New Indian Journal of Surgery

 Mucinous cystadenoma of the appendix is a rare benign tumor of appendix. Histopathologically divided into three groups: focal or diffuse mucosal hyperplasia, mucinous cystadenoma and mucinous cystadenocarcinoma. This condition is often associated with other neo-plasia, especially adenocarcinoma of the colon and ovaries. In this case report we discuss a case of a 48 yearold male diagnosed with mucinious cystadenoma of the appendix treated successfully. We have added the pathology, various diagnostic modalities and treatment for the above mentioned disorder.

 Intestinal obstruction due to a rare cause in an adult with chronic pain abdomen. Introduction: The description of patients presenting with small bowel obstruction dates back to the third or fourth century BC, when Praxagora created an enterocutaneous fistula to relieve a bowel obstruction [1]. Midgut volvulus due to intestinal malrotation is a rare cause of intestinal obstruction when occurring in adult life [2].This paper documents the difficulties in reaching an early diagnosis. Discussion: bowel mal rotation can be a mal fixation, malrotation with volvulus and vascular compromise. Usually present in paediatric age group here we present an adult with intestinal obstruction. Surgeries usually done are release of adhesions, prophylactic appendectomy caecostomy and hemicolectomy.

 A 42yrs female presented with a large suprarenal mass with hypertension and diabetes mellitus. Dexamethasone suppression test was positive suggestive of Hypercortisolism/Cushing’s syndrome. Right adrenalectomy was done. Histopathology revealed Adrenal  myelolipoma with osseous metaplasia.It is a are presentation reported For the first time with hypercortisolism.

 Introduction: Ventral Hernias are second most common type of hernias accounting for 21 to 35% of all verities of hernias. The main danger of all forms of hernia is strangulation and hence need surgical intervention. Repair of ventral hernias can be technically challenging and a myriad of methods have been described. The most important distinctions in describing surgical management of ventral hernias are primary vs mesh repair and open vs laparoscopic repair. Mesh repair became the gold standard in elective management of most ventral hernias. Methodology: The cases are studied as per proforma attached and master chart is made for the cases studied to make the report brief. All cases were clinically diagnosed and all patients included in the study underwent surgery following preoperative investigation in the form of Hb%, BT, CT, FBS, PPBS, Blood urea, serum creatinine, urine for albumin, sugar and microscopy, ECG, chest X-ray. No other special investigations were required for any of the patients except patients who underwent ultrasound examination of the abdomen for ascites. Results: At the 2nd month of follow-up, there was not much difference in quality of life between the two groups. Significant difference was found in vitality (57.45 vs 54.78,p=0.07), and mental health (50.21 vs 47.37,p=0.06). Conclusion: Overall quality of life at the end of 1st month follow-up was good in laparoscopic group.

Objective: To study postoperative pattern of complication following Trendelenberg surgery with venous stripping and ambulatory phlebectomy To study prevalence and severity of complications. Method: Prospective study. The parameters observed were pain, recurrence, infection, haemorrhage, neurological. Results: Out of 52 patients, 71% patients had varicose veins on their left leg. The mean operating time varied between 87 ± 22.87 minutes, mean hospital stay among the study population were seven to eight days and time taken to returned to work was 40±5 post op. After the immediate post op the minimum and maximum VAS score was observed to be 5 and 9 respectively and the minimum and maximum VAS score at 6 months was observed to be 0 and 6 respectively and nil recurrence,infection, haemorrhage and neurological complication.This shows the effect of the new intervention. Conclusion: From the results we have concluded that the Trendelenberg surgery with venous stripping and ambulatory phlebectomy. is advantageous in terms of decreased complications, better functional outcomes and morbidty.

 Introduction: Hernia may be either symptomatic or asymptomatic, and commonly cause pain or are aesthetically distressing. These problems, coupled with the risk of obstruction & incarceration, are the most common reasons for patients seeking surgical repair of hernias. Advances made in the basic and clinical sciences have allowed for the better understanding of pathophysiology of hernia formation. It is known that based on Pascal’s principle of the hydrostatic forces and the law of LaPlace that a hernia will continue to enlarge over the time if not treated. Methodology: Patients with age between 18years and 60 years were included in the study. Patients with severe comorbid conditions (severe cardiopulmonary disease, uncontrolled ascites), with pre-existing skin infection at surgical site, with multiple post-op scars, and patients undergoing emergency surgery were excluded from the study. Results: There were no post-operative deaths, no major cardiovascular, pulmonary complications. 3 patients in the laparoscopic group developed seromacompared to 9 patients among open repair group.14 patients developed surgical site infection, 2 patients at laparoscopic port site and 12 who underwent open mesh repair. 17 patients had chronic pain at the operated site at the end of 2 months followup. Conclusion: Open hernia repair which are riddled with higher incidence of complications is reiterated once again in our study too. Thus management of ventral hernia with open method can be narrowed down to only cases which are complicated with multiple adhesions or irreducible incarcerated, strangulated hernia.

Introduction: Quite often, Diabetic patients present with uncontrolled infection, ulcerations leading to compromise of part of foot. Thus there was a need to study various measures to prevent these complications.

Methodology: All operative and medical management findings were noted and patients were followed up at intervals. All the data received during this procedure are placed in a special pro-forma that is prepared for the said purpose.

Results: Out of 50 cases, 21 cases couldn’t turn up for a follow up and so the prognosis could not be evaluated for these cases. Satisfactory local healing was achieved in 11 cases including 2 cases of gradel and 9 cases of toe amputation after 6 weeks of follow up. 1 case of transmetatarsal amputation came for check-up and a satisfactory healing with no pressure complications was noted at the time of follow-up.

Conclusion: HbA1c control was found to be poor (>8%) in a very high percentage of patients conforming the risk relation between glycosylated hemoglobin and diabetic foot infections.

 Introduction: The morbidity and mortality rates associated with appendicitis are greatly increased when perforation ensues, wound infection rates increases, intraabdominal abscess formation increases 15 fold and mortality may be 50 times greater. Ruptured retro-cecal appendicitis can present as extremely fulminant form of a common disease such as extensive retroperitoneal and right thigh abscess. Methodology: This study was performed on 114 consecutive patients who were operated on for clinically and/or radiologically suspected acute appendicitis. All these patients are subjected to diagnostic laparoscopy and appendicectomy. The presence of normal appendix, inflamed, perforated etc. are noted. The diagnosis was also confirmed histopathologically. Results: Alvarado score and CRP in showed sensitivity of 85% and 81% respectively. But TLC showed highest specificity of 100%.CRP shows 73% specificity in our study. 62(54.4%) cases of positive Alvarado score patients showed positive c-reactive protein (CRP) in 53 (85.5%) cases, which shows a significant ‘p’ value of 0.0048. CRP showed positive predictive value of 97%, but it has a low negative predictive value of 29%. Conclusion: Acute appendicitis remains a diagnosis based primarily on history and clinical examination. Serum CRP estimation does not undercut the skill of an experienced surgeon, but compliments it.

 Introduction: Diabetic foot disease is a serious medical, social and economic problem and it continues to be a prominent area of discussion and research. It is a major cause for morbidity, which may lead to amputation of the foot. In developed countries, it has been estimated that 20% of all diabetic admissions to the hospital are due to foot problems and 5 out of 6 major amputations are due to diabetic foot disease. Methodology: A detail history of all the patients were taken, relevant investigations were performed, special attention is taken for estimation of Glycosylated Hemoglobin level in all patients. All operative and medical management findings were noted and patients were followed up at intervals. All the data received during this procedure are placed in a special pro-forma that is prepared for the said purpose. Results: Among the 50 patients of diabetic foot 2 cases (4%) were Grade I, 3 cases (6%) were Grade II, 8 cases (16%) were Grade III, 36 cases (72%) were Grade IV, 1 case (2%) under Grade V and no cases were recorded under Grade 0. Conclusion: Ulceration and infection of the diabetic foot poses a big problem with regard to bed occupation in surgical wards owing to longer duration of stay.

Keywords: Diabetic Foot; Ulcer; Clinical Profile.

 Introduction: Infective factor seems to be a major cause of formation of gallstones. Moynihan’s aphorism that “gall stone is a tomb stone erected in the memory of the organism with in it” is true today [1]. Evidence in favour of infection includes isolation of E. coli, bacterium typhosum, streptococcus from the gallbladder bile and from the center of the gallstones. Methodology: All patients who were subjected to laparoscopic cholecystectomy had their Gallbladder retrieved in a plastic endobag and bile collected in a culture bottle under strict aseptic precautions and transferred at room temperature in an hour to the laboratory for culture. Results: The organisms grown from bile culture were E-Coli 45.5%(41/90), Klebsiella 27.7% (25/90), Enterobacter 8.8% (8/90), Pseudomonas 7.7% (7/90), Staphyl-ococcus 2.2%(2/90), Non-fermenting gram negative bacilli 2.2%(2/90), and Citrobacter freundii 1.1%(1/90). Conclusion: Fluroquinolones (Levofloxacin/ Ofloxacin) may be used as first line drug for preoperative prophylaxis in gallstone diseases undergoing surgery.

 A case series of the 8 case in ventral hernia repair by the Hybrid method. A study was conducted in the Shanmuga hospital and salem cancer institute, Salem,Tamil nadu. Total 8 No of the case included in the case series study.

 Appendicitis is one of the commonest acute surgical diseases and treatment by emergency openappendicectomy is the most frequently performed surgical procedure in many centers. On review of more than 100 cases, around 50% of cases proceeded with McBURNEYS Incision, another 50% cases we have done with Lanz incision. We found Lanz incision is superior in the approach to the base of the appendix & also cosmetically better for the both male & female and also for the children. The study has been done in the various hospitals where I worked both in India & Abroad. 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. In Saudi Arabia- from 2004 to 2008, Maldives in 2015, in Botswana in 2016.

 Background: Surgical problems in the HIV patient include not only abnormal presentation of common illnesses but also include unique problems that are consequences of the acquired immuno suppression. Aims: 1. To study the pattern of various surgical presentations of HIV patients. 2. To know the pattern of impact of effective ART on surgical presentations. Settings and Design: We conducted a cross sectional study on patients admitted in Surgery ward over 6 months time among the patients initiated on ART (Anti retroviral therapy) from a comprehensive HIV care centre to analyze the various conditions in HIV patients warranting surgical care and intervention. Materials and Methods: We collected data from March 2014 to August 2014 by personal interview with the HIV infected patients who attended General Surgery, other Surgical Specialties, Obstetrics & Gynecology and Casualty departments of Medical College, Thrissur. Their details about anti retroviral treatment were collected from ART clinic in the hospital and their data regarding various surgical interventions were collected from registers in respective departments. Results and Conclusion: We had 92 cases of surgical admissions during study period. 85 (92%) patients in this group had surgical interventions and 7 (8%) cases were managed conservatively. The conclusions of this study were effective ART increases the number of elective surgical problems in HIV patients due to their increased survival and it also shows the different types of surgical presentations in HIV patients.

 Sigmoid Volvulus is a very common cause of large bowel Obstruction. On review of 14 cases of Sigmoid Volvulus underwent Emergency resection and Primary Anastamosis with Tube Caecostomy as a Decompression of colon by Malecots Catheter alternate to Hartmanns or Paul-Mukulicz operations, to reduce the time & another surgery of colostomy closure. The study has been done in a few hospitals where I worked, Coimbatore Medical college from June1987 to April1991, Erode Head Quarters hospital Erode from September 1991 to December 2000 & Perundurai Medical College Hospital, Perundurai from November 2002 to June 2004.

 Background:Non healing ulcers are a very common complication of diabetes. It increases the morbidity and economic burden of the patient. Ischemia is one of the common causes for none healing in diabetic patient. Even after angioplastic revascularization some patients’ shows delay in healing. Non achievement of direct flow to ulcer area may be a reason for this and it was proposed by Ian Taylor who in his angiosome concept. Objective: To evaluate the factors predicting outcome after revascularization based on angiosome concept in Diabetic Foot Ulcer. Methods : A prospective observational study was done which included 50 diabetic foot ulcer patient who underwent endovascular revascularization in our hospital during the period January 2013 to March 2015 and they were followed up for 6 months to look for Ulcer healing rate, ulcer recurrence, leg salvage rate and major amputation . Results: Out of 50 participants in 52% direct revascularization was done. Base line characteristics of both the groups were comparable except gender (where proportion of females was higher in indirect group), CKD, smoking, UTCWS grade of ulcer which were more in direct group. Ulcer predominantly affected toes (70%) and Anterior Tibial angiosome was the most common (50%) angiosome involved by clinical classification. Most common affected arterial segment pattern by Peripheral angiogram was multisegmental followed by infrapopliteal disease. In 78.3% of cases ulcer healed at 6 months in the indirect group whereas 57.7% patients had healed ulcers at 6 months in the Direct group (p value =0.12). Female gender, CKD, smoking and ulcer grade found to have no association with healing at 6 months. No significant difference was found in leg salvage rate, ulcer recurrence and major amputation. Conclusion: Endovascular revascularization is a good modality to reduce morbidity in diabetic foot ulcer patients. There was no significant difference in outcome between these two groups.

 Intruduction: Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing procedure for anal fistula. The success rate is comparable with other sphincter-preserving techniques. The objective of the study is to evaluate the results of LIFT in the management of transsphincteric and suprasphincteric anal fistula and to assess any change in continence after the procedure. Methods: One hundred and ten patients with transsphincteric and suprasphincteric anal fistula were included in the study. Assessment of continence and anal manometry were performed before and after the procedure. Primary outcome measure was complete healing. Minimum follow-up was one year following the procedure. Results: Primary healing occurred in 83.63% patients. The average healing time was seven weeks. None of the patients reported any change in continence after the procedure. There was no significant difference in resting and maximal anal pressures before and after the procedure. Conclusion: The results of the LIFT technique are very promising. This technique has the potential to become the gold standard for transsphincteric and suprasphincteric anal fistula.

 Background: The timing of operation for acute appendicitis is still a matter of controversy. This study aims to compare the outcomes between early and delayed emergency appendectomy and assess the feasibility of delayed operation. Methods: Patients who underwent emergency appendectomy at Victoria Hospital, Bengaluru between July 2015 and June 2016 were reviewed retrospectively. Outcome measures were clinical findings, white blood cell (WBC) count at the time of presentation, duration of surgery, intra-operative findings, complication rate, surgical site infection (SSI) rate, length of hospital stay and re-admission rates. Results: A total of 178 patients underwent emergency open appendectomies out of which 156 patients were included. Patients were divided into two groups based on time from onset of first symptom to incision: 73(46.7%) in group A and 83(53.2%) in group B. There were no significant differences in age, sex ratio and comorbidities between the two groups. However there was significant difference in WBC count and differential neutrophil count with Group A showing higher leukocytosis and neutrophilia. Group A showed higher intra-operative complication 32(43.83%) when compared to Group B 35(42.16%) p=0.013. There were no significant differences in wound infection, length of postoperative hospital stay and readmission rate between two groups. Conclusions: This study reveals that delayed appendectomy is safe and feasible in adults, not worsening the intra-operative or post-operative complications. The surgeon can decide the appropriate timing of appendectomy based on the available hospital resources and perform the surgery in a semi-elective manner.

 Backgound: Various clinical presentations, ranging from chronic abdominal pain to acute midgut volvulus with ischaemic bowel injury, may result from intestinal malrotation. In general it is possible to detect the intestinal malrotation, however there are many variables and exceptions. The purpose of this study was to retrospectively analyse the patients of intestinal malrotation at a single surgical centre in the last 10 years and to identify the spectrum of presentation, factors responsible for the delay affecting the diagnosis and outcome in these patients. Methods: The study was conducted in a tertiary referral centre with separated Department of Paediatric Surgery. Patients admitted and operated from July 2005 to July 2015 with complains of intestinal malrotation were included in this study. Case records were analysed with special emphasis on age, mode of presentation, any delay in treatment if any and the reason for it was noted. The operative records were retrieved to know the exact operative findings, the procedure performed and the outcome of surgery. Follow up was done for at least 1year, after surgery and postoperative complications if any were analysed. Results: Total 220 patients of intestinal malrotation were included in this study. Male were 143 and 77 were female. Neonates constituted the largest group (n=87) followed by infants (n=56). There 40 patients who had delay in diagnosis. Bilious vomiting was the commonest presentation (n=62/153) in early age group while chronic abdominal pain was seen in older age group (n=37/77). Ladd’s procedure was the commonest surgical procedure (n=167) followed by intestinal resection and stoma formation (n=28) and resection and anastomosis (n=21). There were 14 mortalities and 17 complications needing admission in follow-up period of 1 year. Conclusion: Intestinal malrotation is a surgical problem mostly of neonates but it is more likely to be ignored in older children who are otherwise being treated for some unrelated conditions and continue to develop chronic abdominal pain and intermittent distension, and poor growth. A high index of clinical suspicion is needed especially in these patients. The problem if not diagnosed properly leads to bowel loss, increased morbidity and mortality.

 Telemedicine is becoming an important part of clinical practice in today’s armamentarium. Telemedicine has various utilities like tele consultation, tele surgery, tele education, tele monitoring, tele pharmacy, tele nursing etc. Improved technology and use of simple gazettes have contributed to its utility even in remote areas. Hence telemedicine is not confined to big cities only. It is being used remote towns and villages also. It may not be possible for everyone, especially belonging to remote areas, to visit at higher centers regularly because of distance, money and time factors. Telemedicine plays very important role in such scenarios where it not only helps patients by providing benefits of specialist’s consultation but also is prevents the progression and complications of the disease by reducing the visit gaps. Through this article we highlight the use of telemedicine in saving time and money of the patient with improved outcomes.

 Background: Surgical Site Infection rate is an important health care index. Prophylactic antibiotics have been used to prevent surgical site infections. A continuous surveillance is called for to keep a check on the resistance pattern of microbes to the prophylactic antibiotic. Objectives: 1. To estimate the Rate of Surgical Site Infections in the years 2014 and 2015 with reference to CDC guidelines at a tertiary care hospital (PSGIMS&R) located in Tamil Nadu, Southern India 2. To estimate the frequency of various organisms causing Surgical Site Infections 3. To study the antibiotic resistance pattern to the prophylactic antibiotic used. Type of Study: Retrospective Observational study Period of Study: January 2014 – December 2015 Methodology: The present study was conducted in PSG Institute of Medical Sciences & Research, Coimbatore. We did a thorough retrospective analysis of case files of 467patients reported to have culture positive SSI. SSI was established using clinical and Standard microbiological testing. Results: The outcome of this study is that the SSI rate of 4.9% reported in our hospital is consistent with or less than the rates reported in other parts of the country. Diabetes is a very important comorbidity which makes the person significantly vulnerable to SSI. In culture positive cases 24.4% of SSI showed resistance to the prophylactic antibiotic used. Conclusion: There is a significant rise in incidence of organisms exhibiting resistance to the prophylactic antibiotic and a constant surveillance with feedback to the surgeons and strict adherence to antibiotic policies is essential.

 Background: Laser epilation is a standard method for permanent hair removal. Intense pulsed light is another accepted and comparable method for the same. The previous studies were in conclusive about the efficiency and mandates further research. Aim: To study the efficacy of Nd: YAG laser in comparison with Intense Pulsed Light (IPL) for treatment of unwanted body hair. Methods: The study was conductedfrom April 2014 to November 2015. This is a preliminary result of an ongoing thesis project. All patients between 6 to 60 years ofage with unwanted hair who consented to participate in the studywith Fitzpatrick skin types IV, V &VI. PatientswhohadPrevious laser to the same area, Gross hormonal dysfunction, Waxing, depilation, electrolysis or bleach use within six weeks, history of keloid scarring and pregnant patients were excluded. Twenty patients were included in the study, they were Randomized into 2 groups. Group 1- patients were treated with Nd:YAG Laser. Group 2- patients were treated with IPL. Parameters studied were: Hair Counts, Mean Hair Reduction, Pain Severity , patient satisfaction and complication rates. Results: Total 20 patients were included in the study. Of which 19 were females and one was male. The mean age of the patients was 27. Based on skin type, 19 patients were Fitzpatrick type-5 and one was type-6. After randomization 12 patients were selected into group-A and received Nd:YAG laser for hair removal and 8 patients were selected in to groupBand received IPL for hair removal. The mean fluence used for Nd:YAG was 24 and for IPL 4.3. Of the IPL group, 5 out of 8 patients and Nd:YAG, 9 out of 12 patients had mild burning sensation during the treatment. The mean patient satisfaction score during all 5 sections were 87.3 for Nd:YAG and 86 for the IPL group. The mean pain scores during the 5 treatment sections were 11 for Nd:YAG and 12 for IPL. One patient treated with IPL had hyperpigmentation post-treatment, which disappeared completely with conservative management in 3 weeks’ time. The mean hair reduction was calculated as 40.23 % for Nd:YAG and 32.49 for IPL. Conclusion: The mean hair reduction rates by Nd:YAG was relatively higher for Nd:YAG than IPL in our study. However, a study with large sample size is required for better analysis.