Traumatic extradural hematoma - role of non-surgical management and reasons for conversion.

BACKGROUND: To study the role of conservative management and various reasons for conversion to surgical intervention in traumatic extradural hematoma (EDH). SETTING: Government Medical College Jammu. MATERIALS AND METHODS: One hundred-twenty trauma patients diagnosed as extradural hematoma on CT scan were managed during 1 year period. OUTCOMES: Role of conservative management and various reasons for conversion to surgical intervention were studied. RESULTS: Out of these 120 patients admitted 67 were managed conservatively, 53 cases were operated upon. 31 were operated upon immediately and 22 were operated upon as delayed. There was 1 death and 4 had poor outcome in this group of patients. CONCLUSION: It is stressed that small size <10 ml, GCS >12 and locations other than temporal area are the criteria for conservative management. Twenty-two patients out of 89 were needed to be treated surgically during the course of conservative management due to neurodeterioration, increase in size of hematoma on CT, bradycardia, hemiparesis, pupillary abnormalities, delay in referral and only 18% had poor outcome. A strict vigilance is to be kept for clinical deterioration and various reasons mentioned above are to be kept in mind and patients should be subjected to repeated CT scan. Early diagnosis and immediate surgical intervention had good outcome, which shows the fruitful results of early diagnosis and intervention.

Left-sided gall bladder: Report of two cases.

Left-sided gall bladder without situs inversus viscerum is a rare albeit recognized clinical entity. We report our experience of two cases of left-sided gall bladder in two women aged 36 and 48 who underwent laparoscopic cholecystectomy for chronic calculous cholecystitis. Left-sided gall bladder may provide an unusual surprise to the surgeons during laparoscopy as routine pre-operative studies may not always detect the anomaly. Awareness of the unpredictable confluence of the cystic duct into the common bile duct (CBD) and selective use of intraoperative cholangiography aid in the safe laparoscopic management of this unusual entity.

Biliary ascariasis: surgical aspects.

Presentation and management of 204 patients with biliary ascariasis seen over a period of 5 years is reported from a highly endemic area of Kashmir. Ultrasonography is the single most useful means of diagnosis. Endoscopic retrograde cholangiopancreatography is extremely helpful. Most patients respond to conservative management and around one-fifth of all patients require surgery.

Surgical manifestations and management of ascariasis in Kashmir.

Amongst 876 cases suffering from ascariasis 662 cases were managed conservatively and 214 cases were treated by surgery. Surgical complications were found to be more common in males in the age group of 6-10 years. Principal clinical features included pain abdomen (99.54%), constipation (80.25%), vomiting (67.46%), abdominal distension (47.03%), palpable worm masses in abdomen (35.50%), visible peristalsis (27.63%), worms in vomitus (24.20%) and palpable worm clumps on rectal examination (20.09%). Principal clinical diagnosis were worm colics (48.74%), sub-acute intestinal obstruction (27.74%), acute intestinal obstruction (11.42%) and acute intestinal obstruction with strangulation (5.71%); rest of the cases included worm cholecystitis (2.63%), obstructive jaundice (1.71%), bile peritonitis (0.91%), intestinal perforation (0.68%) and acute appendicitis (0.46%). Surgical procedures performed were milking of worms (34.12%), resection anastomosis of small intestine (23.36%), enterotomy with removal of worms (16.36%), cholecystectomy with T-tube drainage (12.15%), cholecystectomy (8.41%), appendectomy (1.87%), resection anastomosis with excision of Meckel's diverticulum (1.40%), repair of intestinal perforation with peritoneal toilet (1.40%) and cholecystectomy with choledochoduodenostomy (0.93%). In surgically managed patients 35 cases died of septicaemia and in conservatively managed cases 3 died of encephalitis with an overall mortality of 4.34%.

Primary ascaridial perforations of small intestine and Meckel's diverticulum.

The clinical presentation of six cases with primary ascaridial perforations of the terminal ileum (4 cases) and Meckel's diverticulum (2 cases), without any associated underlying intestinal disease, is described. All the cases presented clinically as peritonitis and had worm masses in the intestinal lumen with maximal impaction in the terminal ileum. Ileal perforations were surgically closed in two layers after removal of the worms. Diverticulectomy after removal of the worms was performed for Meckelian diverticular perforations. Peritoneal toilet was done in all the cases. Pressure necrosis from the impacted worm masses probably resulted in these perforations.

Biliary ascariasis.

The clinical presentation of 12 cases with biliary ascariasis is reported. Ultrasonography was employed to demonstrate worms in the gallbladder and common bile duct preoperatively. Ten cases were operated upon and operative findings were compared to assess the accuracy of sonography in biliary ascariasis. Our results show that ultrasonography can be relied upon for the demonstration of biliary tract ascariasis.

Prepubic suprascrotal vasectomy.

PIP: Observations of 300 males vasectomized by a prepubic suprascrotal procedure are presented in this series from India. Acceptability of the scrotal method was less than for the prepubic. More discomfort was associated with the scrotal procedure. There were also more complications with the scrotal approach: 34 vs. no hematomas; 20 vs. 2 stitch abscess and wound infection; 12 vs. 1 persistent sinus; 8 vs. no orchitis; and 30 vs. 6 palpable granuloma. The procedure requires no sedation or general anaesthsia. An oblique incision about 1.5-2 cm long was made in skin just above and medial to each pubic tubercle with its center almost opposite the tubercle. The vas is palpated and using the tip of an index finger is caught and held out with the help of tissue holding forceps. Excision and ligation were carried out and hemostasis was ensured.^ieng