The impact of preemptive ropivacaine in inguinal hernioplasty--a randomized controlled trial.

INTRODUCTION: This study was aimed to assess the outcome of Ilioinguinal, Iliohypogastric block and wound infiltration with 0.75% ropivacaine on pain perception, first analgesic request and hospital stay following inguinal Lichtenstein mesh repair. METHOD: This was a prospective, randomized, double-blind study with 60 patients undergoing inguinal hernioplasty under general anesthesia. Patients were randomly allocated to one of the two groups by the sealed envelope method. Group 1 (n=30) received nerve blocks and incision infiltration with 0.75% ropivacaine while group 2 (n=30) received isotonic saline. Postoperatively pain intensity, time of demand for the first analgesic and duration of hospital stay were assessed. RESULTS: Median Visual Analog Scale (VAS) score of group 1 was 4 (high=6, low=3) while for group 2 was 5.50 (high=8, low=4) and the p value was <0.001. Mean time for the demand of the first analgesic was prolonged from 1.19±1.05 h to 5.31±1.14 h with the p value of <0.0005, while the mean time of hospital stay was reduced from 22.5±3.30 h to 14.1±2.99 h with the p value of <0.0005. CONCLUSION: Preemptive analgesia with 0.75% ropivacaine causes significant reduction in pain perception, request for an analgesic and hospital stay. Therefore it is advisable before inguinal hernioplasty.

Modified Lanz incision in appendicectomy - the surgical trainees best friend.

Appendicitis is one of the commonest acute surgical diseases and treatment by appendicectomy is the most frequently performed surgical procedure in the western world. After obtaining adequate basic surgical experience, an open appendicectomy is an ideal procedure for junior surgical trainees to develop their operative skills and despite a reduction in training hours, recent figures suggest that surgical SHOs still perform about 30% of these cases. Although they are clearly routine and suitable for junior staff to perform under supervision, as many as 20% of appendicectomies, are for a variety of reasons considered difficult. We aim to be the first to present a modified Lanz incision that we believe provides not only a cosmetic scar but also is placed more frequently over the base of the appendix. It gives adequate access in difficult cases and we feel this is the most appropriate incision for a trainee to use when performing an appendicectomy.

Intrathoracic meso-axial chronic gastric volvulus: erroneously investigated as coronary disease.

Gastric volvulus can result in complications such as gastric ischemia, perforation, and haemorrhage. There is consensus on repair upon diagnosis. We present a patient of gastric volvulus, who remained under the care of physicians with symptom of chest pain for over three years and was eventually treated by laparoscopic surgery.

Obstructive uropathy secondary to pneumoperitoneum in a patient with ileal conduit.

Pneumoperitoneum has become an established first step when performing laparoscopic procedures. No specific guidelines are available for creating pneumoperitoneum in patients with ostomies. We present a patient with a urostomy (ileal conduit), undergoing a laparoscopic cholecystectomy. After surgery the stoma became edematous leading to obstructive uropathy and renal insufficiency. We suggest that the pneumoperitoneum should be created at low pressures among patients with ostomies and further recommend that a drainage tube is placed in the ileal conduit to ensure unobstructed drainage of urine.

Suture knot forming the apex of an adult ileo-ileal intussusception: a case report.

A revision laparotomy in an adult for early post-operative small bowel obstruction revealed retrograde ileo-ileal intussusception. The apex was formed by the suture knot from the recent anastomosis. Segmental resection was performed.

Torsion of gallbladder: a diagnostic predicament.

A 69-year-old woman underwent an emergency laparotomy and cholecystectomy, revealed gangrene of the gallbladder secondary to torsion.

Comparison of topical glyceryl trinitrate with lignocaine ointment for treatment of anal fissure: a randomised controlled trial.

INTRODUCTION: Topical glyceryl trinitrate (GTN) has gained popularity as a treatment for anal fissure in the West. In our country, lignocaine is still the current treatment for the entity. This study was done to compare the effect of GTN with lignocaine in terms of healing rate and recurrence in South Asian population. METHODS: A prospective, double blinded, randomised controlled trial was conducted on 50 patients (both treatment arms included) of all ages and either gender with a clinical diagnosis of anal fissure. Group A was given 0.2% GTN ointment and Group B was given lignocaine ointment. Both subjective and objective signs of healing were assessed and adverse effects of the treatment were sought. RESULTS: Symptomatic relief was earlier with GTN as compared with lignocaine. Pain relief was steady and sustained in those treated with GTN but returned to pre-treatment status within 5 weeks in patients with lignocaine. After 8 weeks of treatment, 80% of patients in Group A showed clinical signs of healing compared to 32% in Group B (p=0.001). Headache was the main side effect of GTN. At 6-month follow-up, recurrence was seen in 3/8 patients in Group B compared to 8/20 in the GTN Group (p=1). CONCLUSION: Topical GTN has earlier and a higher rate of clinical healing of anal fissure with acceptable side effects. The recurrence rate is high and comparable to lignocaine ointment. It is a safe and an effective treatment of anal fissure in a South Asian population.

Day case laparoscopic cholecystectomy is safe and feasible: a case controlled study.

BACKGROUND: Day case laparoscopic cholecystectomy (DC-LC) is being practised in the USA and at sporadic centres in the UK including our department. The aim was to evaluate the admission rate after DC-LC. PATIENTS AND METHODS: Prospectively collected data was analysed retrospectively. The case notes of all patients were retrieved from the medical records and reviewed individually. Inclusion criteria for DC-LC were cholelithiasis, non-acute cholecystitis, ASA I-III and informed consent. Standard laparoscopic cholecystectomy was performed. All patients had anti-DVT prophylaxis (pneumatic compression and enoxaparin), per-operative antibiotic, oro-gastric tube, paracetamol suppository and local anaesthetic to all wounds. They were discharged the same day. The end point was 6-week follow-up (86% overall). RESULTS: Over a 32-month period, 164 consecutive patients with symptomatic cholelithiasis and ASA score of III or less were included. M:F was 1:5 and median age 45y. There were two conversions. The direct admission rate (DAR) was 26/164 (14%). The indication for direct admission included observation alone (7/26), wound pain (6/26), nausea (3/26), suction drain (2/26) and operation in the afternoon (2/26). Six (3.6%) required re-admission. One had a cystic artery pseudo-aneurysm presenting with colonic bleeding and another with an injury to CBD. One had post-operative mild pancreatitis and three had wound pain and bruising. Fourteen out of 41 were admitted in the >55y age group compared to 12/123 from <55y age group (p=0.00054). CONCLUSION: DC-LC is safe and feasible in non-acute patients with symptomatic cholelithiasis. Over-55y age group had a higher chance of admission, mainly due to caution.

Adult intussusception--a surgical dilemma.

BACKGROUND: Adult intussusception is rare. It is expected to be found in 1/30,000 of all hospital admissions, 1/1300 of all abdominal operations, 1/30-1/100 of all cases operated for intestinal obstruction and one case of adult intussusception for every 20 childhood ones. METHODS: The authors encountered 4 cases of adult intussusception. M:F ratio was 1:1. Mean age was 47years. Small bowel obstruction was documented in all. They were investigated by radiographs, ultrasound exam, barium studies, endoscopy and CT scan. RESULTS: All however were diagnosed at operation although some pre-operative suspicion was raised in one case. All had a laparotomy. Two were ileo-ileal and two ileo-caecal intussusceptions. One was chronic intussusceptions and three sub-acute. One intussusception had a malignancy (lymphoma) as a lead point. Two had a submucous lipoma at the apex. In an interesting case the suture knot from a recent small bowel anastomosis (2-3 weeks prior) was forming the lead point of the intussusception! The 2 ileo-ileal intussusceptions had segmental resection. Right hemicolectomy was done for the 2 ileo-caecal cases. "Target lesion" and leumen-within-leumen were the CT hallmarks on review. Retrospective barium enema review failed to show the intussusception. This may suggest the intussusception may have been recurrent or chronic. All 4 recovered uneventfully and remained well. One patient was referred for chemotherapy for intestinal lymphoma. CONCLUSION: Adult intussusception remains a rare cause of abdominal pain. The treatment almost always is surgical.