Initial Experience of Robot-Assisted Surgeries.

OBJECTIVE: To present initial experience with the first 100 cases of robotic-assisted surgery by the Department of General Surgery. STUDY DESIGN: Descriptive study. Place and Duration of the Study: Department of Surgery, National Hospital and Medical Centre, Lahore, Pakistan, from May 2022 to August 2023. METHODOLOGY: Demographic and postoperative details of the first 100 patients to undergo robotic-assisted surgery by the Department of General Surgery were reviewed. Prospective data were collected from the hospital information database as well as the CMR database. The data collected in the hospital database included the patients' age, diagnoses, genders, complications during hospital stay as well as 90-day readmission, morbidity, and mortality. Data collected by CMR via Versius robotic surgery console or internal databases included operative minutes using the console. RESULTS: The average age of patients undergoing robotic surgery was 44.26 ± 14.08 years. Cholecystectomy (78%) was the most commonly performed robotic-assisted procedure. Only one patient had blood loss of more than 100ml. There was no postoperative complication, readmission or mortality during the study period. CONCLUSION: With proper patient selection, robotic-assisted surgery is safe and feasible even in low- middle-income countries (LMICs). KEY WORDS: Robotic-assisted surgery, Pakistan, Initial experience, Outcomes, Versius.

Comparison of Laparoscopic Intraperitoneal Onlay Mesh (IPOM) Hernioplasty With Laparoscopic IPOM-Plus: Our Initial Experience in Pakistan.

Objectives Laparoscopic intraperitoneal onlay mesh hernioplasty (IPOM) for ventral hernias has been used for a long time. However, there have been some issues associated with it, thereby leading to the introduction of a new technique that involves laparoscopic closure of the fascial defect with suture followed by intraperitoneal onlay mesh placement (IPOM-Plus). We carried out this study to compare the outcome of laparoscopic IPOM with fascial defect closure versus without defect closure in midline ventral hernia repair in terms of recurrence. Methodology This comparative study was carried out in the Department of Surgery, Services Hospital, Lahore, from October 16, 2020, to April 15, 2022. A total of 84 patients of both genders, aged between 18 and 70 years, presenting with midline ventral hernia were included in the study. Patients with recurrent hernia, unstable cardiopulmonary conditions, neurological or psychiatric diseases, chronic renal disease, congestive cardiac failure, and chronic obstructive pulmonary disease (COPD) were excluded from the study. Patients were assigned to two groups. Group 1 underwent IPOM with the closure of the defect, and Group 2 underwent IPOM without the closure of the defect. Patients were observed for immediate postoperative complications. Patients were monitored for one year to assess recurrence through clinical evaluation and ultrasonography. Results In this study, seroma formation was found in 3 (7.14%) patients for laparoscopic IPOM with fascial defect closure and 10 (23.81%) in those undergoing laparoscopic IPOM without defect closure (P-value = 0.035). Recurrence was identified in 2 (4.76%) patients undergoing laparoscopic IPOM with fascial defect closure and 9 (21.43%) in those undergoing laparoscopic IPOM without defect closure (P-value = 0.024). Conclusions This study concluded that the frequency of recurrence is less after laparoscopic IPOM with fascial defect closure in midline ventral hernia repair than after laparoscopic IPOM without fascial defect closure.

Laparoscopic Gastro-jejunostomy: An Ideal Solution to the Problem of Gastric Outlet Obstruction Post-corrosive Intake.

OBJECTIVE: To evaluate the outcome of Laparoscopic Gastro-jejunostomy in patients presenting with Gastric Outlet obstruction secondary to Corrosive intake at the Services Hospital. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Surgery, Services Hospital, Lahore, Pakistan, from June 2013 to June 2021. METHODOLOGY: Data was gathered from the patients who presented with gastric outlet obstruction with a pre-hospitalised history of corrosive intake. Consenting patients subsequently underwent laparoscopic gastro-jejunostomy and were followed up post-operatively at a 1-week time-point and 4-week time-point to monitor progress. Studied variables included duration of surgery, duration of hospital stay, complications, and mortality at the 1st and 4th weeks. RESULTS: A total of 30 patients participated in the study including 27 (90%) females and 3 (10%) males. The mean age was 27.2 ± 4.07 years. The mean duration of hospital stay was 9.3 ± 3.2 days. Complications were seen in 3 patients (10%) with 1 death (3.33%). CONCLUSION: Laparoscopic gastro-jejunostomy appears to be safe and effective in corrosive intake patients presenting with gastric outlet obstruction. KEY WORDS: Corrosive Intake, Gastric outlet obstruction, Laparoscopic, Gastrojejunostomy.

Outcome of Laparoscopic Repair for Perforated Peptic Ulcers in a Resource-Limited Setting.

Background Perforation of peptic ulcers is a common cause of emergency surgery and has significant morbidity and mortality. The use and range of laparoscopic surgery have greatly increased over the past three decades. Laparoscopic approach is an option for perforated peptic ulcers because of the simple nature of the intervention. The aim of this study was to evaluate the outcome of laparoscopic approach for peptic ulcer repair in emergency setting by means of operative time, post-operative pain, mean hospital stay, and post-operative complications. Methods In this study, we enrolled patients presenting with perforated peptic ulcers in the emergency department of a tertiary care hospital in Lahore, Pakistan. Approval from the hospital ethical committee and informed consent were taken from all patients. After resuscitation, the patient underwent laparoscopic repair of perforation. Post-operative course of patients was monitored. Duration of surgery, post-operative pain, length of hospital stay, and post-operative complications were noted for all patients. Results Between December 2018 and December 2021, 31 patients with perforated peptic ulcers underwent laparoscopic repair at our hospital. Mean age of patients was 37.25 ± 7.80 years. Most of the patients were male (70.76%). The mean operation time was 109.35 ± 17.02 minutes for laparoscopic repair. Mean duration of hospital stay was 5.10 ± 0.87 days. Mean post-operative pain was 3.55 ± 0.85 assessed using the Visual Analogue Scale. There were no mortalities during the 30-day post-operative window. Conclusion With proper patient selection, laparoscopic surgery offers better results as compared to open surgery in patients undergoing emergency surgery for perforated peptic ulcers.

Efficacy of Cross-Linked Hyaluronic Acid Gel for the Reduction of Post-operative Obstructive Symptoms Due to Adhesions.

Background Adhesions occur frequently after surgery. A number of methods are being employed for reducing post-operative adhesions. The purpose of this study was to determine the efficacy of hyaluronic acid gel in the reduction of post-operative bowel obstruction symptoms in patients undergoing emergency laparotomy due to small bowel perforation and presenting with peritonitis. Methods In this experimental study, 78 patients were evaluated. All had presented to the emergency department with peritonitis secondary to small bowel perforation. Exploratory laparotomy was performed and after thorough lavage, a loop stoma was formed on the right side of the abdomen with an injection of hyaluronic acid gel injected into the abdominal cavity before the closure of the abdomen. Postoperative obstructive symptoms at one, three, and six months were evaluated. All patients underwent stoma reversal at three months. Results Obstructive bowel symptoms were seen in 18 patients (23.07%) patients. The cumulative incidence of obstructive symptoms at three months was only 8.97% but after the second intervention without protective gel, it increased to 23.07% at six months. Conclusions Cross-linked hyaluronic acid gel was effective in the reduction of post-operative bowel obstructive symptoms due to adhesions in patients who had presented with peritonitis due to small bowel perforation and had undergone exploratory laparotomy with stoma formation.

Outcomes in High Perianal Fistula Repair Using Video-Assisted Anal Fistula Treatment Compared With Seton Use: A Randomized Controlled Trial.

Background Anal fistula, or fistula-in-ano, is a chronic abnormal communication between the epithelialized surface of the anal canal and the perianal skin. Video-assisted anal fistula treatment (VAAFT) is a novel, minimally invasive, and sphincter-saving alternative to traditional seton use. This study aimed to determine the short-term and long-term outcomes of VAAFT compared with seton treatment. Material and methods This randomized control trial was conducted at the Department of Surgery, Services Hospital, Lahore, from August 2014 to July 2020. Patients were randomly assigned to either the VAAFT group or the seton group, and postoperative outcomes were assessed for up to three years. Results The study included 80 patients (64 men and 16 women) with a mean age of 39.1 ± 11.2 years. The most common type of fistula was a transsphincteric fistula (n=36, 45%). The mean duration of surgery was significantly longer in the VAAFT group (78.6 minutes) compared with the seton group (36.97 minutes; p=0.000). The mean pain score was significantly higher in the VAAFT group (4.22) compared to the seton group (2.82, p=0.000). The mean time to return to work was shorter in the VAAFT group (7.4 days) than in the seton group (9.2 days, p=0.000). The mean healing time was significantly shorter for patients treated with VAAFT (5.75 weeks) than for those treated with a seton (9.7 weeks; p=0.000). Fistula recurrence after one, two, or three years was not significantly different between groups, and neither group had incidences of anal incontinence. Conclusions VAAFT is associated with earlier healing time and earlier return to work than the traditional seton technique, with no significant difference in fistula recurrence. VAAFT is minimally invasive and, when used in patients where indicated, allows for a prompter return to routine life for the patients, which is an optimal outcome for both patients and physicians.

Cardiopulmonary resuscitation: Knowledge and Attitude of doctors from Lahore.

OBJECTIVE: The objective of study was to assess the knowledge and attitude of doctors from Lahore regarding CPR as per American Heart Association (AHA) guidelines. METHODS: The researchers visited various hospitals and filled e-questionnaires by interviewing respondents.The study was conducted at Jinnah Hospital Lahore, Mayo Hospital Lahore, Punjab Institute of Cardiology Lahore, Sir Ganga Ram Hospital Lahore, Services Hospital Lahore and Mid City Hospital. Data were analyzed using statistical package for social sciences (SPSS) 23 version. Knowledge was assessed based on the scores, with those scoring 10 or more being considered to have good knowledge while those having score less than 10 were considered to have poor knowledge. P values < 0.05 were considered statistically significant. RESULTS: Out of 792 participants, 68 refused to take part in the study. The total respondents were 724 with the response rate of 91%. The knowledge regarding cardiopulmonary resuscitation of 601(83%) respondents was poor with only 123(17%) doctors having good knowledge. The doctors who received formal CPR training had better knowledge (20.17%) than the doctors who didn't get any training regarding CPR (4.69%). Anesthesiologists scored better among all specialties. The overall attitude of the doctors towards CPR was positive with 93.8% of the respondents willing to do CPR. CONCLUSION: The overall knowledge of the doctors regarding CPR is not satisfactory. A practical and functional approach is needed to improve this situation. However, the attitude of the doctors towards CPR is positive.

Role of Chewing Gum in Reducing Postoperative Ileus after Reversal of Ileostomy: A Randomized Controlled Trial.

BACKGROUND: Postoperative ileus is one of the most prevalent and troublesome problems after any elective or emergency laparotomy. Gum chewing has emerged as a new and simple modality for decreasing postoperative ileus. The aim of this study was to determine the effectiveness of chewing gum in reducing postoperative ileus in terms of passage of flatus and total length of hospital stay. PATIENTS AND METHODS: This single-blinded, randomized clinical trial was conducted in department of surgery, Services Hospital Lahore, between November 2013 and November 2015. The patients were divided into two groups: chewing gum (Group A) and no chewing gum (Group B). Starting 6 h after the operation, Group A patients were asked to chew gum for 30 min every 8 h; bowel sounds, passage of flatus and total length of hospital stay were noted. Outcome measures such as passage of flatus and total length of hospital stay in patients undergoing reversal of ileostomy were compared using t-test. RESULTS: Mean age of the patients in Group A was 26.12 (± 7.1) years and in Group B was 28.80 (± 10.5) years. There were 25 males (50%) and 25 females (50%) in Group A. In Group B, there were 29 males (58%) and 21 females (42%). Mean BMI in Group A was 23.5 (± 5.3), and in Group B was 21.4 (± 4.6). The mean time to pass flatus was noted to be significantly shorter, 18.36 (± 8.43) hours, in the chewing group (Group A), whereas in the no chewing gum group (Group B), it was 41.16 (± 6.14) hours (p value < 0.001). The mean length of hospital stay was significantly shorter 84 (± 8.3) hours in the chewing gum group (Group A) as compared to 107.04 (± 6.4) hours in the no chewing gum group (Group B) (p value 0.000). CONCLUSION: It is concluded that postoperative chewing of gum after the reversal of ileostomy is accompanied with a significantly shorter time to passage of flatus and shorter length of hospital stay.

Whipple Procedure: A Five-Year Clinical Experience in Tertiary Care Center.

INTRODUCTION: Whipple procedure is one of the major surgeries performed in tertiary care centers. Once considered a high mortality procedure is now being practicing with mortality declining to less than 5%. This study describes our five-year experience of the Whipple procedure in terms of preoperative, operative, and postoperative parameters of patients undergoing surgery in a local tertiary care setting. MATERIAL AND METHODS: This was a non-randomized interventional study that was conducted at the Surgical Department of Services Hospital Lahore from January 2014 to December 2018. A total of 57 Whipple procedures were performed during this period. Demographic data, presenting symptoms, physical signs, past medical history, preoperative stenting details, intra-operative duration of surgery, postoperative course and complications, pathology, and causes of postoperative death were collected on a pre-designed questionnaire. Data were entered and analyzed by using SPSS 22 (IBM Corp., Armonk, USA). RESULTS: Out of 57 patients, 19 were females and 38 were males. The mean age of patients was 53±05 years. The most common presenting symptom was jaundice 39 (68.4%), followed by abdominal pain 32 (56.1%). The mean size of the tumor on CT-scan was 2.8±1.4 cm, the mean operation time was 315±38.3 min, mean blood loss during surgery was 500±130 ml, and mean hospital stay was 10±6 days. The major postoperative complication was the pancreatic fistula (12%). Twenty-one out of 39 patients presented with jaundice had undergone preoperative biliary stenting by endoscopic retrograde biliary stenting. The most common histological diagnosis was adenocarcinoma of pancreas 19 (33.3%). Out of 57 patients, nine (15.8%) patients expired in the first 30 days and the most frequent cause of mortality was septic shock. CONCLUSION: In this study, the most common presentation of patients undergoing Whipple procedure was obstructive jaundice, the most frequent operative complication was pancreatic fistula, and the most prevalent histopathology was carcinoma of the pancreas. Perioperative parameters such as mean operative time, mean blood loss during surgery, and mean length of hospital stay were comparable with other studies. However, mortality in this study was slightly higher. It can be concluded that with meticulous surgical technique, securing hemostasis strictly and standard critical care postoperatively can decrease morbidity and mortality after the Whipple procedure.

Effect of COVID-19 on the Working of a Tertiary Care Hospital.

OBJECTIVE:  To evaluate the effect of COVID-19 on the working of a tertiary care hospital. STUDY DESIGN: Audit study. PLACE AND DURATION OF STUDY:  Services Hospital, Lahore from 1st March to 30th June 2020. METHODOLOGY:  We calculated and compared various parameters of hospital working. Two time periods were selected. The study period was defined as the time after first confirmed case of COVID-19 in Pakistan. The control period was defined as one year prior to the first case being reported, taken from 1st March 2019 to 29th February, 2020. The parameters we studied included were number of number of hospital admissions, emergency patients, OPD patients, major surgeries, total surgeries, radiological investigations done, laboratory investigations done, births and mortalities. All parameters were calculated by taking monthly average during each time period and then compared. RESULTS:   A decrease in almost all parameters was seen when the cases of the two time periods were compared. There was a decrease in the average hospital admission by 51%, while the patients seen in OPD fell by almost 60%. A slight decrease of 25% was seen in the cases presenting to the emergency. The most marked decrease was in the elective surgeries, which was 66% closely followed by average monthly mortality which decreased by 64%. Average monthly minor surgeries and births were decreased by 33% and 35%, respectively. CONCLUSION:  There had been a decrease in the number of patients presenting to the hospital across the board with the most marked increase being in elective surgeries. Key Words: COVID-19, Hospital working, Patient load, Elective surgery.

Neurectomy versus Nerve Sparing in Open Inguinal Hernia Repair: A Randomised Controlled Trial.

OBJECTIVE:  To determine the effect of neurectomy in reducing the frequency of chronic inguinodynia after mesh hernioplasty in open inguinal hernia repair. STUDY DESIGN: Single blind randomised controlled-trial. PLACE AND DURATION OF STUDY: Surgical Unit-I, Department of General Surgery, Services Hospital, Lahore, Pakistan from September 2018 to September 2019. METHODOLOGY: All male patients undergoing open groin hernia surgery were included in the study. A total of 100 patients were randomly categorised into group A (neurectomy group) and group B (nerve sparing group). Patients were followed up for three months for the development of chronic inguinodynia. Signifiance was determined at p <0.05 using Chi-square and Fisher's exact tests. RESULTS: Out of 100 patients, 50 patients were enrolled in group A, while 50 were enrolled in group B. Mean age of patients was 42.1 ± 17.5 years. The median (IQR) acute pain score in neurectomy group was 3.0 (2.0-4.0), while median (IQR) acute pain score was 4.0 (3.0-6.0) in nerve sparing group with statistically significant difference (z = -3.256, p = 0.001). The frequency of chronic inguinodynia was significantly less in group A compared to group B [3 (6%) vs. 13 (26%), p = 0.012]. CONCLUSION: Excision of ilioinguinal and iliohypogastric nerve in inguinal mesh hernioplasty reduces the frequency of chronic inguinodynia. Ilioinguinal neurectomy may be practised routinely in patients undergoing Lichtenstein mesh hernioplasty.   Key Words: Inguinal neurectomy, Inguinal hernia, Chronic inguinodynia, Lichtenstein mesh hernioplasty.

Setting up a COVID-19 care facility at a prison: An experience from Pakistan.

Since its emergence from Wuhan at the end of last year, the novel coronavirus has spread to almost every country of the earth posing a significant challenge to healthcare systems everywhere. This article presents a practical model adopted in light of the WHO guidelines which was used by our team to set up the facility and care for the 69 COVID-19 prisoners within the prison itself. In addition to the challenges posed by the COVID-19 the healthcare team also had to overcome the challenge of the unique nature of the setup. The purpose of this article is to describe our response to help providers tasked with caring for prisoners especially in lower socio-economic countries.

Acute Presentation and Management of Abdominal Tuberculosis.

OBJECTIVE: To study the clinicopatholgical profile and outcomes of surgical management of abdominal tuberculosis (ATB) Study Design: Cross-sectional observational study. PLACE AND DURATION OF STUDY: Department of Surgery, Services Hospital, Lahore, Pakistan, from May 2008 to April 2018. METHODOLOGY: All patients who underwent emergency laparotomy during the study period due to abdominal tuberculosis, and consented to participate in the study were included. Demographic variables and type of surgical procedure performed were recorded. Patients were followed-up for histopathology, recurrence, or any anti-tuberculous therapy related complications at 1, 4, 6, and 12 months. Data were analysed using SPSS version 21. RESULTS: Out of the 80 patients, 36 were males and 44 were females. The median age was 23.5 years (range = 11-90 years). Mean weight of the patients was 48.7 ±12.2 kg. Commonest presenting symptom was abdominal pain 72 (90%). On exploration, ileocecal region was most commonly involved segment 68 (85%). Stoma formation was the most common surgical procedure performed in 59 (73.8%) patients. Complications and mortality rate were 48 (60%) and 7 (8.7%), respectively. A significant relationship of complications was found with prolonged hospital stay (p <0.001). CONCLUSION: Abdominal tuberculosis is a major public health concern. Vague symptoms lead to diagnostic delay so patients present late with intestinal obstruction. Ileocecal tuberculosis is the most common site of involvement.

Transmigration and spontaneous passage of a gossypiboma documented on contrast study.

Gossypiboma or textiloma is a rare but very unfortunate complication of surgery. It refers to a retained foreign body usually forgotten within the abdominal cavity at the end of an operation. It may be a surgical sponge, gauze pad or other form of textile. We present the case of a middle aged lady who following cholecystectomy had a forgotten gauze which underwent transmural migration and was later expelled via the rectum demonstrated by radiological studies.

Stone in the distal jejunum presenting as small bowel obstruction: A case report.

INTRODUCTION: Gallstone ileus is a rare presentation of cholelithiasis accounting for around 4% of cases of small bowel obstruction under 65 years of age but rises to 25% in those more than 65 years of age. Most gall stones, if impact in the bowel, are seen to lodge at the ileocecal valve as this is the most narrow part of the bowel. PRESENTATION OF CASE: We present a case of small intestinal obstruction because of a gallstone stuck in the distal jejunum. Patient was explored and one-stage surgery was done i.e. cholecystectomy, enterotomy and stone retrieval, and fistula repair. Our patient had uneventful postoperative recovery and was discharged after a week. DISCUSSION: Gallstone ileus is a rare entity presenting a significant diagnostic challenge to surgeons due to lack of specific findings. Moreover, the surgical management options to be adopted are diverse and depend upon the condition of the patient. Stable patients can be managed with two-stage procedures i.e. enterotomy and stone retrieval earlier with cholecystectomy in an elective setting. Our patient was managed with one-stage procedure i.e. cholecystectomy was done in the same setting and our patient did well. CONCLUSION: Gallstone ileus needs to be kept in the differential diagnosis list of intestinal obstruction in middle aged patients even in the absence of history of gallstones as this may be the first presentation of gallstone disease.

Occult Pneumothorax: What Do We Need to Do?

Occult pneumothorax is a condition in which a patient's clinical examination and chest radiograph are normal; but there is pneumothorax on computed tomography (CT) scan. We here describe two cases of trauma whose initial survey and chest X-ray showed normal lung markings bilaterally; but CT scan done subsequently, showed pneumothorax which was managed by chest intubation. There is still an ongoing debate about the management of occult pneumothorax. Simple observation is recommended for an asymptomatic pneumothorax. However, chest intubation is recommended for patients undergoing a surgery or mechanical ventilation due to the fear of converting a close pneumothorax into a tension pneumothorax.

Tuberculosis of Gallbladder Mimicking Carcinoma.

Gallbladder is a rare site of tuberculous involvement. Less than 150 cases have been documented in the last 150 years. It may mimic malignancy. Histopathology examination is the mainstay of diagnosis. Gallstones and obstruction appear to be pre-disposing factors. Treatment involves localizing other sites and starting patient on anti-tuberculosis therapy. The report describes this rare site of involvement in an adult Pakistani man.

A case report of pneumo-retro-peritoneum: An unusual presentation of ischio-rectal abscess.

INTRODUCTION: Ano-rectal abscesses are common. They however usually do not present with abdominal symptoms. CT although useful is not routinely carried out. Finding of Pneumo-retro-peritoneum with ischio-rectal abscess is rare. CASE PRESENTATION: We present the case of a diabetic gentleman who presented with abdominal pain and distension and was found to have ischio-rectal abscess on perianal examination. Although initially suspected to have acute abdomen due to perforated viscus, CT scan revealed pneumo-retro-peritoneum which appeared to arise due to the abscess. Patient underwent incision and drainage of the abscess followed by serial debridement. He made a complete recovery. CONCLUSION: Abdominal symptoms are rare in ischio-rectal abscess, but they must be kept in mind. Proper diagnosis may avoid a negative laparotomy.

Laparoscopic Sleeve Gastrectomy - A Prospective Follow Up Of 30 Patients.

BACKGROUND: Morbid obesity has become a surgically treatable problem. Laparoscopic sleeve gastrectomy is becoming a popular choice both for surgeons and patients due to effectiveness and low complication rates. METHODS: It was a prospective case series spanning over 6 years. Patient enrolment started from January 2009 and data collection completed in January 2015. Patient with BMI (weight in kilogram/height in meter square) of more than 35 were included in the study. Follow up was at 2 weeks, 1 month, 6 months and 12 months. Success was defined as 25% of excess weight loss at 1 year. Paired t-test was used as a test of significance. RESULTS: A total of 34 patients were included in the study over a 6-year period, 3 were lost to follow up and one patient died of cardiac arrest. Data of 30 patients is considered for final analysis. Mean age was 39.5±10 years, while mean BMI 45.8±6.3 (range 37.1-62.2). Average weight of the patients preoperatively was 129.9±20.8 kg while mean excess weight was 70.3±20.8 kg. Average weight loss at two weeks was 8.9±2.9 kg, at one month 14.7±4.6 kg, at 6 months 25.0±7.6 kg and at twelve months was 31.4±6.8 kg. Mean percentage of excess weight loss after 2 weeks was 13.5±4.6%, at one month 22.0±6.1%, at six months 37.6±12.0% and at twelve months 47.3±10.1%. CONCLUSIONS: Laparoscopic sleeve gastrectomy is an effective weight loss surgery with minimal complications. On average weight loss of about 30 kg at one year was achieved which equals to almost half of excess body weight.