Damage to recurrent laryngeal nerve [RLN] with and without exposure in thyroidectomy

Objectives: To determine damage of RLN with and without exposure during thyroidectomy. Study design: Randomized control study Sampling technique: Non-probability consecutive sampling. Sample size: 150 patients. Setting: Surgical units of Allied Hospital Faisalabad

Methodology: With informed consent, study was conducted on two groups[75 in each group].Patients were distributed on alternate basis into group A and group B for thyroidectomy with and without identification of RLN respectively

Results: In group A 30[40%] patients were between 31-40 Years and 18[24%] between 41-50 Years. In group B 32[42.7%] were between 31-40 Years,13[17.3%] between 41-50 Years and 15[20%] between 50-60 Years. Mean of age was 38.5 +/- 10.9[standard deviation].In group A,28[37.3%] were male and 47[62.7%] females while in group B 25[33.3%] were males and 50 [66.7%] females. In group A 38[50.7%] patients were of MNG, 10 [13.3%] diffuse goiter, 7[9.3] solitary nodules, 13 [17.3%] suspicion of malignancy and 7[9.3%] malignanacy. In group B 33[44%] patients were having MNG, 15[20%] diffuse goiter, 10[13.3%] solitary nodule, 6[8%] suspicion of malignancy and 11[14.7%] malignant disease. In group A 39[52%] patients underwent STT, 20[26.7%] NTT, 10[13.3%] TT and 6[8%] hemi-thyroidectomy. In group B 35[46.7%] patients underwent STT, 21[28%] NTT, 12[16%] TT and 7 [9.3%] hemi-thyroidectomy. In group A 3 [4%] patients developed transient paralysis and 1[1.3%] permanent paralysis of RLN. In group B 7[9.3%] patients developed transient paralysis and 3[4%] permanent paralysis of RLN

Conclusion: Preservation of RLN is more likely with exposure and identification of RLN post-operatively

Falls- underestimated but significant mode of trauma!

Aim. To review the common causes of injuries and high light the importance of falls in trauma

Method. This retrospective study was carried from 1st of January to 30 November 2013 at Zayed Military Hospital Abu Dhabi, UAE. The International Classification of Diseases Ninth Revision, Clinical Modification [ICD-9-CM] code is applied to all cases who attended for various types of injuries for data recording. Top five causes were further analyzed

Result. A total number of 2295 cases visited for care ofvarious injuries, 777 were due to different type of falls. Male cases were 505 and 272 were females. Age distribution showed 45% cases were up to 14 years, 51% were between 15 to 64 years old and 4% were above 65 years old. Seventy six cases were admitted in the hospital and remaining were treated on outpatient basis

Conclusion. Falls constitute a very significant percentage of trauma. This is potentially preventable through public awareness and application of safety measures

Hypocalcaemia after total thyroidectomy, potentially a serious issue!

Introduction: Hypocalcaemia is a common post thyroidectomy complication in addition to nerve injuries and bleeding. The incidence is variable in different studies and total thyroidectomy has higher incidence than partial thyroidectomy

Objectives: To study the incidence of temporary and permanent hypocalcaemia and to review value of post-operative calcium level in predicting short and long term cases of hypoparathyroidism

Methods: This was a prospective study carried out at Zayed Military Hospital, Abu Dhabi from January 2007 to December 2011. A total of 105 cases were included in the study who underwent total thyroidectomy. Calcium levels at 6 and 24 hours operatively were recorded

Results: Temporary hypocalcaemia of 25.7% patients and permanent hypocalcaemia of 3.8% was noted. Calcium drop of less than 1 mg/dl from pre-operative level was not significant as all patients recovered without any symptoms. Calcium drop of more than 1.1 mg/dl needs close follow up. Females had slightly higher incidence of hypocalcaemia

Conclusion: Post thyroidectomy calcium is an easy and cost effective way to identify high risk cases which need close monitoring and treatment with vitamin D and calcium

Laparoscopic adjustable gastric band -long termresults in 81 patients

Objective: The object of this study is to evaluatethe long term outcome in respect of weight loss andlong term complications following LABG

Setting:Department of Surgery, Sheikh Zayed MilitaryHospital Abu Dhabi UAE

Period: From August2005 to August 2007

Patients and methods:Eighty one [81] patients with morbid obesityunderwent LABG at the Zayed Military Hospital,Abu Dhabi UAE and were followed up till date.Twenty one cases followed up for 2 years aftersurgery and forty four cases followed up till today.Forty eight patients were female and thirty threewere male. Age ranged from 21 to 51 years withmedian of 29 years. BMI in patients ranged from 31to 59. Preoperative weight ranged between 93 kg to170 kg with average weight of 129 kg

Results:The following long term complications were seen in65 cases with at least 2 years follow up. Retrosternalburning, severe dysphagia, gastric band erosion intostomach, port displacement, port hernia, bandmigration over the body of the stomach. Weight losswas evaluated in 44 cases with more than five yearsfollow up. Maximum weight loss achived was 71kg, with an average of 30 kg of weight loss. Weightloss peaked by the end of the first year andthereafter remained more or less static with averagefluctuation of 6 kg

Conclusion: With correct caseselection, LAGB is an effective method in reducingweight with fewer long term complications inpatients with morbid obesity and is a potentiallyreversible procedure

Three port versus four port laparoscopic cholecystectomy

Objective: The objective of this study is to compare the outcome of three vs four port laparoscopic cholecystectomy and detect safety of three port laparoscopic cholecystectomy [LC] as routine procedure

Study Design: Simple comparative study

Setting: One year starting from June 2010 to May 2011. Sample size: 100 patients

Methods: All patients were divided into two groups. Group A: three port laparoscopic cholecystectomy was done. Group B: Conventional four port laparoscopic cholecystectomy was done. Outcome is determined in terms of postoperative pain [determined by visual pain scale] and complications [bleeding, infection, bile duct injury]

Results: 35 patients in Group A had low pain score and 15 were high pain score. In group B, 24 had low pain score and 26 high pain score. In group A only 10 patient needed nalbuphine as compared to 35 patient in group B. Both groups have almost same operating time [48.5min A and 48min B]. Hospital stay is same [48h]. Complications like port site bleeding [2 patient in A and 4 in B], wound infection [2 in A and 3 patients in B], abdominal pain [3 in group A and 4 in group B] of three port laparoscopic cholecystectomy are comparable with four port cholecystectomy. No patient in both groups suffered bile duct injury

Conclusion: The three-port technique is as safe as the standard four-port for LC. The main advantages of the three-port technique are that it is less painful, safe, less chances of wound infection and leaves fewer scars

Amoebic liver abscess; incodence and outcome

Amoebic liver abscess is a common infection in third world countries like ours due to poor sanitary arrangements. It presents with severe pain and high grade fever and if not diagnosed and treated promptly, may lead to complications and mortality. To estimate the incidence, need for aspiration and treatment outcome. Case series study. At respective consultations centers in Faisalabad. From 1[st], January, 2007 to 31[st] December 2008. All patients suspected of the diagnosis of liver abscess whether presenting to physicians or surgeon were referred for ultrasonography for the confirmation of the diagnosis. Basic biodata, coexisting medical or surgical diseases and relevant investigation were recorded, and patient was assessed for the need to aspirate the abscess. After initial treatment patients were reassessed for the need to aspirate the abscess on third, tenth and twentieth day both clinically and ultrasonically. We had 188 cases in the study. There were 128 [68%] males and 60 [32%] females. Majority, 156 [76.6%], of the abscesses were single, 40 [21%] had double and 4 [2%] had three abscesses. 166 [83%] were situated in the right lobe, 28[15%] in the left lobe and 4 [2%] had abscess in both lobes. 16 [9%] were aspirated at presentation due to their size or position. Only 4 [2%] were aspirated at first follow-up on third day due to non resolution of pain or fever or increase in size. All the patients who were not lost from follow up responded to standard treatment of metronidazole. Amoebic liver abscess is a common diagnosis in our setup. Patients presents with right upper quadrant pain and fever. Clinical background and ultrasonogram give a reasonable suggestion about amoebic etiology. If initial aspiration is not indicated due to size larger than 5cm. or proximity to surface or nonresolution of symptoms or lesion in left lobe, conservative treatment with oral or intravenous metronidazole is successful

Role of adjuvant topical oxygen therapy [Topox] versus conventional methods in the management of non- healing infected wounds

Objectives: To compare the role of adjuvant topical oxygen therapy versus conventional methods in the management of non-healing infected wounds

Study Design: Simple comparative study

Setting: The study was carried out in one year duration from January 2010 to December 2010 in Surgical unit-1 Allied Hospital Faisalabad

Sample Size: 60 patients

Methods: Total of 60 patients was divided into two groups. In one group [A] topical oxygen therapy was given along with conventional measures for management of wound. In second group [B] only conventional methods were used for wounds

Results: 60 cases included in this study,30 in group A and 30 in group B. From patients of group A, 16[53.3%] showed clinical improvement in first week and 25[83.3%] showed clinical improvement in second week. While in group B 5[17%] and 11[36.7%] showed clinical improvement in first and second week respectively.5[17%] patients in group A developed granulation tissue in first week and 19[63%] in second week. While in group B 2 [7%] developed granulation tissue in first week and 8[27%] in second week. From group A 10[33.3%] and 24[80%] patients showed complete wound healing in second and third months respectively. In group B 3[10%] patients showed complete wound healing in two months and 12[40%] in three months.1[3.3%]patient in group A deteriorated in first week and 2[7%] in second week.8[27%]patients from group B deteriorated in first week and 4[13.3]in second week

Conclusion: Use of TOPOX along with conventional method is more safe and effective in the management of nonhealing infected wound than conventional methods alone

Intestinal anastomosis; comparative evaluation for safety, cost effectiveness, morbidity and complication of single versus double layer

To evaluate the safety and cost effectiveness of single layer interrupted intestinal anastomosis in comparison with the double layer conventional method of intestinal anastomosis. Prospective comparative study. Surgical unit 4 DHQ hospital Faisalabad operated by single team during 12 months starting from Feb. 2007 to Jan. 2008. The cases were assigned to the two techniques, each being applied on alternate patient, single layer extra mucosal interrupted anastomosis and double layer anastomosis. In group 1 we used black silk 3/0 and in double layer we used vicryl 3/0 for inner continuous layer and black silk 3/0 for outer continuous layer. Comparison between two techniques was done on the bases of procedure time, cost effectiveness, morbidity in terms of rate of leakage. Average time for the construction of the single layer anastomosis was 20 minutes and in double layer was 35 minutes, the difference in average time is statistically significant [p<.001] while average duration of stay was 168 hrs and 216 hrs in group 1 and 2 respectively [p<.001]. Leakage rate was double [12%] in group 2 while 6% in group 1. Moreover structure material consumption was more in two layered technique and longer stay added to that lead to more hospital expenses on two layered technique. Anastomosis using a single layer interrupted extra mucosal technique was faster to perform, cost effective, less likely to leak and as strong as a 2-layer anastomosis

Impact of pneumoperitoneum on hepatic functions after laparoscopic cholecystectomy [LC]

To find out the alterations in hepatic functions after laparoscopic cholecystectomy and the possible mechanisms behind such effect. A prospective analytic study. The study was conducted in surgical unit-1; Allied Hospital Faisalabad, from January 1st, 2009 to June 30th, 2009. With approval from the institutional ethical committee and informed consent, as per inclusion and exclusion criteria, 100 patients for laparoscopic cholecystectomy were included in the study. The blood samples of the patients were collected to test liver enzymes; bilirubin, alanine aminotransferase [ALT] aspartate aminotransferase [AST] and alkaline phosphatase [ALP] once preoperatively and then on 2nd and 10th post operative days. The preoperative values were compared with that of postoperative values. During LC intraabdominal pressure for pneumoperitoneum was maintained at 14 mmHg of CO2 and the duration of CO2 insufflation was measured. Forty eight hours after LC, levels of ALT, AST and bilirubin were found to be increased [ALT: 51.11 U/L, P<0.001; AST: 53.79 U/L, p < 0.001 and Bilirubin: 1.38mg/dl P < 0.001 which were statistically significant. Moreover, these hepatic enzymes were significantly increased in patients who had longer durations of CO2 insufflations. The changes in alkaline phosphatase measurements were found to be non significant. The levels of hepatic functions returned to normal or near normal values in samples of 10th post operative day. Transient alterations in hepatic functions are frequently observed after uneventful laparoscopic cholecystectomy, which clinically appear to be insignificant. CO2 Pneumoperitoneum seems to be the main reason for theses changes but other factors may also contribute

Evaluation and determination of prognostic factors in typhoid ileal perforation

To determine the prognostic factors of typhoid ileal perforation. A prospective study. The study was conducted in the departments of A and E and surgery at Allied Hospital Faisalabad, from September 1st, 2008 to August 31st, 2009. With informed consent, the study was conducted on 56 who underwent laparotomy for peritonitis due to typhoid ileal perforation as per inclusion and exclusion criteria. The ileal perforations were managed by either primary simple transverse closure or primary defunctioning loop ileostomy. The prognostic evaluation was assessed by the impact of pre operative prognostic factors and per operative findings on post operative complications and mortality. For statistical significance, the data was analyzed by SPSS. Among the total 56 patients, thirty four [61%] patients were managed by primary simple transverse closure while 22 [39%] patients had primary defunctioning loop ileostomy. The age and sex had no effect on the prognosis of typhoid ileal perforation. Mortality rate was 5.4%. Different post operative complications and their rates were burst abdomen 23%, residual intra abdominal abscess 16%, fecal fistula 7% and septicemia 5.4%. Twenty eight [50%] patients developed wound infection which reflected only morbidity. Mortality remained nil in all those cases who had early presentation, admission-operation interval shorter than 12hours, size of perforation less than 1cm, amount of pus/fecal fluid less than1000ml and had primary simple closure. Three mortalities [5.4%] occurred among the cases with primary loop ileostomy due to a significant impact of pre operative and per operative prognostic factors on post operative complications and had a significant association with late presentation, admission-operation interval longer than 12hours, multiple perforations with size more than 1cm, amount of pus/fecal fluid greater than 1000ml. Late presentation, longer admission-operation interval, multiple perforations, size of perforations more than 1 cm and massive amount of intra peritoneal feco-purulent fluid significantly and adversely affect the prognosis of typhoid ileal perforation irrespective the surgical procedure used to manage the perforation

Incisional hernia repair by preperitoneal [sublay] mesh implantation

Incisional Hernia is a common surgical condition with a reported incidence of 2-11% following all laparatomies. Results of tissue repair have been disappointing. The optimal approach for abdominal incisional hernias is still under discussion. To evaluate the technique of preperitoneal [sublay] mesh repair of incisional hernias. This retrospective study of consecutive 50 cases was done from January .2004 to January 2006 using a computerized database. Preperitoneal [sublay] mesh implantation was done in all the 50 cases. Follow up of 12-24 months was carried in the OPD and on telephone with regards to postoperative complications, hospital stay and recurrences if any. In our study of fifty patients, eighty percent of females [n= 40] outnumbered twenty percent males [n=10]. The female to male ratio was 4: 1 and the highest incidence was in the 5th decade of life. The main presenting feature was swelling of the abdomen in all the fifty patients [100%] in the vicinity of the previous operative scar. In sixty percent of patients [n=30], the most common incision leading to incisional hernia was the midline incision of abdomen followed by Pfannensteil's incision in fourteen percent [n=7] and paramedian incision in twelve [n=6]. Major wound infection occurred in two patients [4%] only but without the removal of mesh. Forty patients [80%] attended for follow up ranging from 12 months to 24 months. Twenty seven patients [67.5%] attended OPD for follow up and thirteen patients [32.5%] replied the questions on phone. No recurrence was noted in follow up group. Based on this study, we conclude that preperitoneal [sublay] mesh repair is the ideal technique for incisional hernia. Though still there are few publications regarding this technique of repair

Incidence of SIRS in acute biliary pancreatitis

To see the incidence of systemic inflammatory response syndrome [SIRS] in acute biliary pancreatitis. Setting: Department of surgery, Armed Forces Hospital Dhahran, Saudi Arabia. Period: From January 2001 to January 2009. Patients and Clinical and biochemical data of 102 patients of acute biliary pancreatitis was analyzed retrospectively. Acute biliary pancreatitis was more common in females [74.5% vs. 25.5%] with a female to male ratio of 2.9:1. Majority of patients [70.6%] were in the age range of 21-50 years. All patients had ultrasound abdomen, hemoglobin, TLC, BUN, Creatinine, blood gases, liver function tests, serum amylase and lipase. Computed tomography of abdomen [CT] was done in 16 [15.69%] patients and ERCP was done in 30 [29.4%] patients. Only 2 patients had fever and leukocytosis consistent with SIRS whereas 8 [7.8%] had fever above 38°C only and another group of 22 [21.6%] patients had TLC >12000 cu mm. Clinical and biochemical abnormalities normalized in almost all patients within 72 hours. The group of patients who do not show SIRS and their clinical and biochemical abnormalities settle quickly should be named differently for statistical correction and management

Determinants of outcome of primary repair of colonic trauma

To search of parameters for the selection of the group cases of colonic injuries getting maximum benefit of primary repair. A prospective non-randomized study. Surgical Unit IV, DHQ Hospital, Faisalabad. Patients with colonic trauma due to penetrating and non-penetrating injuries. The main outcome determinants found significant were age, proper prompt treatment, severity of injury, haemodynamic status at the time of operation and gross faecal contamination. Thirty patients colonic trauma who the basis of history, clinical examination and investigations. Patients were closely observed for sign and symptoms of anastomotic leak, and intra- record of these patients was maintained on preformed proforma. All risk factors were made measurable on abdominal sepsis, wound infection. Out of 30 patients, presented to Emergency Ward during one year, underwent exploratory laparotomy. The complete 24 patients were managed by primary repair and six patients were managed by staged procedure. All the 24 patients developed no infective complications. One out of six patients of staged procedure group died on 3[rd] post-operative day due to sudden myocardial infarction and three out of six patients developed infective complications. Age, proper prompt treatment, severity of injury, haemodynamic status at the time of operation and gross faecal contamination are determinants of outcome of primary repair of colonic trauma

Blunt liver trauma: selective conservative approach

To highlight the scope of conservatism in the selective blunt liver injuries in patients who are hemodynamically stable. Prospective non-interventional descriptive study. The study was conducted in Surgical Unit-I and IV of Allied and DHQ Hospitals, PMC, Faisalabad, during three years from August 2004 to august 2007. Out of 45 patients received during this period, 28 were hemodynamically unstable and were immediately explored, the remaining 17 were enrolled in the study who were managed conservatively. After resuscitation all the patients underwent Ultrasound and then followed up with serial Hb% estimation and repeat ultrasound scanning in the High Dependency Unit of the wards. The patients were discharged on 7[th] day, if the hematology and check Ultrasound scan was normal with the advice to restrict physical activity and the regular follow-up in the OPD. Out of the 17 patients treated conservatively, 14 were male and only 3 were females.the SGPT levels were elevated in 84%. More than one liter of hemoperitoneum was detected in two cases who were given 4 units of blood and 11 of the 17 patients needed blood transfusion. There was no missed intraabdominal injury in our series. The mean length of hospital stay was 10.2 days. The two patients [11.76%] developed perihepatic abscess and were treated by subcutaneous drainage. Selective non-operative approach is a valid policy for patients with blunt liver trauma who are hemodynamically stable

Stapler haemorrhoidectomy: a novel and safe technique

To demonstrate advantages of stapler haemorrhoidectomy and its applicability to all patients who require surgical treatment of haemorrhoids. Case Descriptive Study. Allied/DHQ Hospitals, Faisalabad. [February 2004 - July 2005]. A total of 20 patients having grade III or IV hemorrhoids were included in the study. After a detailed GIT history, patients were subjected to standard stapler hemorrhoidectomy under regional anesthesia. Patients were asked to record the postoperative pain intensity according to visual analogue score ranging from [0-10] on daily basis and the drugs required for pain control noticed. Patients were followed at weekly intervals for one month. Main outcome measures were postoperative pain, bleeding, sepsis, urinary retention, continence, relief of preoperative symptoms, operation time, hospital stay and recovery time. Pain was the most common postoperative complication affecting 18 patients [90%age].There was significant reduction in postoperative pain except for one patient in which pain was severe [VAS=8] due to technical error. Two patients developed urinary retention on the day of surgery. Postoperative bleeding was not observed in any of the patients. Pelvic sepsis and incontinence was not found in any patient. Preoperative symptoms were resolved in majority of the cases [80%age] with marked improvement in the rest[20%age]. The mean operative time was 17 minutes and mean hospital stay 1.3 days. Most patients were back to their work after 11th post operative day. Stapler Haemorrhoidectomy is a simple, quick and safe procedure that gives benefit in terms of reducing the postoperative complications namely pain and its sequelae with early return to activity. The vast majority of patients currently undergoing conventional surgical haemorrhoidectomy would be suitable for stapler approach, however the long term benefits need to be evaluated

Incisional hernia repair by mesh implantation

The occurrence of incisional Hernia after abdominal surgery is not uncommon problem. Here we present a retrospective study of 30 cases of repair of incisional hernia by mesh implantation. This study was extended over a period of three years from 1993 to 1995. Out of 30 patients, 13 were males and 17 females. Prolene mesh or Mersilene mesh was implanted using only technique. Wound infection occurred in three patients. Only one patient developed reoccurrence