Laparoscopic Management of Double Gall Bladder: A Case Series.

Double gall bladder or duplication of the gall bladder is a rare congenital malformation. It poses a challenge to the surgeon and the radiologist, both in preoperative evaluation and intraoperative management. In the era of minimal invasive surgery, clear knowledge of extrahepatic biliary anatomical variations is very much essential. The operating surgeon should be very careful and overcautious in identifying such variations to prevent untoward biliary tract injury. In this series of two cases, we present the clinical peculiarities, preoperative diagnosis, and laparoscopic management of the duplicate gall bladder.

Negative pressure wound therapy in surgical practice: an Institutional experience from a tertiary centre of North India.

<b>Introduction:</b> Negative pressure wound therapy (NPWT) has been suggested as a gold standard for managing complex wounds and to reduce the time of healing and overall morbidity and mortality of the patient. </br></br> <b>Aim:</b> We have done a retrospective study to observe the outcome in patients managed with negative pressure wound therapy for varied etiologies. </br></br> <b> Methods:</b> Patients with complicated wounds including lower limb wounds post-debridement, upper limb wounds post-debridement, postoperative abdominal wound dehiscence, abdominal and chest abscess wounds post-debridement and amputation stumps, managed with negative pressure wound therapy were studied on the basis of wound outcome, total hospital stay, days of NPWT application and pressure and mode of NPWT. </br></br> <b>Results:</b> A total of 42 patients with complicated wounds were included in the study. Mean hospital stay was 16.2 days and mean NPWT application time was 8.29 days with NPWT being applied on average for 3.91 days post-procedure like debridement or amputation or after wound dehiscence in which debridement was not done. As many as 41.5% of wounds were closed with suturing, 48.8% healed by secondary intention and 9.8% were covered with split-thickness skin grafts. A significant observation was made for lower pressure being used for abdominal wound dehiscence (75 mmHg) compared to other wounds on limbs (mean 98.33 mmHg) (P < 0.001). Re-debridement after the 1st cycle of NPWT was needed in 40% of wounds managed with intermittent mode compared to 6.2% in continuous mode (P = 0.028). </br></br> <b>Conclusion:</b> NPWT can reduce and manage wound complications with improvement in the quality of life of patients when used at an appropriate time with knowledge of its mechanism and functionality.

Transverse Testicular Ectopia Presenting as Right Inguinal Hernia in an Adult Patient: An Incidental Finding During Robotic Transabdominal Preperitoneal Repair.

Transverse testicular ectopia (TTE) is a rare anomaly in which both the testes descend through a single inguinal canal and enter the same hemiscrotum. While TTE most commonly occurs in children, a few cases have been reported in adults as well. In this report, we present a case of TTE found accidentally during robotic exploration for right inguinal hernia with left cryptorchidism. Surgeons who frequently engage in the repair of inguinal hernia should be aware of the diagnostic and management options available to them when this condition is found unexpectedly during exploration.

A Giant Sacrococcygeal Teratoma in an Adult Male: A Case Report.

Sacrococcygeal teratoma (SCT) in adults is very rare with only a few cases reported in the literature. Its presentation in the adult is asymptomatic to a slow-growing cystic tumor with a 1-2% chance for malignant transformation and may attain a huge size causing pressure effect on pelvic and intra-abdominal organs. It can present unusually as a perianal abscess which needs to be evaluated radiologically. We present a giant, long-standing SCT in an adult male patient which presented as a tender fluctuating swelling with spontaneous rupture and whitish discharge in the perianal region masquerading as a perianal abscess. Diagnosis of our case was suspected by clinical examination, ultrasound, and magnetic resonance imaging of the pelvis and histopathology confirmed the diagnosis. It was excised en bloc with coccygectomy and primary wound closure and had a good postoperative recovery. Long-standing perianal swelling in an adult should raise the suspicion of SCT and should be kept in the differentials. The author prefers the posterior perineal approach for excision in Altman type 2, as it has convenient control over the mass during surgery with good cosmetic results as in our case, but the role of coccygectomy to prevent recurrence needs long-term data.

Staples Versus Sutures for Skin Closure in Standard Four Port Laparoscopic Cholecystectomy: A Prospective Cohort Study.

Introduction Many studies have been done comparing sutures versus skin staples in various wounds. To the author's knowledge, there is no study comparing these two in an laparoscopic cholecystectomy (LC) wound. Our study aims at comparing the clinical outcome of skin closure by monofilament nylon suture and stainless-steel skin stapler in standard four-port LC. The results of this study can help in developing guidelines for skin closure in LC. Objective To compare the clinical outcome of skin closure by monofilament nylon suture and stainless-steel skin stapler in standard four-port LC. Methods The study was conducted as a time-bound prospective cohort study on diagnosed patients of cholelithiasis admitted in a single unit of the Department of Surgery at All India Institute of Medical Sciences, Rishikesh, India from February 2018 to February 2019. The standard four-port LC was done by the same surgeon. After the completion of the surgery, port closure was done using absorbable sutures, and skin was closed by either 2.0 monofilament nylon suture (Ethilon, Ethicon, Scotland) or stainless-steel staples (Proximate plus MD, 35W, Ethicon, Scotland). The time taken for skin closure in both the groups was noted using a stopwatch. Each wound was assessed on the post of day (POD) 1 during discharge, on POD 10 during suture/stapler removal, and POD 30 by the operating surgeon for pain, wound infection, scar status using validated scales. Statistical analysis used The outcome measures were calculated as mean and standard deviation. Continuous variables were analyzed using a two-tailed student t-test. Results Out of 48 suture vs 45 stapler cases the average time for closure is 277.14 seconds in suture vs 77.2 seconds (p = 0.0001) in the stapler group. All other parameters studied were not statistically significant among the two cohorts. Conclusion We conclude that stapler requires minimum time for closure with no statistically significant difference in wound infection, post-op pain, pain during removal, and scar results are the same in both the groups.

Unusual Complication of Intercostal Tube Drainage of Penetrating Chest Injury: A Case Report.

Penetrating chest injuries can lead to diaphragmatic injuries, which are often missed easily on initial assessments, especially in patients with polytrauma. We are usually more focused and biased towards other evident, immediately life-threatening injuries. The fact that clinical and radiological findings are subtle, especially on chest X-rays, which is sometimes the only investigation performed, highlights the importance of using higher imaging modalities in stable patients and that a clinician should be suspicious of this entity with the corresponding history. Intervening in such patients with the placement of intercostal drain can contribute to morbidity and mortality, as in our case, by causing inadvertent injury to the herniating structures. The case report briefs the same and emphasizes that thoracic injuries, especially penetrating ones, should ring a bell and should be carefully investigated further before the intervention.

Gastric Perforation Secondary to Fungal Gastritis in an Immuno-Competent Adult.

Gastrointestinal (GI) tract perforation is a surgical emergency. The epidemiology and etiology of perforation vary considerably across geography. Lower GI tract perforations in the elderly predominate in the West compared to upper GI perforations in the younger population in the tropics. Fungi and viruses have been reported to cause GI perforations in immuno-compromised individuals but it is rare in immuno-competent individuals. We report a very rare case of gastric perforation secondary to fungal gastritis in an immuno-competent 35-year-old female who presented with features of peritonitis. At emergency laparotomy, gastric perforation was found which was repaired by the Cellan-Jones method. Perforation edge biopsy findings were consistent with fungal etiology. She responded well to Antifungal therapy. We conclude that fungal etiology can be considered in patients with gastric perforation without any history of peptic ulcer disease (PUD) or use of oral non-steroidal anti-inflammatory drugs.

Role of hospital anxiety and depression on the healing of chronic leg ulcer: A prospective study.

A chronic leg ulcer is a debilitating illness, owing to the local condition of the wound and a decrease in physical activity and productivity, resulting in anxiety and depression among patients. The study aimed to find any association of anxiety and depression in the healing of chronic wounds. A total of 125 patients with chronic leg ulcers were enrolled in the study. HADS questionnaire assessment followed the local wound examination in all patients. A follow-up assessment of the ulcer was done after appropriate local treatment, and data analysed with the HADS scale. In the present study, the ROC curve showed a cutoff value of 14 for the HADS score in predicting ulcer status (non-healing vs healed) after 30 days. A total of 54.4% (68) patients had a HADS score ≥ 14 and 39% (49) were true positive for the non-healing wound at a 1-month follow-up. This study revealed a sensitivity and specificity of 83.1% and 71.2%, respectively (P-value <.001), and diagnostic accuracy of 76.8%, for HADS score > 14 in the detection of non-healing ulcers. Chronic leg ulcers should be subjected to HADS assessment and if found significant corrective measures must be instituted for improving wound healing.