Is It Mandatory To Ligate Sac In Emergency Herniotomy In Paediatric Age Group? A Prospective Cohort.

BACKGROUND: Herniotomy is standard treatment for inguinal hernia in children. Paediatric surgeons remain divided on whether ligation of sac is mandatory. In our study, we left the sac open to see early recurrence. METHODS: This quasi=experimental study, done in emergency cases, was sequel to our previous study done in elective cases. It was carried out at surgical unit C of Ayub Hospital Complex, Abbottabad, from Jan 2016 to June 2020. Children from birth to 12 years of age were randomly divided into two groups. In group I (experimental), sacs were cut high up and left open during herniotomy while in group II (control), high ligation of hernia sac was done. Follow up was scheduled for day 10 and 1, 3 and 6 months. Patients were assessed for early recurrence and other complications. RESULTS: A total of 151 emergency inguinal herniotomies were done including 147 males (97.4%) and 4 females (2.6%). 136 sacs (90.1%) were ligated with vicryl 3/0 or 4/0 while 15 sacs (9.9%) were left open. We did not find early recurrence, but found 1 case of scrotal hematoma (n=1/15) (6.7%) and 1 case of scrotal oedema (n=1/15) (6.7%) in the experimental group. In control group, complications were similar with 7 cases of hematoma (n=7/136) (5.1%) and 9 cases of scrotal oedema (n=9/136) (6.6%). CONCLUSIONS: Complications are comparable in herniotomy with or without ligation of sac but ligation adds an extra step. Herniotomy without sac ligation in children is safe and preferable in emergency setup.

Role Of Choledochoduodenostomy Revisited In The Era Of Minimal Invasive Procedures.

BACKGROUND: Present era of endoscopic and laparoscopic approaches have revolutionized surgical management of Common Bile Duct (CBD) stones. Open procedures like Choledochoduodenostomy (CDD) have become a rarity but are not completely obsolete. It may be considered a relatively safe alternative when dealing with recurrent, too large or impacted stones, a failed ERCP, and CBD stricture with stones. The aim of this study was to establish safety, efficiency, cost effectiveness and easy availability of CDD in selected patients. METHODS: In this observational study, the outcome of 90 consecutive patients undergoing CDD between 1st January 1995 and 31st Dec, 2016 in surgical unit C, Ayub Medical Complex, Abbottabad was reviewed. Choledochoduodenostomy was offered to patients who refused or had a failed ERCP and when CBD size was more than 1cm. Common Bile Duct was anastomosed to Duodenum using standard technique. RESULTS: Medical records of 90 patients (age range 34-96 years) were reviewed; 5 were excluded and 85 were included in the study. Complication rate was 31.76% (n=27) including respiratory complications in 16.47% (n=14), wound infection in 10.6% (n=9), anastomotic leak in 2.35% (n=2) and Cholangitis in 1.18% (n=1) and Mortality in 1.18% (n=1). There was no evidence of Sump Syndrome. Total cost of procedure was Rs.50 as admission fee, which included daily provision of food and there were no room charges. CONCLUSIONS: Choledochoduodenostomy is a safe procedure, with fewer complications and significantly low cost. In case of ERCP failure, CDD is recommended.

NON-LIGATION OF INDIRECT HERNIAL SAC IN CHILDREN.

BACKGROUND: It is still a matter of debate whether to ligate the indirect hernial sac during herniotomy or leave it open. We designed this study to find out the complications associated with leaving the sac open. METHODS: This observational study was carried out at Surgical Unit C, Ayub Medical College, Abbottabad from January 2007 to December 2012. The hernial sacs of some children, aged 5 months to 12 years, undergoing herniotomies were left open, and these children were closely followed for development of complications especially early recurrence, due to this non-ligation of hernial sac. RESULTS: A total of 23 male children who underwent herniotomies for indirect inguinal hernia and undescended testes were included in the study. No early or late hernia recurrence was observed in these children although minor complications like wound infection and seroma were noted in 2 children. CONCLUSION: Excision of the hernia sac and leaving the stump open is safe and effective with no early recurrence.

CAUSES OF DELAYED PRESENTATION OF ACUTE APPENDICITIS AND ITS IMPACT ON MORBIDITY AND MORTALITY.

BACKGROUND: Acute appendicitis is one of the commonest abdominal emergencies and appendectomy. is one of the commonest emergency procedures performed all over the world. The study was done with an objective to evaluate the different causative factors for delayed presentation of appendicitis. METHODS: This cross-sectional study was carried out in the Surgical "C" unit, at Ayub Teaching Hospital, Abbottabad, Pakistan from 20th June 2013 to 19th June 2014. A total of 130 patients presented with appendicitis in OPDs or emergency department. Detailed history, general physical and systemic examination especially abdominal examination was done along with investigations. RESULTS: It was found that 23.08% of complicated appendicitis presentation is due to missed diagnosis by physicians, 30.77% is due to missed diagnosis by non-doctors, 23.08% is due to conservative management at DHQ hospitals by surgeons, and 23.08% presented late because of self-medication at home. CONCLUSION: All patients with pain Right iliac fossa, there should be suspected of appendicitis. Proper workup should be done to exclude it. If kept on conservative management then regular monitoring of vitals with laboratory investigations should be done.

Carcinoma of prostate in clinically benign enlarged gland.

BACKGROUND: Carcinoma of the prostate is one of the common tumours of old age in men. This cross sectional study was conducted to detect carcinoma of prostate in clinically benign enlarged gland and to evaluate the efficacy of Digital rectal Examination in detection of prostatic cancer in patients presented at Khyber Teaching Hospital, Peshawar from July 1998 to July 1999. METHODS: Patients presenting with lower urinary tract symptoms over the age of 50 years were evaluated on English version of International Prostate Symptoms Score (IPSS), clinically examined and post-voiding residual urine determined on abdominal sonography. The selection criteria were; Severe IPSS, absence of signs of malignancy on Digital Rectal Examination (DRE) and post-voiding residual urine more than 100 ml. Thus a total 100 patients were selected for further study. Four ml blood was taken to assess Prostate Specific Antigen (PSA) level pre-operatively. All these patients underwent either transvesical prostatectomy or transurethral resection of prostate (TURP) and enucleated prostatic tissues were sent to histopathology. RESULTS: Eighty-five percent patients had PSA level up to 10 etag/ml. PSA level of 15 (15%) patients were above 10n gm/ml out of which 13 (13%) patients were having PSA in range of 11-12 etag/ml and two (2%) had PSA level between 20-25 etag/ml. Histopathology report of 2% patients turned out as adenocarcinoma of the prostate. CONCLUSION: Out of 100 patients who were having clinically benign DRE findings, 2 turned out as Carcinoma of the prostate histologically.

Abdominal tuberculosis an experience at Ayub Teaching Hospital Abbottabad.

BACKGROUND: Abdominal tuberculosis is one of the common diseases in our country. This study was performed at Surgical A Unit Ayub Teaching Hospital Abbottabad from August 2006 to December 2007 to asses the clinical presentation of abdominal tuberculosis and its management. METHODS: All patients presenting to outpatient department with clinical feature suggestive of abdominal tuberculosis were included in the study. They were investigated. On the basis of clinical presentation, patients were divided in two groups. Patients with acute abdomen (peritonitis, intestinal obstruction) were prepared for laparotomy and operated upon. Required surgical procedure performed and tissue diagnosis was obtained. Patients with sub-acute obstruction, chronic pain abdomen and mass abdomen with out peritonism were managed conservatively. These patients were started on anti TB drugs on the basis of clinical and laboratory assessment. Empiric therapeutic trial was conducted for at least for 3 months with standard four drugs regimen. They were sent home on 9 month course of Anti TB drugs and were advised to come for follow up twice a month. On reassessment good clinical response was considered abdominal tuberculosis and anti TB continued with monthly follow up. In case of no response patients were operated. Required surgical intervention performed and tissue was taken to establish diagnosis. Detailed history, family history, examination findings, results of investigations, operative findings of the histologically proven cases of abdominal tuberculosis were recorded on a separate proforma and analyzed. RESULTS: Amongst 76 patients majority were females 52 (68.40%). Most of the patients were young with mean age of 34 years. Abdominal pain was the most common presentation 73 (96%) followed by fever and anorexia. Tender lower abdomen as found in 53 (70%) patients and mass abdomen was found in 35 (46%). Family history of TB was present in 20 (26%). Fifty three (70%) patients underwent laparotomy. Bands and adhesion was the most frequent finding on laparotomy. CONCLUSION: Abdominal TB is more common in female and abdominal pain fever and nausea are the most common presentations.