New Indian Journal of Surgery

 Fibroadenoma is one of the commonest benign lump of the breast. It is classically described as an irregular firm to hard lump of variable size with such a mobility to name it aptly as a ‘breast mouse’. This clinical presentation is so well known that most of the times the diagnosis is made clinically with reasonable accuracy. We encountered an unusual and interesting presentation of this common pathology and are presenting the same. We hope this will interest the clinicians working in this field.

Keywords: Fibroadenoma; Sarcoma; Breast Lump.

 Not Provided.

 We report a case of 24 years old male presenting with painless peno-scrotal swelling for 3 years. On examination, a large soft bag of worm like superficial, non pulsatile swelling was present in scrotum and penis. Color doppler showed dilated tortous vessels and on angiography no connections to corpora or vessels was seen. So a diagnosis of Hemangioma was made and a surgical excision was carried out by circum-coronal and scrotal incisions. Post-op course was uneventful. At 6 months follow up, no recurrence was seen and wound had healed with excellent cosmetic appearance. 

Keywords: Hemangioma; Angiography; Intralesional Sclerotherapy.

 Surgical instruments and materials continue to be retained in the peritoneal cavity despite precautionary measures. Even though uncommon it is also underreported and carries serious medico legal consequences. Gauzes and sponges are the most commonly retained materials and intra abdominal retained artery forceps are much rarer but when they do occur lead to chronic abdominal pain and can be a rare cause of intestinal obstruction or strangulation with significant morbidity and mortality. The retained large artery forceps during a caesarian delivery is never reported before in literature searched.   

 Background: Ectodermal Dysplasia is a rare disorder. The otolaryngological manifestations range from chronic upper respiratory tract infection to more severe infections of the para nasal sinuses including nasal myiasis. Purpose: The present report describes the rare occurrence of palatal perforation in a case of ectodermal dysplasia, leading to difficulty in feeding and regurgitation. Conclusion: Early detection and addressal of otolaryngologicalproblems associated with ectodermal dysplasia is suggested, so that complications like palatal perforations do not occur.

Keywords: Ectodermal Dysplasia; Otolaryngological Manifestations; Nasal Myiasis Palatal Perforation.

 Introduction: Postoperative dressings of the scalp are cumbersome to apply especially when the patient is still anesthetized. They are difficult to maintain in the postoperative period, often leading to displacement of the dressings with exposure of the incision line to the external environment. Case Report: Here we present a case report of a patient who underwent acrylic cranioplasty for whom a bolster dressing was used following surgery. Conclusion: The use of a bolster dressing to cover wounds over the scalp is easy, safe and cosmetic.

Keywords: Bolster; Cranioplasty; Postoperative Dressing; Cosmesis.

 Objective:To assess and analyze the quality of life of patients suffering with uncomplicated grade I and II hemorrhoids in an adult general population following treatment by eitherrubber band ligation or cryosurgery through Short Form-36 quality of life survey questionnaire. Background: No study comparing the quality of life following treatment of hemorrhoids by rubber band ligation or cryosurgery has ever been done. Method: Sixty comparable patients with symptomatic uncomplicated grade I and II hemorrhoids were recruited in the study. Their quality of life was assessed using sf-36 version 2 questionnaire. The patients were then randomized into two equal groups to undergo either rubber band ligation or cryosurgery. The patients were followed after 2 months and Quality of life was reassessed using the same questionnaire. Change in quality of life in either group was then assessed and analyzed using appropriate statistical methods. Results: Mean age of patients was 41.15±14.16 years. There were 45 males and 15 females. Bleeding was the main symptom in all patients followed by pruritus ani in 8 patients. The two groups were comparable regarding age and symptoms. There was significant improvement in quality of life after treatment by rubber band ligation and cryotherapy. However, for the cryotherapy group, the change was much higher in mental component score as compared to physical component score. The inter group difference of change in score from pre operative to post operative level was not statistically significant except for general health. Conclusion: Hemorrhoids negatively affect the quality of life of patients.Treatment of hemorrhoids by either rubber band ligation or cryotherapy is equally effective in improving their quality of life.

Keywords: Hemorrhoids; Rubber Band Ligation; Cryotherapy; Quality of Life.

 Introduction: The organisms cultured from Fournier gangrene are often polymicrobial and include both aerobic and anaerobic organisms. Methodology: The diagnosis was made on clinical basis, supported by other relevant investigations. Post operative follow up will be done to note the complications both in hospital and after discharge for 6-12 months. Results: Eleven patients (36.66 percent) had diabetes mellitus, Nineteen (63.33 percent) had a urogenital predisposing factor (e.g., urethral stricture, peri urethral abcess, epidydimoorchitis, phimosis), and seven (23 percent) were alcohol abusers. Conclusion: The common presenting complaint was scrotal swelling in 9 patients(30%), overall scrotal involvement was seen in (93%) of cases.

Keywords: Fournier‘s Gangrene; Clinical Profile; Etiology.

 Introduction: Buerger’s disease occurs almost exclusively in smokers who are males usually between 20 and 50 years of age. The typical patient is one who is a heavy smoker and had started smoking at an early age. Following is the spectrum of presentation of disease. Methodology: The treatment of each patient was individualized with the aim to achieve foot salvage wherever feasible. A record of patient’s progress and response to various modalities of treatment was mode to evaluate severity of disease, in long term prognosis and also evaluate the efficacy of treatment. Results: Ulceration was seen in 9 patients (18%). 11 patients (45.83%) out of total 24 patients with gangrene had a definite line of demarcation and 13 patients (54.17%) did not have definite line of demarcation. Conclusion: All the cases were diagnosed with Shionoya criteria, Lower limb medium to small caliber vessels were commonly involved in Buerger’s disease.

 Introduction: Perforation of gas containing hollow viscus organs usually gives rise to a life threatening emergency which is most commonly managed by general surgeons. Methodology: This was a descriptive clinical study carried out at a Tertiary care hospital. Preoperative resuscitation of patients was done by fluids and electrolyte imbalance was corrected. Antibiotics like 3rd generation cephalosporins and metronidazole were used initially, later shifted according to culture and sensitivity. Results: In this study two patients expired, one patient of ileal (typhoid) perforation developed septicemia and expired on the day of surgery. Another patient of colonic carcinoma perforation had developed septic shock expired on post- perative day 3. Conclusion: Factors contributing to the high mortality and post-operative complications are advanced age, late presentation, delay in the treatment, septicaemia, and associated co-morbidity.  

 A comparative study between Apache II and Ranson scoring systems in predicting the severity of acute pancreatitis is a prospective study of 50 cases of acute pancreatitis with an objective to compare the efficacy of Apache II scoring system with Ranson scoring system in predicting the severity of acute pancreatitis.A total of 50 cases of were included in the study acute pancreatitis admitted in K.S. Hedge Medical Academy were considered in the study. All had a diagnosis on admission of acute pancreatitis based on clinical suspicion and raised serum amylase levels. They were assessed with multiple variables of Apache II and Ranson scoring system. The sensitivity, specificity, positive and negative predictive value of Apache II was compared with standard literature.

Key words: Apache II Scoring System; Ranson Scoring System; Acute Pancreatitis; Sensitivity; Specificity.

 Introduction: Hydrocele is abnormal collection of serous fluid in the tunica vaginalis. There are several methods in the treatment of hydrocele and it is mainly surgical. Apart from surgery, Sclerosant therapy is also available. After surgery several complications like hematoma, infection, scrotal edema, torsion of testis, epididymitis and testicular atrophy can occur. Methods: A total of 60 patients will be selected after applying the various inclusion and exclusion criteria. The patients will be subjected to various modalities of management like Lord’s plication, Jaboulay’s procedure, Radical excision of sac and tapping with sclerotherapy depending on the presentation. Patients will be followed up for 6 months for complication. Results: Of the total 60 patients selected, 50 patients were subjected to open surgeries while the remaining 10 patients were subjected to Aspiration Sclerotherapy. The following study reveals that among open surgeries, techniques in which no dissection or excision of the tunica vaginalis is done are superior since they have less post-operative complications. Results of aspiration sclerotherapy reveal that complications are minimal and comparable with that of open surgeries. Conclusion: Among open surgeries Lord’s plication is better than Joboulay’s procedure and radical excision of sac with respect to effectiveness, complication and postoperative hospital stay. Aspiration sclerotherapy can be utilized as an effective alternative to open surgery in patients who are not fit for surgery or those who refuse surgery.

Keywords: Hydrocele; Management; Sclerotherapy.

 Introduction: The treatment team for pseudocysts includes radiologists, endoscopists and surgeons. The radiologists by way of guided per-cutaneous techniques for aspiration/drainage to the therapeutic embolization of bleeding aneurysms the endoscopists by way of various endoscopic drainage procedures contribute to the team. Methodology: Patients admitted to department of surgery with symptomatic pseudocyst of pancreas of greater than 6 weeks duration are included in the study. Percutaneous drainage involves either simple percutaneous aspiration or percutaneous catheter placement, most commonly performed under CT control, but in some cases under sonographic or fluoroscopic guidance. It is a valuable alternative to operative management, as maturation of the pseudocyst wall does not have to be awaited. Results: Among aspiration group, 60%(18 patients) patients needed only 2 aspirations to relieve symptoms, whereas 30%(9patients) patients needed 3 aspirations and 10%(3 patients) needed 4 aspirations. Among 30 patients who underwent surgery, 16 patients (53.3%) had cystogastrostomy,  patients(23.3%) had cystojejunostomy, 3 patients(10%) had cystoduodenostomy, 2 patients(6.7%) had distal pancreatectomy. 2 patients(6.7%) had external drainage as surgical procedure. Conclusion: USG is simple and can be done bedside and also palliative option in patients who are not fit for surgery and are debilitated. 

Keywords: Pancreatic Pseudocyst; USG Guided Aspiration; Surgery.

 Introduction: A high index of suspicion is essential to diagnose visceral perforation early as significant morbidity and mortality results from diagnostic delay. Methodology: Each patient was examined thoroughly, after taking a detailed history. Clinical diagnosis of hollow viscus perforation is made based on history and physical examination which will be confirmed by investigations and laparotomy. Results: Patients with duodenal ulcer perforation were treated with omental patch (5), two layer closure (5) and truncalvagotomy with pyloropasty (1). 16 patients had appendicular perforation treated by appendicectomy. Gastric perforation closed by omental patch in one patient. Ileal perforation was closed in two layers. Conclusion: Most patients with appendicular tip perforation treated surgically by appendicectomy.

Keywords: Viscus Perforation; Management; Appendicectomy.

 Purpose: To determine the efficacy of routine exploration in peritoneal injuries occurring as a complication of neonatal umbilical vein cannulation. Methods: Twenty patients who had peritoneal breach during umbilical vein cannulation were included. They were divided randomly into two groups. Ten patients (Group A) underwent exploration and ten patients (Group B) were under observation following peritoneal suturing. The results were compared in terms of outcome. Results: There was no difference in the outcomes of the two groups. Conclusion: Serial observation after suturing of the peritoneal defect may be attempted as a method in dealing with peritoneal breach without any bowel protrusion.

Keywords: Umbilical Cannulation; Peritoneal Injuries; Umbilical Vein; Surgery; Suturing.

 In Diabetes mellitus, fetid foot infection is more common. On review of 30 patients of fetid Diabetic foot treated in Ahalia Diabetic Hospital, Palghat, during the period from April 2012 to December 2013. Out of which in 15 patients pseudomonas & in 5 patients Proteus were isolated. Both Pseudomonas & Proteus were sensitive only to Imepenem groups of Antibiotics. In other 15 patients, MRSA- methicillin resistant Staphylococcus Aureus & E.Coli were isolated & they were sensitive to Augmentin, Amikacin, Gentamycin, & Piperacillin- azobactam.

Keywords: Diabetes mellitus; Pseudomonas; Proteus; Diabetic Foot.

 Objectives: To review the management of Splenic trauma (operative vs conservative management) and our outcomes. Type of Study: Retrospective observational study. Period of Study: 2000-2015. Methodology: There have been 36 cases who were admitted with splenic trauma in our institution over the last 15 yrs. ICD-10 Code S36.0 was used to identify these patients. A thorough review of their files was undertaken. Results: AAST Grading for splenic injury was done for these cases and there were 3 cases of grade 1, 6 cases of grade 2, 13 cases of grade 3, 12 cases of grade 4 and 2 cases of grade 5. Of these, both cases of Grade 5 injury were operated immediately, while 4 out of 12 cases of grade 4 injury were operated immediately. Of the 8 cases of grade 4 injury which were managed conservatively, One case needed to be operated at a later date, which is our only case of failure of conservative management. Usion criteria. One case of grade 3 injury was operated, while all cases of grade 1 and 2 were managed conservatively. We had 7 cases of Operative management (OM), 28 cases of Successful conservative management (CM) and 1 case of Failure of conservative management (FOC). Conclusion: The goal of this study was to evaluate the success of the various strategies (conservative vs surgical) and their outcome. Our study shows that conservative management has a major role to play in hemodynamically stable patients even if their AAST grading of Splenic injury was 4. But these patients who are managed conservatively, need to be monitored closely and the surgeon should be ready to take the patient up for emergency surgery if any signs of worsening are evident. The failure of non-operative management can be life-threatening and even fatal if the deterioration is not picked up immediately.

Keywords: Splenic Trauma; Splenic Injury; Conservative Management; Non-Operative Management; Splenectomy; AAST Grading.

 Malignant Gastric out Let obstruction- GOO is most common presentation of a Advanced Carcinoma of stomach in males. On review of 20 patients of advanced Malignant GOO in males, 10 male patients were treated with Palliative Gastrectomies; other 10 male patients were treated with Anterior Gastrojejunostomy & Jejuno jenostomies, followed with Chemotherapy of 5 FU, 750 mgs IV infusion for 3 days for 6 months. Survival rate & Quality of Life were the same in both groups around 2 yrs. The study has been done in a few hospitals where I worked, Government Royapettah Hospital from September 1982 to May 1987, Coimbatore Medical college Hospital from June 1987 to April 1991, Government Head quarters Hospital, Erode from September 1991 to December 2000, Perundurai Medical College Hospital, Perundurai from November 2002 to July 2004. 

 Aims: Purpose of this study is to put forward NON DESCENT VAGINAL HYSTERECTOMY as procedure of choice for the management of patients with non-malignant pelvic disease involving the uterus, whenever technically feasible. Methods: A prospective study carried out to determine the short term morbidity for vaginal hysterectomy done for non descent uterus. The study was done on 200 patients scheduled to undergo hysterectomy for benign conditions during the period of January 2007 to December 2012, at Umaid Hospital, Jodhpur. A written informed consent was taken from each patient. A preformed questionnaire was made for data collection. Exclusion criteria included were uterine size of more than (>20wks), restricted mobility of uterus, uterine malignancy, cervix flushed with vaginal vault, previous fistula repair and gross adenexal pathology. Observation: Total 200 hysterectomies were performed during the study period, vaginal route was employed in all patients but few of them converted to laprotomy(1%). Out of 200 vaginal hysterectomies maximum 68 (34%) patients were in age group 40-45 years.DUB is most common (42%) indication for the vaginal hysterectomies. Vaginal hysterectomies were successful in most of case but 2 case required laprotomy. Mean operative time was 50-60 minutes with 100-150 ml blood loss and mean average hospital stay was 4day. Complication was minimal except few had rectal (2%)injury. Conclusion: Non Descent Vaginal Hysterectomy is safe, minimally invasive natural orifice, scarless hysterectomy which can be done easily, faster with shorter anesthesia. Early and smooth post operative recovery, early return to work and cost effectiveness. For obese patients and patients with history of preexisting cardio-pulmonary disease there is excellent patients recovery with least complications.

Keywords: NDVH; Fibroid; Haemorrhage; Spinal Anesthesia.

 Introduction: Fournier’s Gangrene often begins insidiously, with non specific prodromal symptoms such as malaise and scrotal discomfort. This discomfort progresses into pain, and at this time, the patient may develop blackish discoloration of the skin perianally or of scrotal skin. Methodology: The diagnosis was made on clinical basis, supported by other relevant investigations. Post operative follow up will be done to note the complications both in hospital and after discharge for 6-12 months. Results: Scrotal involvement was found in 29 cases (93.0 percent),perineum in 11 cases (36.66 percent), vulval region in 1 case (3.33 percent), groin in 2 cases (6.66 percent),and abdomen in 1 case (3.33 percent). Conclusion: Scrotal involvement as swelling was more common.

Keywords: Fournier’s Gangrene; Clinical Profile; Scrotal Swelling.

 Introduction: “Primary vaginal hydrocele is defined as abnormal accumulation of serous fluid in tunica vaginalis.” It is one of commonest disease occurring worldwide. The common complications observed during the surgery of hydrocele are bleeding, injury to the cord structures and epididymis, torsion of the testis due to faulty positioning during surgery. There are many numbers of types of operations performed for hydrocele, which needs comparision to select best of them. Methodology: A total of 60 patients were selected after applying the various inclusion and exclusion criteria. The patients were subjected to various modalities of management like Lord’s plication, Jaboulay’s procedure, Radical excision of sac and tapping with sclerotherapy depending on the presentation. Results: Eight of ten patients were cured of their hydrocele. Among the eight patients who were cured 4 patients had only one instillation. 1 patient developed a recurrent hydrocele 2 wks following primary treatment while 3 patients developed recurrent hydrocele 2, 3 & 6 mths after primary treatment. Conclusion: There was no incidence of hematoma after Lord’s placation.

Keywords: Hydrocele; Lord Plication; Complications.

 Introduction: The aetiology of the disease again is not known till today. Despite many efforts and studies, the aetiology remains obscure. But one advantage of such a vast study done in this field to find out its cause is the emergence of a body of knowledge regarding various factors that contribute towards worsening or lessening the severity of the disease. Methodology: The method of the study consisted of taking a good clinical history in a chronological order as soon as the patient was admitted. A thorough clinical examination was carried out personally to find out and establish clinically first, the presence of vascular obstruction. Detailed vascular system examination was done as per the proforma provided and blood pressure measured to rule out hypertension. Results: claudication was the commonest presentation seen in 32 patients (64%). Among them calf claudication is seen in 20 patients (40%) and foot claudication seen in 12 patients (24%). Rest pain is seen in 18 patients (36%). Ulceration is seen in 9 patients (18%). Gangrene was seen in 24 patients (48%). Superficial thrombophlebitis is seen in 1patient (2%). Conclusion: Majority of patients were in age group 41-50 years.Lower socio-economic strata are commonly involved with Buerger’s disease.

Keywords: Buerger’s Disease; Claudication; Smoking.

 Fine needle aspiration cytology (FNAC) is now being accepted as the most cost-effective, minimal invasive technique with very low incidence of complications in the diagnosis of most of the thyroid lesions with an added advantage of segregating the patients of solitary thyroid nodule (STN) into operative and non-operative groups. Aim: To determine the accuracy of FNAC in terms of sensitivity, specificity, positive predictive value and negative predictive value in comparison with histopathology in the diagnosis of a thyroid swelling. Methodology: A prospective longitudinal study was undertaken over a period of 1 year from Jan 2015 to Dec 2015 at the out-patient department of Annapoorana medical college and Hospital. Patients with visible thyroid swelling with a solitary nodule, in euthyroid state and with no other serious medical disorders were included in our study. . FNAC was performed with 23 gauge needle, smears were fixed with ether-95% alcohol solution, and staining was performed using papanicolau’s staining. The thyroid specimen which was excised during the thyroidectomy procedure was processed in automated tissue processing units and sent for histopathological examination. Results: The validity of FNAC in terms of sensitivity and specificity was assessed by comparing it with the histopathological examination. The sensitivity of FNAC in detecting all the benign and malignant type of thyroid lesions was found to be in the range of 80–100%, whereas the specificity and the positive predictive value was almost 100% and the negative predictive value was between 98-100%, for all the lesions detected by FNAC. So this shows the accuracy of detection of lesions through FNAC is almost 94%. Conclusion: The use of FNAC has reduced the number of patients with solitary thyroid nodules undergoing unnecessary surgery and has led to proper planning of surgery in malignant cases.

 Introduction: gangrene is a rare and potentially fatal infectious disease characterized bynecrotizing fasciitis of the perineum and abdominal wall ina ddition to the scrotum andpenis in men and the vulva in women. To repair the scrotal and perineal defects remains asurgical challenge. Methods: This is a prospective study, includes 30 patients who were diagnosed as Fournier’s Gangrene. Allpatients were admitted and were subjected to routine investigation such as BC, TLC, DLC, C/S, ECG,CXR, HIV. The choice of reconstructive procedure was basedon the size, location, severity of defects and availability of local tissue. Post operativefollow up was done to note the complications both in hospital and after discharge for 6-12 months. Results: various reconstructive procedures were performed (Table 8), with special emphasis on flaps, constituting 16cases (53.33%) of flaps. Mean hospital stay duration was 30.6 ± 9.32days (range, 19- 3days). Conclusions: Management of this infectious entity should be aggressive. Several techniques that areused to reconstruct the lost tissue have shown good results.

Keywords: Fournier’s Gangrene; Scrotum; Bilateral Superomedial Thigh Flap.

 Introduction: Hydroceles may differ in size but most of the cases are asymptomatic. Acquired hydroceles are usually developed gradually and are not that much alarming. Larger hydroceles may result in chronic pain in the scrotum or lower back and can cause injury to the scrotal contents such as the testicle. Methodology: The patients who presented in the OPD with a swelling in the scrotum were identified and following inclusion and exclusion criteria applied. All men with primary vaginal hydrocele with no signs of hernia or other scrotal disease will be selected. A total of 60 patients were selected for the study. Results: The youngest patient was 11 years of age while the oldest patient is 75 years of age. Maximum number of cases was seen in 20 - 29 years age group followed by that in 30-39 year age group while minimum no of cases were seen in 70 - 79 years age group. Conclusion: In this study almost equal number of cases were seen in most of the occupations. This indicates that hydrocele does not have any predilection for a particular occupation.

Keywords: Hydrocele; TunicaVaginalis; Clinical Profile.

 Cleft lip and palate are variations of a type of congenital deformity caused by abnormal facial development during gestation. The main organs affected are mouth, nose and ear. Hence treatment of the condition is aimed to provide optimum function of all these organs. Apart from correction of oral competence and ear pathology, speech correction is always a challenging aspect of the management in patients of cleft palate. Various methods of palatoplasty have been described ranging from anatomical closure to the functional closure of the defect. Both methods have their own advantage, disadvantages and outcomes. We present a case series to compare these two methods with special reference to speech outcome.

Keywords: Cleft Palate; Palatoplasty; Intravelar Veloplasty.

 Introduction: The ruptured or perforated viscus challenges the surgeons skill as a technician and his knowledge of preoperative, transoperative and postoperative care of the severely ill surgical patient and assessment needed to decrease both the morbidity and mortality of patients significantly. Methodology: This study has been based on the analysis of 40 cases of hollow viscus perforation and each patient was examined thoroughly, after taking a detailed history. Clinical diagnosis of hollow viscus perforation is made based on history and physical examination which will be confirmed by investigations and laparotomy. Results: Out of 40 cases in this study, 16 patients presented with appendicular perforation (40%), duodenal ulcer perforation was in 11 patients (27.5%), typhoid perforation was in 5 patients (12.5%), 2(5%)patients had small bowel gangrene perforation due to stricture and adhesions, one patient had tubercular perforation (2.5%), one patient had malignancy of left colon presented as perforation (2.5%), 3 patients had traumatic perforation each one in duodenum (2.5%), ileum(2.5%) and intraperitoneal rectum(2.5%). Conclusion: Most common site of perforation was appendix followed by duodenum.

Keywords: Appendix; Hollow Viscus; Perforation.