Role of laparoscopy in evaluation of abdominal pain

Objective: To evaluate the diagnostic efficacy of laparoscopy in ill-defined recurrent chronic abdominal pain

Study Design: Prospective study

Place and Duration of Study: Surgical department, Military Hospital Rawalpindi, from Jul 2011 to Dec 2013

Material and Methods: A total of 102 patients who presented to surgical department with chronic recurrent abdominal pain of unknown etiology and underwent diagnostic laparoscopy were included in our study. Patients with acute onset of abdominal pain, hemodynamically unstable, pregnant or those in which diagnosis can be made by radiological techniques were excluded from our study. Patient's demographic data, clinical findings and laparoscopic findings were recorded. Finally data was analyzed by using SPSS version 21

Results: Out of 110 patients 96 were female while remaining 14 were male. The age range of the patients was 20-70 years with mean age of 50 +/- 10 years. The most common site of pain was lower abdomen while mean duration of abdominal pain was 34 weeks. Laparoscopic findings include acute recurrent appendicitis in 32 [29.09%] patients, cholecystitis with biliary sludge in 14 [12.72%], pelvic inflammatory disease in 12 [10.90%], ovarian cyst in 11[10%], adhesions in 10[9.09%], intestinal tuberculosis in 8 [7.27%], mesenteric lymphadenitis in 7 [6.36%], lymphoma in 4 [3.63%], ectopic pregnancy in 3 [2.7%], CA gallbladder in 2 [1.81%], meckels diverticulum in 2 [1.81%], endometriosis in 2 [1.81%] and crohns disease in 1 [0.9%] patients. Mean operative time was 48 min while average hospital stay was 2-3 days. No major complications were noticed

Conclusion: Laparoscopy in our clinical setup has significant role in diagnosing cases of vague abdominal pain which cannot be diagnosed by routine investigations

Bile duct injuries and outcomes: a retrospective medical record review

Objective: To report on our experience of cholecystectomy associated bile duct injuries and observe factors influencing outcomes

Study Design: Simple descriptive study

Place and Duration of Study: Surgical unit IV, Military Hospital [MH] Rawalpindi, over a period of seven years from 01-01-2005 to 1-12-2012

Material and Methods: Eighty eight patients who underwent repair of bile duct injuries during this period were included in this study. Patients referred from class 'W and 'C' hospitals to our institute were also included

Results: Fifteen immediate repairs [0-72 hours] post cholecystectomy, forty eight intermediate repairs [72hrs-6wks] and twenty five late repairs [> 6 wks] were performed [table-1]. Short term morbidity was higher in patients with upper biliary tract injury [p=.04].The most common long-term complication was biliary stricture, which occurred in 28 patients [31.8%]. Patients with bile duct injuries [BDIs] repaired in intermediate period were more prone to develop stricture of biliary tree than those repaired in immediate or late period [p=.03] [table 3]. Long term morbidity was also higher in patients who presented with bile contamination of peritoneum [p=.03] and had sustained complex biliary tract injuries [E4/E5] [p=.03].The overall morbidity and mortality rate was 31% and 3% respectively

Conclusion: We observed that complex hilar injury, presence of intra-abdominal bile and timing of BDI repair is an important predictor of long-term outcome. Injuries repaired in early [0-72hrs] or late period [>6wks] were less likely to develop biliary stricture as compared to injuries repaired in intermediate period [72hrs-6wks]. Moreover complex hilar injuries and intra-abdominal bile at presentation increases the possibility for development of late biliary stricture

Laparoscopic cholecystectomy: a clinical practice audit

To evaluate laparoscopic cholecystectomy by a clinical practice audit at Military Hospital, Rawalpindi. Prospective study. Surgical department Military Hospital from Jul 2011-Dec 2013. A total of 1020 patients who underwent laparoscopic cholecystectomy for acute or chronic cholecystitis and gallstone panereatitis were included in our study while those who had previously undergone abdominal surgeries, those with high risk for general anesthesia, immunocompromised patients, with age greater than 70 years and having comorbidities like cardiac insufficiency, severe asthma, chronic liver disease with ascites and compromised renal functions were excluded from the study. Patients' demographic data, operative time, intra-operative findings, intra-operative difficulties, post-operative complications, conversion rate to open cholecystectomy and post-operative recovery time were recorded. Data was analyzed by using SPSS version 21. Out of 1020 patients 907 were females while 113 were males with male to female ratio of 1:8.02. Age range was 20-70 with mean age of 50 k 10.456 years, 447% patients presented with the clinical features of acute cholecystitis, 540 [52.94%] with chronic cholecystitis and 23 [2.28%] with acute panaeatitis. Mean 1 operative time was 20 minutes in asymptomatic patients, while 40 minutes in acute cholecystitis and 35 minutes in chronic gallstone disease. Gall bladder perforation, bleeding from cystic artery and bile spillage were mostly encountered per-operative difficulties. Only 37 [3.6%] patients were converted to open cholecystectomy. Post-operative complications occur in only 122 [12%] patients. 938 [92%] patients were discharged within 48 hours. of surgery. Laparoscopic cholecystectomy in our setup has comparable results to the data available from other surgical facilities around the world and it has become a gold standard technique for the treatment of non-complicated gallstone disease

Spectrum of diseases in acute intestinal obstruction

To determine the etiological spectrum of acute intestinal obstruction in our clinical setup Military Hospital Rawalpindi. Descriptive study. Surgical department of Military Hospital, Rawalpindi from Jul 2012 to Jul 2013, over a period of about 1 year. A total of 120 patients with acute mechanical intestinal obstruction who underwent laparotomy were included in our study while those with non-mechanical intestinal obstruction like history of trauma and paralytic ileus were excluded from the study. All the patients were selected by non-probability purposive sampling technique. Emergency laparotomy was done and operative findings were recorded. A total of 120 patients with mechanical intestinal obstruction were included in this study out of which 93 [69.17%] were female and remaining 27 [30.83%] were males. Male to female ratio was 1:2.24. Age range of patients was 22-85 years. Out of 120 patients operated for acute intestinal obstruction post-op adhesions were found in 37 [30.83%] patients followed by intestinal tuberculosis in 23 [19.17%] patients, obstructed inguinal hernias in 13 [10.83%], gut malignancies in 15 [12.5%], Meckel's diverticulum with bands in 7 [5.83%], volvulus in 7 [5.83%], perforated appendix in 6 [5%], intussusception in 2 [1.7%], inflammatory bands in 5 [4.17%], trichobezoar and faecal impaction in 2 [1.7%] while in 3 [2.5%] patients no definite cause was found. Post-op adhesions are the commonest cause of mechanical intestinal obstruction in our setup followed by intestinal tuberculosis as second most common clinical pattern of presentation

Subcutaneous versus subcutaneous and intraperitoneal local anaesthetic in the management of post appendicectomy pain

To compare the efficacy of subcutaneous only and combined subcutaneous and peritoneal infiltration of 0.5% bupivacaine during appendicectomy for the management of early post operative pain. Randomized controlled study. Department of Surgery, CMH Kohat from 13[th] December 2007 to 20[th] December 2008. Sixty patients of acute appendicitis, divided into two groups of 30 each, were included in the study. Group A was given 0.5% bupivacaine subcutaneously, whereas group B was given the anaesthetic subcutaneously as well as intraperitoneally during appendectomy. In group A, 24 [80%] were VAS [visual analogue scoring] 3 [uncomfortable] and 6 [20%] were VAS 2 [mild pain] whereas in study group B, 11 [36.6%] were VAS 3, 19 [63.3%] were VAS 2 and 19 [63.3%] were VAS 2 during 1st 12 hrs postoperatively [p=0.001]. In 12-24 hrs post operatively, 15 [50%] patients were VAS 3 in group A and same number was VAS 2 and in group B, only 3 [10%] were in VAS 3 and 27 [90%] were VAS 2 [p=0.001]. A combination of subcutaneous and peritoneal infiltration with bupivacaine is superior in relieving post appendectomy pain so patients require less dosage of analgesics in early post operative period along with early mobilization

Pattern of toy bomb injuries in Azad Jammu and Kashmir [a hospital based study]

An observational, hospital based study was conducted at CMH, Muzaffarabad to see the pattern of Toy Bomb blast injuries in a period from 1st Jan 2002 to 31st Dec 2003. On an incidence of Toy Bomb Blast injuries, patients reporting to a hospital in Azad Jammu and Kashmir [AJandK] were the core study material for this article. To study the pattern of injuries and their consequences in the studied population. Patients reporting to the hospital with history of toy bomb blast injuries were examined evaluated and followed up. Documents of patient with similar injuries in past treated in the hospital were also included in the study. A checklist guided the follow up of the patients from the incidence that triggered the study. The patients were scrutinized/evaluated according to Advanced Trauma Life Support [ATLS] system of trauma care. Altogether 48 patients record was checked. The age ranged from 1 - 63 years [majority of the patients [80%] were male below 13 years of age], 38 [79%] cases sustained major trauma with multiple injuries of head/neck, maxillofacial, chest, Abdomen and all four limbs. Twenty-four cases [50%] had permanent disabilities. Mortality rate was 20%. Wound infection was very high [60%]. The major complications were depending upon the organ involved/injured. This study points to the need for further studies of this unique method of causation of injuries [toy bomb blast injuries], the pattern they evoke and possible handling of such eventualities. It is desired that at one end the community must be informed and educated about the type, shape, injuries and prevention of the toy bomb casualties and on the other end quick evacuation and proper management of cases be ensured

Massive splenic hydatid cyst

Hydatid disease can involve any organ of the body and a high suspicion of this disease is justified in endemic regions. A case of massive splenic hydatid cyst with hepatic hydatidosis presented with 5 years history of abdominal distension with discomfort is reported. Clinically she had massive splenomegaly with hepatomegaly. Laboratory and radiological findings were diagnostic of hydatid disease of the liver and spleen. Peroperatively huge [35 x 20 cm] splenic hydatid cyst with two liver cysts was seen. Splenectomy was performed and hepatic lesions were subjected to endocystectomy with capsulorrhaphy