right hypochondrium, fever and hepatomegaly. The chest X-ray showed right sided pleural effusion. Bio-chemical examination of aspirated fluid confirmed it to be CHYLE. A laparotomy and biopsy of mesenteric lymph node confirmed it to be tuberculous