Identification and preservation of the external laryngeal nerve during thyroid surgery: surgical and anatomic considerations

Iatrogenic injuries of external branch of superior laryngeal nerve [EBSLN] during thyroid surgery are not uncommon due to the possibility of anatomic variations in the relationship of this nerve with superior thyroid vessels and the result may be devastating to those patients who rely on their voices professionally. The study included 2 groups. Group A was a prospective nonrandomized analytical series of all consecutive patients undergoing thyroidectomies for various conditions in Surgical Unit II, Shaikh Zayed Postgraduate Medical Complex, Lahore, Pakistan during a three years period [November 2004 - November 2007]. This group consisted of 133 patients. Male to female ratio was 1:3. Mean age was 35.22 years [range: 17-71 years]. Ninety one [68.42%] patients had bilateral dissection [total, sub-total or neartotal thyroidectomies] and 42 [31.57%] had unilateral dissection [hemithyroidectomy I lobectomy and isthumusectomy]. Thus, a total of 224 superior polar dissections were carried out. Three [3 .296 %] patients out of the 91 patients in the bilateral dissection group had asymmetrical nerves. Eighty one [60.9%] patients had benign disease, 32 [24.06%] had malignancy and 20 [15.03%] had toxic goiter. Nerve could not be identified in 42 [18.75%] polar dissections [positive identification in 182 [81.25%] polar dissections]. Three [2.25 %] patients in this study had clearly documented EBSLN injury as determined by voice changes, patient interview and IDL. In Group B, the anterior neck triangles of 19 embalmed human cadavers [i.e. 38 neck half preparations] of both sexes and variable ages with neither enlarged thyroid glands nor any other signs of abnormality in this region were dissected in the dissection halls of two medical colleges in Lahore. The course and topographical relations [especially in relation to the superior thyroid vessels, superior pole of the thyroid and the cricothyroid muscle] of the EBSLN as well as bilateral asymmetry were noted as for Group A. Nerves were classified according to classification of Cernea et al. Good knowledge of the anatomy and relations of the EBSLN with meticulous dissection and ske letonisation and individual ligation of the superior polar vessels is the key to success

Critical factors effecting morbidity and mortality in patients operated for typhoid ileal perforation

Typhoid perforation is the most important surgical complication of typhoid enteritis and is associated with a significant morbidity and mortality. To determine the factors affecting morbidity and mortality in patients with typhoid intestinal perforation, the complete medical records of a pool of patients from two major teaching hospitals of Lahore were reviewed. A total of 39 patients diagnosed to have typhoid Heal perforation at operation included 27 patients operated in the emergency of South Surgical Ward. Mayo Hospital Lahore from January 1998 to Dec 2000, and 12 consecutive patients operated by the surgical team of Surgical Unit II. Shaikh Zayed Medical Complex. Lahore between December 2000 to May 2005. The average age was 26 years, the male-to-female ratio 4/1. The mean interval from admission to operation was 09 hours [range 05 hours - 03 days]. Eight patients had more than one perforation at the time of operation. Primary repair of the perforation was performed in 22% of the patients, ileostomy [primary repair and proximal loop ileostomy or exteriorization of perforation as a loop ileostomy] in 46%. and resection with end ileostomy and mucous fistula in 32%. No primary end-to-end anastomosis after resection was performed. Postoperative complications occurred more commonly in patients with delayed admission and/or severe peritonitis. Hospitalization was shorter and the postoperative complication rate lower in patients who underwent ileostomy. Three patients developed an enter cutaneous fistula requiring re-operation. The four deaths [10.25% mortality] resulted from overwhelming sepsis. The most significant factors affecting morbidity were prolongation of perforation-operation interval and severe peritonitis. No single operative procedure is best in all cases: therapy should be individualized and tailor made for every patient. Ileostomy appears to be an effective and safe procedure, particularly in patients with severe abdominal contamination and delayed presentation. Early diagnosis, aggressive resuscitates tion with fluid and electrolyte optimization and prompt operation may result in improved survival in these seriously ill patients

Delorme procedure for complete Rectal Prolapse in young adults - an analysis of 7 cases

The problem of full-thickness rectal prolapse is formidable, with no clear predominant treatment of choice. Several operations have been proposed to correct rectal prolapse which can be divided into transabdominal and perineal procedures. Delorme operation is a suitable procedure for elderly and/or medically unfit patients with rectal prolapse. However, good results have also been demonstrated for younger patients, suggesting that the operation may have wider application. From January 2001 to September 2003, 07 young adult patients underwent the Delorme repair of rectal prolapse in our unit with good results. The main outcomes measured were method of anesthesia, morbidity, mortality, recurrence rates, length of follow-up, and incontinence. In the 07 patients, the mean age of the patients was 24 years. The mean operating time was 55 minutes. Four patients were administered general anesthesia and 03 were administered spinal anesthesia. The mean postoperative stay was 05 days. No patients died as a result of th e procedure. Patients were followed up for 3 - 33 months. Preoperative incontinence was present in 02 patients, both of whom improved after the procedure. Postoperative incontinence was seen in only one of these patients but that too seemed to improve with time. No recurrent postoperative prolapse has yet been seen. None of the patients had complications that required operative intervention in the postoperative period. Although, the best operation for rectal prolapse remains a controversial subject, we believe that the Delorme Operation offers a promising option for the treatment of rectal prolapse even in young adults

Presentation of cancer of the gallbladder at Mayo Hospital, Lahore

Carcinoma of the gallbladder is a progressive malignant disorder with a poor and painful prognosis and high mortality rate'. Our study highlights the enhanced presentation of the carcinoma of gallbladder in patients having cholecystectomies in general ward and its possible aetiological factors in the population of Pakistan in general and Punjab in particular. Analysis of case records and histopathology reports of 100 patients who underwent cholecystectomies was done, with the objective to determine the incidence of cancer of gall bladder and highlight the possible aetiological factors. Out of a total of 100 patients 89% were females and 11% were males. The total incidence of cancer of the gall bladder in these patients was 16% the highest yet reported in literature and if was seen that it was more common in females [13%] who are relatively quite young in age. The aetiological factors held responsible were the unmistakable association of gallstones, the delayed treatment, repeated attacks of cholecystitis, multiparty, congenital abnormalities of biliary tract and infections of the biliary system. Though various modalities of treatment have been described but bulk of the above can be controlled and prevented

Penetrating injuries of the abdominal inferior Vena Cava - the Mayo hospital experience

This is a retrospective study. of 16 patients with penetrating injuries of the abdominal inferior vena cava [IVC]. 81% of the injuries were caused by gunshot and 19% by stabbing. 62.5% of these patients underwent lateral venorrhaphy, 18.75% underwent infrarenal ligation of the IVC and 18.75% died perioperatively before caval repair of any kind could be carried out. There was an overall mortality of 43.75%. Mortality seems to be directly related to the site of the IVC injury [higher for the suprarenal location and highest for the retrohepatic injuries], the presence of shock on admission, free bleeding and the lack of retroperitoneal tamponade at the time of surgery and also on the presence of additional vascular injuries