Thyroidectomy with ultrasonic dissector: an early experience at Lady Reading Hospital

To find out operative times and frequency of complications for total thyroidectomy using ultrasonic dissector. This descriptive study was conducted at Department of Surgery Lady Reading hospital, Peshawar, from October, 2011 till September, 2012 and included 58 patients. The study included those patients who underwent total thyroidectomy using the Harmonic Focus[R] for benign conditions. The age range of the sample was 21-63 years with a mean age of 33.6 +/- 3.4 years. Only five of all patients included were male with female predominance and having a benign disease. The Mean operative time was 59.3 +/- 14.1 minutes. The mean hospital stay was 3.1 +/- 0.65 days and mean blood in drain at 24 hours was 65.6 +/- 17.14 ml. Persistent hypocalcaemia and hoarseness at one week was observed in two cases each [3.44%].The use of ultrasonic dissector is safe and has significantly reduced operative time. Also there was less amount of blood in the drain at 24 hours

Safety of ultrasonic dissection versus conventional electrocautery dissection during laproscopic cholecystectomy in terms of gall bladder perforation

To compare the safety of ultrasonic and electrocautery method of dissection in terms of gallbladder perforation. This randomized controlled trial included 128 patients, which were divided into two groups, ultrasonic dissection [A] and electrocautery dissection [B]. GB perforation [if any] was noted intraoperatively, and all the data was recorded on a structured questionnaire. Data was analyzed using SPSS. The incidence of GB perforation was significantly lower in ultrasonic dissection [10.9%] than electrocautery methods of dissection [29.7%], hence the safety of ultrasonic dissection in terms of gallbladder perforation, was significantly higher than electrocautery dissection [89.1% vs. 70.3% p-value=0.007]. Ultrasonic dissection is safer modality of dissection in terms of gall bladder perforation and its use should be encouraged as routine method of dissection during LC

Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus open Lichtenstein technique

To compare the outcome and cost of laparoscopic inguinal hernia repair versus open repair. This was a randomized controlled study conducted on 100 patients from January 2011 till April 2012, in Surgical 'A' unit, Lady Reading Hospital, Peshawar. A total of 100 patients were randomized and were allocated into two groups i.e. open repair [Lichenstein procedure] and laparoscopic repair [Trans-abdominal pre-peritoneal mesh repair, TAPP] group using lottery method. Type of hernia, type of procedure done, total cost of surgery, duration of hospital stay, post operative pain rating by visual analogue score and post operative complications were assessed. Significant difference was observed between the two groups in relation to the perioperative complications. Mean operative time was short in open repair 55.40 +/- 10.73 minutes compared to TAPP 87.10 +/- 11.60 minutes but the mean length of hospital stay was less in TAPP [2.78 +/- 0.64 days] compared to open [3.5 +/- 0.67 days]. Regarding postoperative complication urinary retention was 22% and 10%, wound discharge was 20% and 08%, recurrence was observed in 12% and 06% in open repair and TAPP respectively. The difference was statistically insignificant. Laparoscopic repair showed significantly less post operative surgical pain compared to open repair. This trial showed no statistical difference between the open and laparoscopic procedures regarding post operative complications but laparoscopic repair showed statistically lower post surgical operative pain and hospital stay with greater operative time and cost. This study supports the use of the laparoscopic repair techniques for the treatment of inguinal hernia

Various surgical options for emergency management of sigmoid volvulus

The objective of this study was to compare the outcome of various surgical options for the emergency surgical management of sigmoid volvulus. This comparative study was conducted in emergency department of postgraduate medical institute Lady Reading Hospital, Peshawar over a period of one year from February 2007 to January 2008. Study comprised of hundred cases to have sigmoid volvulus on clinical and radiological grounds operated in casualty department with various surgical options and outcomes of these procedures were determined postoperatively. Out of 100 cases, 79% were males and 21% females. Majority 51% patients were in the age range of 41-60 years, 36% patients were in age group of 61-80 years. Resection and Hartman's procedure was performed in 52% cases, resection with primary anastomosis with covering colostomy in 18% cases, resection and primary anastomosis in 15% cases, and resection with double barrel colostomy [Paul Mikulicz] in 15% cases. Wound infection/ dehiscence occurred in 21% cases, intra-abdominal abscess in 9% cases, anastomosis leakage in 6% cases. Colostomy complications included bleeding in 7% cases, retraction in 7% patients, prolapse in 4% cases. Resection and Hartmann procedure was performed in majority of patients. Wound infection/dehiscence, intra-abdominal abscess, anastomosis leakage were common postoperative complications with various frequencies

Prognostic indicators of surgery for esophageal cancer: a 5 year experience

To assess the prognostic indicators preoperatively presenting and influencing the mortality rate following esophagectomy for esophageal cancer. This study was a retrospective cohort study, conducted at the Department of Surgery, Lady Reading Hospital, Peshawar, from 1 January 2003 till 31 December 2008. Group 1 included patients who had undergone sub-total esophagectomy and were alive at completion of 12 months; whereas Group 2 included those patients who died by the completion of 12 months. Data were recollected from the Data Bank. A list of variables common to all patients from both groups was categorized and subsequently all data related to each individual patient were placed and analyzed on the version 13.0 of SPSS R for Windows. Significant findings of a lower mean level of serum albumin from Group 2 were observed, whereas serum transferrin levels, also found lower in Group 2, were not statistically significant. Findings of serum pre-albumin, with a mean value of 16.12 mg/dl [P<0.05] and Geansler's index for the evaluation of the presence of obstructive pulmonary disease prior to surgery showed a lower reading of mean ratio in Group 2. Anastamotic leak was not a common finding in the entire study. In most cases, the choice of conduit was the remodeled stomach. Nine patients from Group 2 were observed with evident leak on the fifth to seventh post-operative day following contrast swallow studies. This was statistically insignificant [P = 0.051] on multivariate analysis. Pre-operative variables including weight loss, low serum albumin and pre-albumin, Geansler's index, postoperative chylothorax, pleural effusion, and hospital stay, are predictive of mortality in patients who undergo esophagectomy for esophageal cancer

early closure of stoma warranted in the management of temporary loop ileostomy?

To assess the outcome of closure of temporary loop ileostomies by comparing frequency of post operative complication. This was an experimental study conducted at the surgical A unit of Lady Reading Hospital between Jan 2005 and Dec 2009. All patients who were primarily operated and ended up with temporary loop ileostomy were admitted via the out-patient department. Consecutively allocated into group A whose stomae were closed at 8 weeks and group B whose stomae closed at 4 weeks. Postoperative complications including wound infection, anastamotic leak, dehiscence etc. were recorded and statistical analysis done using version 13.0 SPSS for windows. Group A included 155 patients and Group B 156 patient with male predominance in both groups [p=0.869]. The mean age in both groups was similar 33.6 years and 32.7 years respectively. Anastamotic leak rate and wound dehiscence was lower in early closure group but p value was insignificant. The frequency of wound infection was higher in the early stoma closure group [p=0.001]. The mean hospital stay was similar. Apart from wound infection the frequency of complication following early closure [4 weeks] of temporary loop stoma is similar to delayed closure. Thus delayed closure of stomae should be abandoned

Polyglactine/polypropylene mesh vs. propylene mesh: is there a need for newer prosthesis in inguinal hernia?

To compare outcomes of light and heavy weight mesh for repair of inguinal hernia. This study was conducted at the Department of Surgery; Lady Reading Hospital, Peshawar from January 1, 2007 to December 31, 2008. Patients were divided into two groups based on the type of mesh implanted for inguinal hernia repair. Group 1 included patients in whom light weight composite [VyproII] mesh is implanted: Group 2 included patients in whom polypropylene [Prolene] mesh is implanted. Data concerning the complications and post operative pain in the perioperative and postoperative period were collected and analyzed. Categorical data were presented as percentages with 95% confidence intervals and compared using a x[2] test and P < 0.05 were considered significant. Following allocation and exclusion of violating cases, 111 patients in group 1 and 138 patients in group 2 were analyzed. The mean age in group 1 was 38.20 +/- 13.34 years and in group 2 was 39.55 +/- 13.70 [P = 0.434]. In group 1, hematoma formation was observed in four cases [3.6%] while it was observed in six cases [4.2%] in group 2 [P = 0.766]. During the entire study, ten patients in all developed urinary retention, three of which required transient catheterization. One year post operation, there was a recurrence in only five cases overall, while only two patients complained of pain [P = 0.826]. The frequency of postoperative pain and complications in patients was similar in both groups

Pattern of breast cancer: experience at Lady Reading hospital, Peshawar

Breast Cancer is the commonest malignancy of females all over the world and second leading cause of death due to cancer among females. The aim of this Descriptive study was to see the various features of breast cancer in order to know the pattern of disease in the recent time. The study was conducted from Jan. 2007 to Dec. 2007 in Surgical C Unit, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan. Study included all patients presenting to and admitted in Surgical C Unit LRH, with carcinoma of breast during the above mentioned period. Name, age, sex, other relevant data, history and examination findings and results of histopathology and other investigations were recorded. Total of 46 patients was included in the study, out of which there were 46 female and 1 male patients. Most common age group was 40-49 years with 14 patients, followed by 50-59 years with 12 patients. Most common type of carcinoma was infiltrating ductal carcinoma with no specific features with 38 patients. Other types included 2 infiltrating ductal carcinomas of papillary type, 1 mucinous type and 1 medullary type; 3 invasive lobular carcinomas, and 1 mixed lobular and ductal carcinoma. The disease was left sided in 24 cases, right sided in 20 cases while it was bilateral in 2 cases. Upper outer quadrant of the breast was most commonly involved [n=26]. There were 2 cases of stage I, 16 stage II, 20 stage III and 08 cases of stage IV disease. There were 2 cases of grade I, 16 grade II, and 28 cases of grade III. Carcinoma breast is still a common problem presenting at a young to middle age group with invasive ductal carcinoma being the commonest variant with a high grade and a late stage of presentation due to lack of screening and awareness programs

Early outcome of Lichtenstein technique of tension-free open mesh repair for inguinal hernia

To evaluate the early outcome of Lichtenstein's technique for repair of inguinal hernia using polypropylene mesh. This was a descriptive study conducted over a period of twelve months from 1[st] July 2007 to 30[th] June 2008 in Surgical 'B' unit, Lady Reading Hospital, Peshawar. One hundred and twelve patients were received through the out patient department with diagnosis of inguinal hernia. Inclusion criteria was patients above the age of 18 years, reducible hernia, evidence of swelling in groin >2 months. Exclusion criteria was age less than 18 years, chronic constipation, chronic cough, symptoms of prostatism, irreducible hernia, obstructed hernia, strangulated hernia and patients with diabetes mellitus. All the patients were subjected to inguinal mesh repair using the Lichtenstein technique with polypropylene mesh. Mean age of patients was 48.78 +/- 14.41 years. Sixty patients [53.6%] had right sided inguinal hernia while 46 patients [41.1%] had a left sided hernia and 6 patients [5.4%] had bilateral hernia. Sixty two patients [55.4%] had indirect hernia and 43 [38.4%] cases had direct hernia. Sixteen cases [14.3%] had previous history of surgery for hernia on the same side [recurrent hernia]. Mild pain was observed in 53 cases [47.3%], moderate pain in 42 cases [37.5%], and severe pain in 17 cases [15.2%]. Four patients [3.6%] in all developed a seroma Two patients [1.8%] developed a haematoma that required drainage. Three patients [2.7%] had a prolonged recovery and presented with abdominal distension. Five cases presented with infected wounds. Lichtenstein's technique of inguinal mesh repair is a safe and effective procedure but emerging trends anticipates the implementation of day case surgery

Postoperative nasogastric decompression is not warranted in elective closure of gut stomas and bilioenteric anastamosis: a randomized controlled trial

To compare the outcome of postoperative nasogastric decompression versus no nasogastric decompression in cases of elective closure of gut stomas and bilioenteric anastamosis. This randomized trial was conducted from 01-01-2006 to 31-10-3006 at Lady reading Hospital, Peshawar on 119 patients admitted for stomal closure or Bilioenteric anastamosis. Group A included 58 patients subjected to postoperative nasogastric decompression and group B included 61 patients not subjected to postoperative nasogastric decompression. Out of 119 patients, 61 [Group A=30; Group B=31] patients underwent gut stomas closure and 58 patients [Group A=28; Group B=30] underwent Bilioenteric Anastamosis. Pediatric age group, oesophagogastric disease, emergency procedures and pre-operative co-morbid conditions were excluded. The male to female ratio in group A was 4:1 and in group B was 2.85:1. The morbidity between group A [60.0%] and group B [48.38%] was insignificant [p>0.05]. No mortality was observed during hospital stay in both groups. Length of hospital stay was 7.93+1.27 days in group A versus 6.54+0.85 days in group B. The number of nasogastric reinsertions was in 6 patients; three in either group with a delay of 2.6 days for duration of 3.1 days. Abdominal distension was observed in 12 [60%] cases of stomal closure in group A versus 7 [22. 5%] in group B. In patients undergoing bilioenteric anastamosis the mean stay in group A was no more than group B. Increase hospital stay and complication rates were observed in patients receiving nasogastric decompression compared to those without NG tubes

Surgical management of intestinal tuberculosis

To study the outcome of various surgical procedures performed for intestinal tuberculosis. This Study was carried out from July 2004 to June 2005 at Lady Reading Hospital, Peshawar on 30 operated patients of intestinal tuberculosis provisionally diagnosed on history, physical examination and x-ray findings. Emergency patients had a short work up including routine hamatological, biochemical and chest radiography while those admitted electively, had an ESR and upper gastrointestinal barium studies in addition to routine investigations. Final diagnosis was made after histopathology. Different operative procedures were performed according to the available facilities and preoperative condition of the patient. Study included 10 males and 20 females, ranging in age from 15-60 years with mean of 23.5 years. Twenty Seven patients [90%] were operated in emergency and 3 patients [10%] as elective cases. In 19 cases [63%],. ileum was involved while combined ileum and jejunum in 6 cases [20%]. Twenty patients [66%] had strictures in small gut. The most commonly performed procedures were resection and end to end anastamosis in the form of segmental resection [11 cases], stricturoplasty in 7 cases and loop ileostomy [5 cases]. Wound infection was the main post-operative complication [7 cases]. The average hospital stay was 10 days. Mortality was 10% [3 cases]. Resection of the diseased segment is the standard procedure to relieve obstruction but in the presence of multiple strictures and limited bowel length, stricturoplasty is a better alternative

Emergency management of sigmoid volvulus: experience of lady reading hospital Peshawar

To know the outcome of resection and end to end anastamosis with defunctioning colostomy in patients with sigmoid volvulus, operated in emergency. This study was conducted from Jan 2004 to December 2004 at surgical "C" unit Post Graduate Medical Institute Lady Reading Hospital Peshawar. Patients presenting to emergency department with clinical suspicion of sigmoid volvulus, were thoroughly examined and underwent baseline and radiological investigations before surgery. Final diagnosis was made per operatively and emergency resection and end to end anastamosis with defunctioning colostomy were performed in all patients in casualty operation theatre. During the time period, 25 diagnosed patients with sigmoid volvulus were finally selected for the study. Seventeen patients [68%] were in their 5th and 6th decades of life. Male to female ratio was 11.5:1. In 24 operated cases [96%], the gut was viable while in one case the gut was gangrenous. The average length of stay was 7-days. Mortality was 4% [one case], which was attributed to pre-operative unstable condition and gangrenous gut at the time of surgery. Resection of sigmoid colon with primary anastamosis and a proximal defunctioning colostomy is a safer procedure in inexperienced and learning hands in emergency situations