New Indian Journal of Surgery

Diabetic foot ulcer is one of the common conditions faced by surgeons. A multidisciplinary team approach is mandatory for successful treatment of the condition. Its complexity is mainly due to the involvement of multiple organs and systems. Hence the condition is often found to be difficult to manage. The general concept is that appropriate and timely healing of the wound can prevent various wound-related complications like gangrene, auto amputations, septicemia, multiorgan failure, disfigurement, deformities etc. Adjuvant therapy not only increases wound healing but also can reduce the requirement of graft/flap by reducing the size of the defect and prevent the incidence of various complications like gangrene, amputation. Through this article we present use of Autologous Platelet Rich Plasma (APRP) therapy combined with other modalities of therapy like external tissue expansion and wound closure (ETEWC) technique using hooks and rubber bands as an effective tool to enhance healing in wound bed preparation of diabetic foot.

Context: Postoperative complications following laparotomy remain a major cause of morbidity and mortality. Accurate intraoperative risk assessment tools are essential for early identification of high-risk patients. The Surgical Apgar Score (SAS) is a simple and objective scoring system based on intraoperative parameters including estimated blood loss, lowest mean arterial pressure, and lowest heart rate. Aim: To evaluate the utility of the Surgical Apgar Score in predicting postoperative morbidity and mortality in patients undergoing laparotomy. Study and Design: A prospective observational study was conducted at a tertiary care teaching hospital in India. Materials and Methods: A total of 130 patients undergoing laparotomy were included. The Surgical Apgar Score was calculated intraoperatively using lowest heart rate, lowest mean arterial pressure, and estimated blood loss. Patients were categorized into three risk groups: high risk (SAS 0–4), moderate risk (SAS 5–6), and low risk (SAS 7–10). Patients were followed for 30 days postoperatively to assess complications and mortality. Statistical Analysis Used: Statistical analysis was performed using Chi-square test. Results: The association between low Surgical Apgar Score and incidence of postoperative complications and mortality was statistically significant (p value <0.0001). Conclusion: The Surgical Apgar Score is a simple, reliable, and effective intraoperative tool for predicting postoperative morbidity and mortality following laparotomy. Its routine use can help in early risk stratification, better postoperative monitoring, and optimal allocation of critical care resources. Key Messages: 1. Surgical Apgar Score is a simple intraoperative tool for early postoperative risk stratification. 2. Lower SAS is strongly associated with major complications and mortality after laparotomy. 3. Routine use of SAS can improve postoperative monitoring and ICU triage.

The gold standard treatment for symptomatic gallstone disease is laparoscopic cholecystectomy. Common gallbladder dissection methods include monopolar electrocautery and ultrasonic harmonic scalpel. Aim: To compare harmonic scalpel and monopolar electrocautery for gallbladder dissection in laparoscopic cholecystectomy. Settings and Design: A prospective observational study was conducted at a tertiary care teaching hospital. Materials and Methods: This study comprised 120 laparoscopic cholecystectomy patients. Electrocautery (EC, n=60) and harmonic scalpel (HS, n=60) groups were evenly assigned. Demographics, operative length, intra-operative bleeding, complications, post-operative pain, nausea, and vomiting were documented and analysed. Statistical Analysis Used: Independent Student’s t-test, Chi-square and Mann– Whitney U test were used, with p <0.05 considered significant. Results: Both groups had similar demographics. The HS group had a considerably longer mean operational time (58.38 ± 4.43 minutes) compared to the EC group (45.31 ± 2.84 minutes, p < 0.001). The HS group had considerably decreased intraoperative bleeding (p < 0.001) and post- operative pain severity (p = 0.006). The EC group had greater intra-operative complications such gallbladder perforation and liver damage. No common bile duct injury was found in either group. Conclusion: The harmonic scalpel is a safe and effective alternative to electrocautery in laparoscopic cholecystectomy, with less bleeding, complications, and postoperative pain but a lengthier procedure.

Introduction: Even with all the progress made in minimally invasive surgery, surgical site infection (SSI) still ranks among the more troublesome complications following laparoscopic cholecystectomy. Antibiotic prophylaxis is standard practice, but how long it should be continued is still up for debate. Giving more antibiotics than necessary only adds to healthcare costs, raises the chance of adverse drug reactions, and feeds into the wider problem of antimicrobial resistance which is why it’s worth asking whether a single preoperative dose can hold its own against the conventional multidose approach. Objectives: To compare rates of surgical site infection and other postoperative outcomes between patients given a single preoperative antibiotic dose and those given the conventional multidose regimen during elective laparoscopic cholecystectomy. Methods: This randomized controlled comparative study was carried out in the Department of General Surgery, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner, Rajasthan. One hundred patients undergoing elective laparoscopic cholecystectomy were enrolled and split evenly into two groups of 50. Group A was given a single preoperative intravenous dose of cefotaxime and sulbactam (1.5 g), while Group B received the conventional multidose prophylaxis regimen. Patients were tracked for four weeks after surgery to catch any surgical site infection or other complications. Data were analysed in SPSS, with p<0.05 taken as significant. Results: Baseline age and clinical characteristics were similar across both groups. Surgical site infection turned up in 12% of the single-dose group compared with 6% of the multidose group, though this gap didn’t reach statistical significance (p=0.295). Surgery took an average of 26.9 ± 2.1 minutes in the single-dose group versus 26.7 ± 2.5 minutes in the multidose group (p=0.692), and hospital stays averaged 3.14 ± 0.96 days and 3.10 ± 1.12 days respectively (p=0.852). Postoperative complications were much the same in both groups (p=0.27). Conclusion: A single preoperative antibiotic dose held up just as well as conventional multidose therapy in terms of both efficacy and safety in elective laparoscopic cholecystectomy. In uncomplicated cases, there seems little reason to continue antibiotics after surgery, since skipping the extra doses doesn’t appear to raise the risk of surgical site infection.

Introduction: Laparoscopic cholecystectomy causes less postoperative pain than the open procedure, yet pain in the first 24 hours still shapes how quickly patients recover and how much analgesia they end up needing. Instilling local anaesthetics into the peritoneal cavity and at the port sites has been put forward as a straightforward way to bring that pain down. Objectives: To find out whether intraperitoneal plus port-site instillation of bupivacaine works better than giving no local anaesthetic at all in controlling postoperative pain after laparoscopic cholecystectomy. Methods: This randomized controlled study was carried out in the Department of Surgery, Sardar Patel Medical College, Bikaner. Fifty patients scheduled for elective laparoscopic cholecystectomy were randomly split into two groups. Group 1 (n=25) received 0.5% bupivacaine both intraperitoneally and by portsite infiltration, while Group 2 (n=25) received no local anaesthetic. Pain after surgery was scored on the Visual Analogue Scale (VAS) at 1, 8, and 24 hours. The total analgesic dose needed, the time before the first analgesic was requested, postoperative complications, patient comfort, and length of hospital stay were all noted. Data were analysed in SPSS, with p<0.05 taken as significant. Results: Most participants were women (74%), and the largest share fell in the 41– 60 year bracket (46%). Group 1 had noticeably lower pain scores at 1 hour (p=0.03), 8 hours (p=0.008), and 24 hours (p=0.02) than Group 2. Patients in Group 1 also needed less analgesia over the first 24 hours (p=0.001) and went longer before asking for their first dose (p=0.04). Pain relief was rated adequate in 80% of the bupivacaine group compared with just 28% of controls (p<0.001), and satisfaction followed the same pattern (84% vs 28%, p<0.001). Rates of nausea and vomiting were similar in both groups (p=0.48). Conclusion: Combining intraperitoneal and port-site bupivacaine meaningfully lowers postoperative pain and analgesic use after laparoscopic cholecystectomy and leaves patients more satisfied, all without adding to the complication rate. Given how simple and safe it is, this technique deserves a routine place in perioperative pain protocols.

Columnar Cell subtype of Papillary Thyroid Carcinoma (CC-PTC) is an exceptionally rare histologic subtype, accounting for less than 0.5% of all papillary thyroid carcinomas worldwide.¹,² Despite its rarity, CC-PTC demonstrates aggressive biological behavior and is classified as a high-risk histologic subtype in the World Health Organization Classification of Tumors of Endocrine Organs, 5th Edition (2022)³, owing to its frequent association with capsular invasion, lymph vascular permeation, extrathyroidal extension, and distant metastasis. The tumor poses significant diagnostic challenges due to its distinctive morphology, particularly on cytology and limited biopsy material.4,6 Case Presentation: A 27-year-old woman presented with a one-year history of anterior neck swelling with recent onset throat pain. ltrasonography revealed a right thyroid lobe nodule categorized as TI-RADS 4/5. Fine-needle aspiration cytology showed highly cellular smears composed of tall and columnar epithelial cells arranged in papillary fragments and sheets, exhibiting nuclear elongation, hyperchromatic nuclei, marked pseudo stratification, and occasional nuclear pseudoinclusions, consistent with Bethesda Category VI. Total thyroidectomy revealed a 3-cm ill-defined, unencapsulated grey-white tumor. Histopathological and Immunohistochemical Findings: Histopathology demonstrated circumscribed tumor composed of complex papillary and trabecular architecture lined by pseudostratified columnar cells with elongated hyperchromatic nuclei, conspicuous eosinophilic nucleoli, amphophilic cytoplasm, increased mitotic activity, and extensive lymphovascular invasion. Immunohistochemistry confirmed thyroid follicular epithelial origin with tumor cell nuclear positivity for TTF-1 and retained membranous β-catenin expression, while CDX2 was negative. A high Ki-67 labelling index supported the aggressive proliferative nature of the tumor. Conclusion: This case highlights the importance of recognizing the distinctive cytomorphologic, histopathologic and immunohistochemical features of CC-PTC. Accurate diagnosis requires a multimodal approach integrating clinical findings, cytology, histopathology, and immunohistochemistry, particularly in young patients where aggressive behavior may be unsuspected.

Context: Pain following laparoscopic cholecystectomy can adversely affect postoperative recovery and increase the need for analgesic medication. The transversus abdominis plane (TAP) block is a well-established regional anaesthetic technique for postoperative pain control. Performing the block under laparoscopic guidance offers a practical alternative to the conventional ultrasound-guided approach. Aim: To assess the effectiveness of a laparoscopically guided bilateral oblique subcostal TAP block using 0.2% Ropivacaine in reducing postoperative pain in patients undergoing elective laparoscopic cholecystectomy. Settings and Design: A prospective, double-blind, randomized controlled trial conducted at a tertiary care teaching hospital between July 2023 and March 2024. Methods and Materials: Fifty patients aged 20–60 years who underwent elective laparoscopic cholecystectomy were randomly allocated into two equal groups (25 participants in each group). Patients in the intervention group received a laparoscopy guided bilateral oblique subcostal TAP block with 20 mL of 0.2% ropivacaine on each side, whereas those in the control group were managed with standard intravenous analgesia. Postoperative pain intensity was evaluated using the Visual Analogue Scale (VAS) at 6 hours, 12 hours, and at the time of discharge. The requirement for rescue analgesia was also documented. Statistical Analysis: Data analysis was performed using IBM SPSS version 26.0. Continuous variables were analysed using the independent t-test or the Mann–Whitney U test, while categorical variables were compared using the Chi- square test or Fisher’s exact test, as appropriate. A p-value <0.05 was considered statistically significant. Results: Patients who received the TAP block had significantly lower postoperative VAS scores at 6 hours (4.6 vs. 5.8; p=0.007), 12 hours (2.9 vs. 4.0; p=0.001), and at discharge (1.6 vs. 2.6; p=0.001) compared with the control group. Additionally, 72% of patients in the TAP block group did not require any rescue analgesia. Conclusion: Laparoscopy-guided bilateral oblique subcostal TAP block using ropivacaine is a safe, feasible, and effective adjunct for postoperative pain management following elective laparoscopic cholecystectomy.