New Indian Journal of Surgery

 Introduction: Adrenal Angiomyolipoma is rare. Only four cases have been reported so far. These are commonly found in Kidney but extra renal sites are also mentioned. Angiomyolipoma arising in adrenal is very rare entity, usually asymptomatic, diagnosed incidentally on radiological investigation of abdomen for other conditions. Case Report: We report our experience with a 55­year­old woman who presented with pain in loin and abdominal mass. A computerised tomography (CT) scan showed an adrenal mass. Exploratory laparotomy with adrenalectomy was performed and the histopathological features confirmed the diagnosis of Adrenal Angiomyolipoma. The patient recovered without any complications following surgery. Conclusion: Our review is a brief summary about the adrenal Angiomyolipoma and should be kept in mind while diagnosing a lump in abdomen. Surgery should be considered as the definitive management for larger mass as to avoid associated complications.

Keywords: Adrenal Mass; Extra Renal Tumour; Adrenal Benign Tumour; Abdominal Tumour.

 Ectopic kidney is a congenital defect where kidney is in unusual anatomical position. An ectopic kidneyis often associated with increased incidence of stone formation as a result of stasis because of altered geometry of urinary drainage[1]. Diseases in ectopic kidney may present diagnostic problems and excised mistakenly as an unexplained mass[2]. It can present with chronic urinary symptoms or mass per abdomen.This needs detailed evaluation and effective intervention to prevent loss of kidney.

Keywords: Ectopic Kidney; Urinary Tract Anomalies; Hydronephrosis; Unascended Kidney.

 Introduction: incisions placed on the scalp cause continuous bleeding which obscures the surgeon’s field. There are many ways to control such bleeding like application of Raney clips, scalp tourniquet or infiltration of adrenaline saline solution. Diode laser scalpel was first introduced for oral surgery due to its advantages of hemostasis and better wound healing. Here we describe our experience in a case where the diode laser scalpel was used to place the skin incision while performing an acrylic cranioplasty.

Keywords: Diode Laser; Hemostasis; Cranioplasty

 Tetanus is the only vaccine­preventable disease that is infectious but is not contagious. The diagnosis is based on the presentation of tetanus symptoms and does not depend upon isolation of the ubiquitous bacteria, which is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus. In the United Kingdom, 5 doses of tetanus toxoid– containing vaccine at appropriate intervals are considered to provide lifelong protection, as long as tetanus­prone wounds are treated with tetanus immunoglobulin but the immunity wanes over time particularly in elderly. Recent experience has pointed to Intravenous Drug Users (IVDUs) as being at significant risk of tetanus. Awareness of the risk and value of vaccination in this group, and awareness among those working with them, is extremely important. The reasons for emergence of Clostridium infections in IVDUs in the United Kingdom include an increase in contamination of heroin and an aging cohort of heroin users who are more likely to use “popping” as the mode of injection. Most patients with tetanus lack a history of receipt of a full series of tetanus toxoid immunization and receive inadequate prophylaxis following a wound. Approximately three­fourths of the patients who acquired tetanus recalled an acute injury prior to the onset of their symptoms, but approximately two­thirds of these individuals did not seek medical care. Tetanus is a clinical diagnosis and must be considered in patients with muscle spasms and an inadequate vaccination history. ‘Confirmed cases’ of tetanus need to meet the laboratory criterion.

Keywords: Magnesium and Tetanus; IVDUs and Tetanus; “Skin Popping” and Tetanus; Tetanus Immunoglobulin Vs Human Immunoglobulin.

 Introduction: Perforation of an ulcer is due to sudden sloughing off base of the ulcer due impairment of blood supply, which leads to gastric or duodenal contents leaking into peritoneal cavity, initiating an acute diffuse peritonitis. Methodology: This study comprises of 60 cases of duodenal ulcer perforation admitted in the Department of Surgery. Operative details included the site and nature of operation performed. Mortality was defined as death following surgical procedure. Results: All patients in the present study were subjected to plainX­ray abdomen in erect position. Out of 60 cases studied, 55 patients (91.67%) were found with pneumo­peritoneum. Conclusion: Duodenal peroration was common in lower socioeconomic group.

Keywords: Duodenal Ulcer; Perforation; Pneumoperitonium.

 The incidence of surgical site infection (SSI) varies not just from one surgeon to another, but also between hospitals, between surgical procedures, and most importantly between patients. Use of appropriate preoperative skin antiseptics is an important factor in the incidence of SSI. This randomized prospective study compared the use of two different antiseptic preparations, namely Chlorhexidine and Povidone Iodine, and their role in reducing SSI. It was concluded that Chlorhexidine scrub as a preoperative skin preparation had less patients with SSI, than Povidone Iodine.

Keywords: Surgical Site Infection (SSI); Chlorhexidine; Povidone­Iodine (PI).

 Introduction: Trauma in both forms blunt and penetrating can result in psuedocycts formation. In adults, trauma as an etiological factor is seen in around 15­20% of pseudocysts while in children they are the most common cause of pancreatic psuedocyts seen in around 60%. Methodology: 50 cases adult patients with symptomatic pancreatic pseudocyst are included in the study. The selected patients were subjected to a detailed history elicitationfollowed by thorough evaluation of risk factors and clinical features. Results: Following complaints were recorded, pain abdomen in 93.3%, vomiting in 78.3%, abdominal fullness noted in 60% of patients and loss of appetite in 81.7% patients. Conclusion: In this study patients undergoing surgery had a 6.7% of infection rate

Keywords: Pancraetic Pseudocyst; Clinical Profile; Pain Abdomen.

 Aims: The aim of this study was to investigate association of mortality with the serum sodium level in surgical patients. Methods: The study was a prospective, observational study, conducted on the 167 patients admitted in Surgical ICU over a period of eighteen months (January 2014 ­ June 2015) in Department of Surgery, Mathura Das Mathur Hospital attached to Dr. S. N. Medical College, Jodhpur. Serum sodium values were analysed at admission, at 24 hours, at 72 hours, at the time of shifting to ward in survivors and before death in nonsurvivors. Results: At admission, hyponatremia was present in 8.4%, and hypernatremia in only 0.6% patients. During ICU stay, the prevalence of hypo­ and hypernatremia increased. In nonsurvivors, before death, hyponatremia was seen in 21.5% and hypernatremia in 8.6% patients. Conclusion: In surgical ICU, mortality was shown to have a U­shaped relationship with serum sodium. Both hyponatremia and hypernatremia are independently associated with high mortality in surgical ICU patients. Further studies are needed to find if this association is causal or merely a reflection of differences in severity of illness.

Keywords: Hyponatremia; Hypernatremia; Surgical ICU; Mortality.

 Kerala state of India is producing large quantities of natural rubber and crump rubber industries and foam making industries are very common. Similarly wood industries and brick makingmachineries are commonly used in Kerala. These are producing large number of hand injuries to such an extend that may times it is impossible for complete recovery. This is a major issue in common man’s life and this article tries to study the matter and suggest for a protocolbased management of major hand injuries in view of the manual laborers. We have studied 232 cases of various grades of injuries during 3 yr. period and analyzed the various aspects of treatment and suggest the protocol. The cases other than the industrial injuries are also included in study for comparison.

Keywords: Crush Injury Hand; Rubber Industries; Planner Machine; Flaps; Amputations; Reconstruction.

 Introduction: The formation and closure of diverting stomas is associated with an appreciable morbidity. The most important preventive measure is recognizing the magnitude of the potential problems that can develop and, with these in mind, paying strict attention to technical detail. When a complication does arise, it should be recognized promptly and dealt with in an appropriate manner. Methodology: This was a prospective study on 40 patients undergoing intestinal stoma construction as an elective procedure or as an emergency procedure. Results: Complications were seen more in loop colostomies as compared to other stoma types. End ileostomy seemed to have more complications as compared to loop ileostomy. Conclusion: Most common colostomy associated complication was local sepsis followed by parastomal hernia.

Keywords: Intestinal Stomas; Complications; Sepsis.

 Objective: To study the feasibility and outcome of day care paediatric inguinal herniotomy and open orchidopexy surgery. Methodology: This retrospective study was conducted in Chirayu Medical College hospital of Bhopal from 01­01­2012 to 01­01­ 2016. Male and female paediatric patients (n=100) who underwent inguinal herniotomy and orchidopexy were studied. The data was recorded and analyzed in Microsoft Excel 2007. Results: The mean age of the patients was 21.32±5.12 months. Out of 100 patients, 70(70%) underwent herniotomy and 30 (30%) patients underwent orchidopexy. Out of the 100 patients operated, 82(82%) were discharged on the same day whereas 18(18%) patients were discharged on the next day. Out of 70 patients with herniotomy, 56 (80%) were discharged the same day whereas 14 (20%) were discharged the next day. Out of 30 patients with orchidopexy, 26 (86.6%) were discharged the same day and 4(13.4%) were discharged next day. Immediate Post operative problems (18 pts) leading to delay in discharge was due to pain, nausea, vomiting, urinary retention ,headace,drowsiness and local swelling.. No complications were reported on 4 weeks follow up. Conclusion: Day case herniotomy and orchidopexy in a paediatric population is safe with minimal complications in the immediate postoperative period and should be recommended in developing countries with high volume surgical load.

Keywords: Paediatric Herniotomy; Orchidopexy; Day Case Surgery.

 The low flow vascular malformations are very common in children. The vascular malformations can increase in size and invade locally that could lead to, bleeding deformities and growth defects. There are many modalities of treatment such as embolisation, sclerotherapy and excision. The low flow malformations can be treated and cured with radical excision. This article discuss a few cases treated by radical excision and highlights the importance of surgical treatment in early childhood with the help of microsurgical techniques.

Keywords: Vascular Malformation; Low Flow Malformations; Radical Excision; Sclerotherapy; Embolization.

 Introduction: The most powerful aid to the clinician in reaching a management decision in the acute abdomen is a thorough history and clinical examination, with urgent investigations playing a secondary role. Methodology: All 50 patients who present with acute abdomen including blunt trauma to abdomen and post­operative cases were included for study and evaluated. Results: The most common symptom in our study was pain abdomen, present in all 50 cases followed by distention in 30 cases (78.00%), vomiting 29 cases (58.00%) and least being constipation in 22 cases (44.00%). Conclusion: Acute abdomen should be treated as a surgical emergency unless proved otherwise.

Keywords: Acute Abdomen; Perforation; Peritonitis.

 Introduction: Animal bites pose a public health problem in developed & as well as developing countries. Numerous animal species have the potential to bite humans, the most important are those arising from rabid animals. Aims and objectives: The Aim of the study was to evaluate patients with regards to age, sex, site, types of animal bite, category of bite, stray or pet animal, timing of presentation to hospital, First Aid management and awareness for Anti Rabies vaccine (ARV) in rabid animal bites. Materials and Methods: It was a prospective study carried out by department of surgery at the institute for a period of one year. All patients with animal bites were interviewed as per the proforma & statistical analysis of the data was done for obtaining results. Result: The majority of the bites were by dogs & in male patients, with peak age group in the First decade. Most common site was lower limb. Most bites were by stray dogs, followed by Rats & Cats. Majority applied homemade preparation as First Aid. Most patients were aware of ARV for dog bite. Conclusion: Of all animal bites dog bite cases were more common & seen in children. Majority were in males. Many people are not aware of First aid. With the availability of better media facilities the awareness of First Aid and seeking medical attention at the earliest can be increased. Anti­rabies clinic should be setup for better documentation and management at periphery, preventing the major financial burden incurred by general public.

Keywords: Dog Bite; Category; First Aid.

 Introduction: Breast Tuberculosis (TB) is a rare form of tuberculosis. Incidence of disease is less than 0.1% of all breast lesions in western countries and 4% in TB endemic countries. Breast tuberculosis is one of the extra pulmonary manifestations of tuberculosis. Case Presentations: In this we present a paper series of 4 cases of breast TB confirmed either pathologically or mycobacteriologically or both. These patient were kept on standard Anti­Tuberculosis Treatment for period of 6 months and all the patients showed a drastic positive response. In all the 4 cases lumps size has decreased along with relief of other symptoms. Discussion: High risk population is identified, primary and secondary disease is described. Clinical presentation are analysed. Evaluation of diagnostic workup and limitations are reported. Conclusion: Mycobacterium should be kept in mind for differential diagnosis in patients who have no response to standard antibiotic therapy with chronic breast or soft tissue infections including recurrent breast abscess. The main striking symptoms of breast tuberculosis are painful breast mass, discharge through the fistula and prolonged symptom duration.

Keywords: Breast Lump; Benign; Tuberculosis; Mammary Tuberculosis; Extra Pulmonary TB.

 Objective: The aim of this study is to evaluate the feasibility and safety of non operative [1,2] treatment of acute appendicitis with antibiotics [1,2,3] and avoiding surgery. Although the standard treatment of acute appendicitis [since 1883] is Appendecetomy [2,3,4]. Mortality rate is 0.7% and 2.4% [1,4] in patients with and without perforation respectively. Also in a military setting and in maritimet setting [4], medical management is preferred naturally because it simplifies the situation. Materials and Methods: This study was done in MVJ MC & RH, hoskote, Bangalore From 17th march 2015 to 30th march 2016, patients who were diagnosed of acute Appendicitis were evaluated for medical Management. Discussion and Conclusions: This study indicates that Appendicitis can be effectively managed conservatively in upto 88­ 92% cases [7,8].

Keywords: Appendicitis; Antibiotics; Conservative Management; Appendectomy; Surgery; Appendicucar Mass.

 Introduction:This randomized controlled study was conducted to compare outcomes of both subfascial endoscopic perforators surgery (SEPS) by using conventional laparoscopic instruments and duplexguided open subfascial interruption of perforators. Methods: Patients with clinical lower limb varicosities were allocated randomly to open subfascial interruption of perforator or SEPS. After completion of SEPS if patients had incompetent SFJ, flush ligation and stripping of GSV from SFJ to level of the first port was done concurrently (Trendelenberg’s procedure). Results: Eighteen patients were allocated to SEPS and 17 to the open surgery group. Two patients in the SEPS group were excluded (lost to follow up).Mean operative time (statistically insignificant) and mean number of perforators (statistically significant) were slightly higher in SEPS. Wound complications and mean hospital stay time wassignificantly reduced in SEPS. SEPS also resulted in faster ulcer healing with zero event rates of paresthesia, DVT and recurrence. Conclusion: SEPS warrants an early return to home and minimizes wound complications. DVT and recurrence were not noted in SEPS group. SEPS is easy, safe and feasible by conventional laparoscopic instruments.It is an attractive option of treatment for incompetent perforators in a developing country where endovenous ablation facilities are not widely available.

Keywords: Subfascial Endoscopic Perforator Surgery; Open Perforator Ligation; Varicose Veins; Perforator Incompetence.

 Surgeons’ position during colorectal operations is quite variable. The responses from questionnaire sent to consultant colorectal surgeons in the region demonstrated their preference for standing on patient’s right side for splenic flexure mobilisation and on patient’s left side for anastomosis. There was no preference observed for surgeons position during hepatic flexure mobilisation. This variation in technique might have some implications on training which is uncertain.

Keywords: Colorectal; Surgeon; Position; Open Operation; Surgical Training

 The aim of the present study is to observe patterns of antibiotic use in surgical conditions and also the effectiveness of antibiotics in the prevention and treatment of post­operative infections. The antibiotic use will be studied in patients admitted for various surgical procedures from Sep 2015 to Nov 2015. This study is planned to observe the pattern of antibiotic use for general surgeries, both pre­operatively as well as post­operatively and to assess the outcome. The settings and design of this study was tertiary care teaching hospital, prospective study. The antibiotics used pre­operatively and post­operatively were noted down and also any change in the antibiotic administration. Antibiotic prescription is a major concern in terms of public health, since infections are the most frequent cause of disease. The aim of this a hospital­based study was to assess the pattern of antibiotic use in the surgery ward of a rural hospital, Southern­India. From the result of the study, the frequency and percentage of antibiotic prescriptions identified. The most frequently prescribed single antibiotic was Taxim (Cefotaxime). While the most commonly prescribed multiple antibiotic prescriptions was Xone inj plus Metronidazole inj. From the result we can conclude that, there was a significant oral and inject able antibiotic utilization in the study area compared to similar studies conducted in other part of the world.

Keywords: Antibiotic use; Pattern

 Perforation peritonitis is one of the most common surgical conditions encountered in surgical practice and is a common cause of morbidity and mortality and warrants early surgical intervention. In the study all patients were devided into 2 groups ie. Group Apatients came with in 48 hours from the starting of the symptoms to our institute. Group B­patients came from 48 hours to 144 hours from the starting of the symptoms to our institute. In our study we do a prospective evaluation and comparision of the post operative complications in both the groups viz A&B in the following headings viz. Local complications: Surgical site infection, Burst abdomen, Anastomotic leak, Post operative intestinal obstructionIncisional hernia. Systemic complications: Septicemia Respiratory complications(significant pleural effusion, pneumonia, lung abscess) MODS, Renal failure, DVT, Hospital stay, Deaths. Significant increase in complications rate were observed in late presenting group viz Group B as compared to early presenting group viz Group A.complications rate were increased in Group B by following viz Surgical site infection (by 12.5%),Burst abdomen(by 8.45%), Anastomotic leak(by 7.60%) ,Post operative intestinal obstruction (by 4.90%), Incisional hernia (by 11.39%). Septicemia (by 13.48%), Respiratory complications(by 5.88%), MODS(4.41%), Renal failure(6.74%), DVT (by1.47%) . Average hospital stay was increased by 5 days in Group B patients. Death percentage was also increased by 12.62% in delayed presenting group. Poverty, lack of knowledge and education,lack of sufficient medical facility, lack of registered medical practitioners, practicising quacks and tendency of disease ignorance and self medication make the situation worst which leads to delayed presentation of acute and life threatening illness to specialized medical care centres in India. Abbreviations: MODSMulti organ dysfunction syndrome. DVT­ Deep vein thrombosis.

Keywords: Perforation Peritonitis; Early Presenting Group; Late Presenting Group; Local Post Surgical Complications; Systemic Post Surgical Complications.

 Diabetes mellitus (DM) is the most common cause of amputations. This study aimed toidentify the predictive factors for major lower limb amputation among patients with type 2 DM (T2DM) who were admitted to our hospital, in order to reduce its likelihood. Methods: This study involved 218 patients with T2DM who were admitted for diabetic foot problems from January 2015 to July 2016. A form was developed to document the patients’ profiles, comorbidities, complications, investigations, treatment and clinical outcomes. The predictors for major lower limb amputations were determined using univariate and stepwise analysis. Results: A total of 31 patients underwent major lower limb amputations (25 transtibial, 6 transfemoral). The followingfactors were found to be associated with the incidence of major lower limb amputations: T2DM duration 10 years, diabetic neuropathy, diabetic nephropathy, presentation with gangrene, diabetic foot conditions of Wagner grade 4 or 5, and necrotising fasciitis. Patients who underwent major amputations had significantly lower haemoglobin and albumin levels, and higher total white blood cell counts, erythrocyte sedimentation rates, and C­reactive protein, urea and creatinine levels. However, only T2DM duration  10 years, positive bacterial culture and albumin levels were significant on stepwise analysis. Conclusion: T2DM duration 10 years, positive bacterial culture and low albumin levels were found to be significantpredictive factors for major lower limb amputation among patients with T2DM admitted for diabetic foot problems.

Keywords: Diabetes Mellitus; Amputation; T2DM; Diabetic Foot.

 Pseudocyst is commonly seen around the pancreas in retroperitoneal region. We made an observation of a group of patients diagnosed with pancreatitis due to various etiologies and their presentation as pseudo cyst. Radio diagnosis CECT abdomen has helped in establishing the diagnosis and also in siting the rare site of presentation of pseudo cyst or its extension.

Keywords: Acute Pancreatitis; Pancreatic Pseudocyst.

 Diabetic foot 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 involvement of multiple organs and systems. Hence the condition is often found to be difficult to manage. Various modalities have been evolved time to time for treatment of such condition. General concept is that appropriate and timely healing of wound can prevent various wound related complications like gangrene, auto amputations, septicemia, multiorgan failure, disfigurement, deformities etc. Adjuvant therapy may play an important role here as it is associated with multiple systemic disorders and often the patient is not fit for major surgery. Adjuvant therapy not only increases the wound healing but also can reduce the requirement of graft/ Flap by reducing the size of the defect. Through this article we present use of Autologous Platelet Rich Plasma (APRP) therapy as an effective tool to enhance healing in wound bed preparation of diabetic foot.

Keywords: Diabetic Foot; Wound Healing; APRP.

 The prostate is an androgen­dependent organ. Prostate cancer, the second leading cause of death for men, is androgen dependent so androgen suppression remains the mainstay of treatment for advanced and metastatic disease. Cancer treatment induced bone loss is one of the complications associated with androgen deprivation therapy (ADT) in prostate cancer patients. It is of particular concern because it can lead to osteoporosis and bone fractures, which not only negatively impact patient quality of life but also overall survival. However, these studies were performed in western countries; moreover study of Japanese men with prostate cancer found that they had a low prevalence of osteoporosis that was not increased by ADT. Evaluation of bone mineral density changes along with biochemical markers was done on patients of carcinoma prostate undergoing androgen deprivation therapy in form of castration. Sixteen patients of carcinoma prostate who have under gone androgen deprivation therapy were enrolled in the study.They were followed within the period of 1 year to study BMD changes by dual­energy X­ray absorptiometry (DEXA) scan. BMD was measured at 0, 1, 3 & 6 months during follow­up after excluding bony metastasis in thelumbar spineand femoral neck. We found statistically significant loss of BMD after orchiectomy with BMD decreasing up to 2% at 1 month, up to 5% at 6 month at lumbar spine and a decrease of 2.2% at 1 months & 6.7% at 6 month at femoral neck (p< 0.001), resulting in an increased incidence of osteoporosis from 24% pre operatively to 48% 6 months after orchiectomy.