Port extériorisation appendectomy-our experience.

BACKGROUND: Laparoscopic appendectomy is conventionally performed using 3 ports, with division of appendicular base and artery using staples/endoloops/clips. Paucity of surgical laparoscope and laparoscopic disposables necessitated adoption of laparoscopic technique obviating the need for the above. We document our experience with the port exteriorisation appendectomy performed predominantly using two ports. METHODS: Between July 2008 and April 2009, 65 appendectomies were performed at a zonal hospital, of which 26 were performed using the contemplated technique. Technical challenges, conversions, operative time, complications, postoperative recovery, and cosmesis were analysed. RESULTS: Twenty-six patients (13 males and 13 females), with a mean age of 22.88 ± 11.94 years, underwent port exteriorisation appendectomy. The median operative time was 20 minutes. Two cases (7.7%) needed conversion to open appendectomy. Dense adhesions necessitated addition of a working instrument/port in two cases (7.7%). Postoperative pain was < 25 by verbal response score. Visceral component predominated on the operative day, which got confined to port sites subsequently. One patient (3.85%) developed surgical site infection. Friable, gangrenous, short fibrosed appendix on a fixed caecum and very thick abdominal wall were its limitations. Postoperative recovery and cosmesis were excellent. CONCLUSION: Port exteriorisation appendectomy proves simple, safe, economical, and efficacious, when conditions favour its performance. However, difficult appendices warrant conversion to three ports technique or to open procedure.

Evidence based switch to perianal block for ano-rectal surgeries.

BACKGROUND: Evidence suggests that switch from spinal/general anaesthesia (SA/GA) to perianal block (PAB) may prove advantageous for proctologic surgeries. This study evaluates the practicability of this evidence based switch. METHODS: Feasibility and efficacy of PAB for proctologic surgeries was prospectively evaluated on 100 consecutive patients over 11 months. Thirty ml of local anesthetic (0.25% bupivacaine+1% lignocaine with adrenaline) was infiltrated into the anal sphincter and perianal skin, under sedation, for achieving PAB. Time taken for onset of anesthesia; success/failure of block; conversion rate to GA; operative ease; operative time; post operative recovery; duration of analgesia; post operative pain based on verbal response score (VRS; scale: 0-100); and complications were analyzed. RESULTS: 54 open haemorrhoidectomies; 27 fistulectomies and 19 lateral sphincterotomies were performed. Average of 3 min (range 2-5 min) was needed for onset. Block was successful in 97% of cases. 3% needed conversion to GA. Good anesthesia and sphincter relaxation ensured operative ease. Median operative time was 20 min (range 10-35 min). Analgesia lasted a median of 5 hours (range 3-10 hrs). Subsequent pain ranged between VRS 10-40, tapering off, along with analgesic requirement, over a week. Trivial injection site hematoma (1%) and reactionary bleeding (1%) were the complications observed. Post operative recovery was uniformly smooth in all patients. CONCLUSIONS: Perianal block is a safe, feasible, reliable, and reproducible mode of anesthesia for ano-rectal surgeries. Its evident efficacy justifies its adoption as anesthesia of choice.

Management of necrotizing myositis in a field hospital: a case report.

Necrotizing myositis is a rare and fatal disease of skeletal muscles caused by group A beta hemolytic streptococci (GABHS). Its early detection by advanced imaging forms the basis of current management strategy. Paucity of advanced imaging in field/rural hospitals necessitates adoption of management strategy excluding imaging as its basis. Such a protocol, based on our experience and literature, constitutes: i. Prompt recognition of the clinical triad: disproportionate pain; precipitous course; and early loss of power- in a swollen limb with/without preceding trauma. ii. Support of clinical suspicion by 2 ubiquitous laboratory tests: gram staining- of exudates from bullae/muscles to indicate GABHS infection; and CPK estimation- to indicate myonecrosis. iii. Replacement of empirical antibiotics with high intravenous doses of sodium penicillin and clindamycin. iv. Exploratory fasciotomy: to confirm myonecrosis without suppuration- its hallmark. v. Emergent radical debridement. vi. Primary closure with viable flaps - unconventional, if need be.