A prospective randomized double-blind study of pain control by topical calcium channel blockers versus placebo after Milligan-Morgan hemorrhoidectomy.

INTRODUCTION: Post-hemorrhoidectomy pain is significantly associated with a hypertonicity of the internal anal sphincter. We evaluated the effects of topical diltiazem, a calcium channel blocker, in reducing pain after hemorrhoidectomy. Purpose of our study was to determine difference in extent of pain control by application of topical calcium channel blocker (diltiazem 2%) versus placebo ointment. METHODS: This was a prospective randomized double-blind clinical study conducted at Sawai Man Singh Hospital, Jaipur, from May 2016 to May 2017. Sixty patients, who had undergone hemorrhoid, were randomly assigned to receive 2% diltiazem ointment (n = 30) or a placebo ointment (n = 30) postoperatively. Ointments were applied to the perianal region three times daily for 7 days. Pain scores were recorded using visual analog scale at 6, 24, and 48 h and seventh day postoperatively and number of analgesic doses consumed by patients in the first 3 days. RESULTS: Patients using the diltiazem ointment had significantly less pain and greater benefit than those in the placebo group throughout the first postoperative week (p < 0.001) except for reading at 6 h. Also, there was significantly less number of analgesic doses consumed in the diltiazem group compared to the placebo group. CONCLUSION: Perianal application of 2% diltiazem ointment after hemorrhoidectomy significantly reduces postoperative pain and is perceived as beneficial.

Comparative study of free omental sheet graft and other operative procedures of enteric perforation repair.

BACKGROUND/AIM: In developing countries, enteric perforation due to typhoid continues to have very high morbidity and mortality rates irrespective of the type of operative procedure performed. The aim of the present study was to evaluate the effectiveness of a free omental sheet graft in perforated typhoid enteritis, in comparison to other methods of enteric perforation repair in terms of decreased morbidity, mortality and cost-effectiveness. METHOD: A non-randomized study of 114 patients with enteric perforations was carried out over a period of 4.5 years. The study was divided in two groups; group I includes 38 cases in which a free omental sheet graft was used in typhoid enteritis with perforation and group II includes 76 cases in which other surgical procedures for enteric perforation repair were used. The outcomes were measured in relation to postoperative complications and mortality. RESULTS: The incidence of complications including faecal fistula was 2.6% in group I (free omental sheet graft group) versus 32.89% in group II. The mortality rate of 2.6% was also lower in group I versus 19.7% in group II. CONCLUSION: This study concludes that the use of free omental sheet graft on typhoid enteric perforation site is effective in lowering the repair leak rate and thereby decreases the morbidity and mortality associated with these procedures. By lowering the complication rates, it also entails reduction in financial burden.

Laparoscopic completion cholecystectomy: a retrospective study of 40 cases.

INTRODUCTION: Throughout the world, laparoscopic cholecystectomy is a widely accepted surgical treatment for both acute and chronic cholecystitis. It provides total relief of pre-surgical symptoms in up to 85% of patients. However, about 5% of patients may experience severe episodes of upper abdominal pain similar to those that they had prior to cholecystectomy; this is known as post-cholecystectomy syndrome. Gallbladder remnant with calculi is one of the causative factors. However, there have been only a few case series related to this reported in literature to date. Herein, we present our experience with laparoscopic management of gallbladder remnant with calculi in 40 cases. METHODS: A retrospective study of 40 cases was carried out in our institution. All patients underwent open cholecystectomy at other centres, and their cases were managed by laparoscopic completion cholecystectomy. RESULTS: The mean operating time was 102.4 min (range, 60-120 min). The duration of hospital stay was 2-4 days. Two cases were converted to open surgery because of extensive dense adhesions. One case had minor a common bile duct injury, and another had port-site infection. There were no cases of mortality. CONCLUSION: Gallbladder remnant containing stones may be the cause of otherwise unexplained postcholecystectomy pain. Completion cholecystectomy offers a definitive treatment for any residual gallbladder remnant and can be performed laparoscopically.

Laparoscopic Nissen fundoplication in situs inversus totalis: Technical and ergonomic issues.

We report a laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) in a patient with situs inversus totalis (SIT). A 34-year-old man was diagnosed with SIT on performing chest X-ray and abdominal sonography as a routine preoperative investigations. He presented with chronic gastro-esophageal reflux disease (GERD) inadequately controlled by medications. The laparoscopic procedure was performed using five ports placed in a mirror-image configuration and with the patient in the modified lithotomy position. Few technical difficulties were encountered during the operation. The position of the primary surgeon, working between the lower limbs of the patient as in case of standard fundoplication, was considered most prudent position to the success of this case. In SIT, this position provides the least visual disorientation from the reversed abdominal organs. We recommend that preoperative detection of SIT is essential to understand the symptomatology of the patient and for planning of any upper abdominal laparoscopic procedure.

Transfascial suture hernia: a rare form of recurrence after laparoscopic ventral hernia repair.

Laparoscopic repair of ventral or incisional hernia is among the most commonly performed minimally invasive procedures. Different modes of recurrence have been reported in literature, including missed defects, mesh migration, mesh infection, etc. Transfascial suture fixation in addition to tackers is an established method to prevent recurrence due to mesh migration. We report possibly the third case of recurrent ventral hernia with multiple defects at transfascial suture sites of previous laparoscopic ventral hernia mesh repair. The patient was treated by laparoscopy with a large intraperitoneal PROCEED mesh, covering the new hernia defects and older mesh.

Symptomatic "H" type duplex gallbladder.

Gallbladder duplication with an incidence at autopsy of about 1 in 4000 is important in clinical practice, because it may cause some clinical, surgical, and diagnostic problems. Preoperative identification of this rare anomaly avoids biliary injuries and the other consequences of missed diagnosis. In this report, we present a case of ductular type duplex gallbladder diagnosed preoperatively by magnetic resonance cholangiopancreatography (MRCP) and ultrasound and managed successfully by laparoscopy.