Is routine hospital visit after day case inguinal hernia surgery in children necessary?

BACKGROUND: To observe the prospects of day case inguinal hernia surgery in children without routine postoperative hospital visits. The aim was to access the advantages, acceptability and safety of this change in practice in low resource country like Nepal. METHODS: This was a cross-sectional study in a tertiary care general teaching hospital. Thirty children aged 6 months to 14 years who had elective day case Inguinal Hernia surgery from May 2011 to Oct 2011 were prospectively observed. Children with obstructed hernia, un-descended testis were excluded. Parents were counseled for omission of routine hospital visit after surgery. Main outcome measures were to observe unplanned hospital visit, reasons for visit, post-operative pain, wound infection and overall satisfaction of parents interviewed by telephone. Study was approved by institutional review committee. RESULTS: There were 28 boys and two girls. Average age was five years. Right Inguinal Hernia patients were 19 in number while 11 patients had left sided hernia. None of the children visited health facility for pain or wound problem. Two children were brought to outpatient because they were mistakenly given appointment slip. Mother noticed recurrence and brought one child to surgical outpatient. All 30 parents responded to telephone enquiry and were satisfied. CONCLUSIONS: Routine follow up visit after day care Inguinal Hernia surgery in children is not necessary. This practice is safe, economic and well accepted by children and parents.

Early feeding and discontinuation of intravenous fluid after laparoscopic cholecystectomy.

BACKGROUND: Common practice at most centers in the country is to continue intravenous (i.v.) fluid till morning round next day following laparoscopic cholecystectomy (LC), assess patient and gradually allow oral diet. However this seems unnecessary in view of fast recovery after minimal invasive LC. The aim of this study was to observe the prospects and assess the acceptability, safety and benefit of early oral feeding and discontinuing i.v. fluid after LC. METHODS: This cross-sectional observational study was carried out prospectively from Oct 1, 2009 to Sep 31, 2010 at Patan Hospital, a university teaching hospital. All elective LC patients were included. Oral liquid was introduced after four hours and i.v. fluid was stopped after six hr of LC. I.v. cannula was kept locked in situ. Vomiting, abdomen distension and reasons for continuation or resumption of i.v. fluids were recorded. RESULTS: During one year period 294 LC patients fulfilled study criteria. Average age was 40.8 years. Female accounted for 78.2%. Oral fluid was started in average of 5.5 hrs in 97%. In 3% (9/294) i.v. was continued. Postoperative nausea and vomiting was observed in 25.9% (76/294), of which 6.6% (5/76) required i.v.. There was no untoward affect after i.v. fluid was stopped. CONCLUSIONS: Early oral feeding and discontinuing of intravenous fluid in laparoscopic cholecystectomy is safe, economic and well accepted by patients, family and nursing staff in Patan hospital.

Clipless laparoscopic cholecystectomy--a prospective observational study.

In laparoscopic cholecystectomy (LC), cystic duct and artery are normally secured with titanium clips. Intracorporeal ligation is normally superior to extra corporeal knotting. Most studies report of separate and multiple ligations of cystic duct and artery, which are viewed as technically demanding and time consuming. Similarly the harmonic scalpel and 'LigaSure' are prohibitory expensive for resource limited country like Nepal. After several modifications, we observed the success of intracorporeal "single ligation of cystic artery and duct" with free silk tie. From Jul to Oct 2009, after a pilot study and several modifications ofintracorporeal ligation, we successfully used single ligation of cystic artery and duct (SLAD) with free silk 2/0 in symptomatic cholelithiasis patients.80 cases undergoing elective laparoscopic cholecystectomy. There were 80 patients, females 71.0% (n=57). Average age of patients was 39 yr (14-65). We had no bile leak or other complications related to ligature. The time taken for tie varied from 2 to 7 minutes (average 3 min). In 3 cases, a 5th port was made to grasp and ligate the bleeding vessels. There were 19 (25.0%) acute calculus cholecystitis, including mucocele, empyema, gangrenous cholecystitis. Two patients (2.0%) had inflammation of umbilical port which healed spontaneously. This technique of intracorporeal single ligation of cystic artery and duct (SLAD) in LC is simple, safe and economical. SLAD do not increase operative time as only single tie is used. This no clip laparoscopic cholecystectomy (NCLC) eliminates the clip related complications.

Need of improvement in timing of prophylactic antibiotic in elective surgery.

INTRODUCTION: Infections in surgery are major concern of morbidity, mortality, and costs. Timely antibiotic prophylaxis before incision ensures optimum concentration of AP in blood and tissues to prevent surgical site infections . However, proper timing of AP remains problematic as reported by various studies, though none so far from Nepal. Aim of this prospective observational study was to assess and address the issues for improvements in timing of AP. METHODS: The pattern of antibiotic prophylaxis were prospectively collected in respect to time of induction, and incision time were recorded on predesigned 'AP form'. The study included all the elective major cases who received AP of intravenous Cefazoline 1 g as per our existing protocol. The emergency surgeries and obstetric cases were excluded from the study. RESULTS: There were 125 cases of which 89% received AP before incision (63% within 5 minutes before incision), while 11% had AP after the incision and 1% within the recommended time period of 2 hour to 30 minutes before incision. CONCLUSIONS: Current practice of antibiotic prophylaxis (AP) needs improvement as per standard guidelines of AP within 2 hour to 30 before incision.