New Indian Journal of Surgery

Injuries to the buttocks and the perineal region is a comparatively rare presentation with thermal burns. The patients present with chronic constipation, difficulty in hip abduction and restriction of sexual functions. Complications such as gluteal pouching with hooding of the rectum have also been described. Release and reconstruction of the defect is a challenge with an extra dimension to the contracture, which on release creates a raw area much bigger than expected. Reconstruction of the gluteal fold and cleft is another challenge and requires careful planning as contracture of the gluteal fold may result in anal verge being pulled up. We discuss management of a post burn contracture of the gluteal fold in this article. 

Keywords: Post Burn Contracture; Perineal Contracture; Buttock Contracture; Gluteal Pouching.

Fournier’s gangrene (FG) is a rapidly progressive necrotizing fascitis of the perineal and genitourinary region [1]. Most patients have underlying medical problems which cause a variable degree of immunosuppression [2]. Diabetes mellitus, alcohol abuse, renal insufficiency, and steroid use are the medical problems associated with the entity. It has been postulated that the pathogenesis of Fournier’s Gangrene involves synergistic polymicrobial infection [3]. Fournier’s gangrene is relatively uncommon condition, especially in female patients. Fournier’s gangrene in  women may arise from vulvar orBartholin’s gland abscesses or may result from hysterectomy orepisiotomy wound. Here we report a case of Fournier’s gangrene in a female patient with no known comorbidities.

Keywords: Fournier’s Gangrene in Female Patient; Synergistic; Polymicrobial; Necrotizing Fascitis of Perineal Region; Serial Debridement and Maintenance of Nutrition.

Acute appendicitis is the commonest ailment presenting at the department of general surgery. A number of clinical scoring systems have been developed for assessing right lower Quadrant abdominal pain for suspected appendicitis. Many scoring systems like Alvarado score, Lintula score, Eskelinen score, Ohmann score, Christian score and Ripasa score are used for children, adults or mixed populations. Amongst them the Alvarado score is most accepted and commonly used scoring system. We intended to evaluate the utility of Alvarado scoring system in the diagnosis of acute appendicitis at our institution in dakshina karnataka.

Materials and Methods: A prospective longitudinal and observational study was conducted between October 2015 to October 2017 at our institution. The inclusion criteria included patients between 15-60 years groups who presented with Right Iliac Fossa pain clinically suspected to be Acute Appendicitis. Exclusion Criteria included patients with delayed presentation leading to appendicular mass, cases with perforation and children below 15 years of age. The statistical analysis including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy were then calculated using histopathology (HPR) as a gold standard investigation.

Results: Out of 100 patient who underwent appendicectomy, 54 patient had showed positive Alvarado score >7 suggesting probability of acute appendicitis, 36 patients whose score was <7 showed positive histopathology report. Hence ALVARADO scoring SYSTEM was found to have sensitivity of 60%, specificity of 90%, positive predictive value of 98%, and negative predictive value of 20% and diagnostic accuracy rate of 63%. In our study the Alvarado score had low sensitivity but high positive predictive value. Conclusion: Alvarado score is simple scoring system which can be utilized to ascertain the diagnosis of acute appendicitis made by clinical and laboratory finding rather than utilizing it as a tool for making diagnosis of acute appendicitis.

Keywords: Alvarado Score; Acute Appendicitis; Sensitivity; Positive Predictive Value.

Methodology: A prospective survey of patients with acute generalized peritonitis due to hollow viscus perforation was carried out in general surgical wards of our institute during the period starting from September 2014 to September 2015. Study population consisted of 75 consecutive patients with perforativeperitonitis, which confirmed on emergency laparotomy.

Statistical analysis: APACHE II and MPI scores were tested by quantitative
methods based on statistical criteria.

Results: The area under the curve was 0.938 for APACHE II and 0.914 for MPI as shown in.The APACHE II curve showed that it discriminated better than the MPI. The sensitivity of APACHE II was superior to MPI at any given point of specificity. This difference was maintained across the entire range of values. The area below the curve was 0.938 for APACHE II and 0.914 for MPI showing that APACHE II is better than MPI (p < 0.01).

Conclusion: As per our analyses APACHE II and MPI both had good sensitivity and specificity. Both the scoring systems were accurate, sharp and reliable in predicting outcome. In all these aspects, APACHE II found to be better than MPI in prediction

Keywords: Apache Ii; Mpi Score; Peritonitis.

Background: Thermal burn injuries are relatively common in developing countries which produce more physical and psychological damage. By promoting early healing these complications can be minimised. Phenytoin is one of the easily available drug that promote early wound healing.

Objective: To assess the effect of healing of topical phenytoin in burn wounds caused by 2nd and 3rd degree burns.

Method: It is a prospective study done in tertiary burn centre from the period of December 2015 to November 2016. Total 9 patients (3 males, 6 females) were included in the study based on the inclusion and exclusion criteria. All patients were treated with topical application of intravenous phenytoin solution once 3 days. The data collected include demographic details, tissue culture, wound discharge, severity of pain, appearance of granulation tissue, wound contraction.

Results: Majority of burn wound caused by self-inflicted. At the time of starting of phenytoin therapy majority of wounds were colonised with pathogenic bacteria which were not affecting the phenytoin induced wound healing. Wound discharge got significantly reduced after 3 -5 sittings of phenytoin therapy. Severity of pain got significantly reduced as per patient’s self-assessment of pain. All wounds showed progressive wound contraction as documented and assessed by digital planimetry.

Conclusion: In our study topical application of phenytoin caused progressive wound contracture, re-epithelialisation, reduce in discharge and pain, leads to early wound healing. Bacteriostatic effect also noted in few cases, further controlled trials is required to validate the same.

Keywords: Phenytoin; Burns.

Background: Painless breast lump is the most common symptom found in maximum number of patients with carcinoma breast. It is also the most common presenting sumptom in many benign diseases of the breast.

Aims: To study painless breast lump by clinical examination, imaging and histo-pathological examination and to know the frequency of benign and malignant breast diseases in premenopausal patients in our society.

Settings: Dept of General Surgery, GMC, Omandurar Estate and ISO KGH, Chennai.

Design: Prospective study.

Methods and Materials: One hundred and five female patients with painless breast lump presented to the Dept of General surgery at GMC, Omandurar Estate and ISO KGH, Chennai during the period of April 2017 and July 2017 were studied. Diagnosis was made by a combination of clinical examination, imaging and histopathological examination.

Results: Painless breast lump in premenopausal women was commonly benign (68%) followed by malignant conditions (32%). The commonest diagnosis was fibroadenoma followed by carcinoma of the breast. The common age group of fibroadenomas was between 16-35yrs and carcinoma breast was between 46-55yrs.

Conclusion: The results of this study showed that though painless breast lump in premenopausal women was commonly fibroadenomas (46%) they also account for a significant number of cases of carcinoma breast (32%).

Keywords: Painless lump; Premenopausal women; Mammogram; Fibroadenoma; Carcinoma breast.

Scrotal swellings are a common problem among the men of all ages. The common differential diagnosis includes Hydrocele, Epididymo-orchitis, Epididymal cyst, Torsion, Varicocele, Tumour. The present study has been conducted on fifty patients in Geetanjali medical college and hospital, Udaipur to evaluate the epidemiology and clinical presentation of the scrotal  swelling. Prompt clinical examination followed by appropriate imaging is the key to early diagnosis and management. Ultrasound is an important investigation. Incidence of various scrotal swelling is Hydrocele 48%, Epididymo-orchitis 32%, Testicular torsion 4%, Varicocele 4% and Fournier’s Gangrene is 8%.

Keywords: Hydrocele; Scrotal Swelling; Torsion; Varicocele.

Background: Among chronic venous insufficiency, varicose veins are the most common manifestation affecting upto 25% of women and 15% of men [1]. While conventional surgical treatment for varicose veins has proven effective, it has fallen out of favour due to time away from work, poor cosmesis and procedural complications.

Materials and Methods: The present study was conducted in the Postgraduate Department of General Surgery, Government Medical College Srinagar from February 2013 to October 2014 in 100 patients randomly divided into two groups A and B, each group having 50 patients irrespective of age and sex. Patients in group A underwent Sapheno femoral Junction Ligation and Greater Saphenous Stripping/ Multiple Ligations or Saphenopopliteal Junction Ligation and Lesser Saphenous Stripping/Multiple Ligations. Patients entitled for study in Group B underwent Foam Sclerotherapy Combined with Saphenofemoral Junction / Saphenopopliteal Junction Ligation.

Results: Most of our patients in our study belonged to working age group of 20- 49 years, showing female predominance of varicose veins in our study: In group A in 48 (96%) patients the procedure was successful whereas in group B 44 (88%) had successful outcome. In group A operative time ranged from 70 to 100 min with mean of 83.72 min , S.D of 9.15 and S.E of 1.83 whereas in group B the operative time ranged from 40 to 60 min with mean of 50.96min, S.D of 6.37 and S.E of 1.27. In group A time required to return to work ranged from 4-16 days with mean time of 9.4 days and in group B it ranged from 1-8 days with mean time of 3.92 days (p<0.001). In group A 1 (2%) patient developed recurrence after procedure where as in group B 3 (6%). No major complications like pulmonary embolism, anaphylaxis, stroke occurred in our study except one case of DVT in foam group. Minor complications reported included skin pigmentation, superficial thrombophelibits, wound infections.

Conclusion: Ultrasound guided sclerotherapy combined with sapheno-femoral ligation was found to be safe, very effective, less expensive, involved a shorter treatment time and resulted in more rapid recovery compared to sapheno-femoral ligation, and was cosmetically cosmetically better, with shorter duration of hospital stay compared to surgery alone. It has high patient satisfaction results and improvement in quality of life.

Keywords: Foam Sclerotherapy; SPJ /SFJ Ligation; Varicose Veins.

Background: About 10% of all the abdominal primary hernias consists of umbilical and para umbilical hernia [1]. Earliest literature of umbilical hernia with its complication dates back to 1500 BC. In 1915, Dr.Moschcowitzauthored an article regarding the aetiology of development of umbilical hernias, in which he suggested the pathogenesis related to the anatomical weakness at umbilicus [2]. Predisposing factors include obesity, multiplepregnancies, ascites, abdominal tumours, smoking [3]. Umbilical hernias have tendency to be associated with risk of incarceration and strangulation. Umbilical hernias can be repaired anatomically or using mesh repair, either with open repair or laparoscopic repair. In the present study we used anatomical repair method to close the defect using polypropylene suture material using both intermittent and continuous sutures.

Methods: Study included 25 patients with primary uncomplicated umbilical hernia who underwent anatomical hernia repair using polypropylene suture with intermittent and continuous suturing technique in all the patients .Patients followed up for a period of August 2012-August 2017.

Results: Patients were followed up at 1 week, 1 month and 6 months period. We found success rate of 100% with no recurrence in 6 months follow up period.12% of patients had wound seroma formation (3/25), and 8% of patients had wound infection (2/25). Mild pain was seen in 16% of patients till period of 1 month (4/2).

Conclusion: The method we followed to close the umbilical hernia defect by anatomical repair with horizontal closure using polypropylene suture with both
continuous and intermittent suturing technique had a double surety of the secured closure and the outcome had almost similar results as mesh closure technique with 100% success rate.

Keywords: Umbilical hernia; Polypropylene; Primary repair

Objectives: Three groups were compared on basis of postoperative symptoms and complications and overall duration of hospital stay to assess the role and rationale of use of antibiotics in patients undergoing Laparoscopic Cholecystectomy.

Setting: This study was done in a rural tertiary centre of western region of Uttar Pradesh state of India. This area caters a major population of Gall stone diseases.

Participants: 452 patients were included in the study between the age group of 18-60 yrs. Majority of patients in the study population were females (n=407; 90.04%). Female : Male ratio was 1:0.11.

Interventions: Patients were divided into 3 groups. In Grp A- No Antibiotics were given, in Grp B- preoperative single shot antibiotics were given at the time of induction, in Grp C- antibiotics were given both pre and post operatively.

Primary and secondary outcome measures: Surgical site infection, Pain as per VAS and postoperative symptoms were taken as primary outcome measures.

Results: At stitch removal most common complaint in overall patients was pain abdomen (n=63; 13.94%), followed by port-site infection (n=40; 8.85% each), fever (n=40, 8.85%) and vomiting (n=17; 3.76%). Prevalence of all the above complaints was higher in Group A compared to Group B and Group C, differences were found to be statistically significant only for vomiting, fever and port-site infection for Group A from group B and C while differences were not found to be significant between Group B and C.

Conclusions: After our study we recommend the use of single dose of preoperative antibiotics as they are sufficient and comparable to antibiotics given in both pre-operative and post-operative period in the low-risk elective Laparoscopic Cholecystectomy procedure. This will definitely demoralize the unjudicious use of antibiotics which have a risk of antibiotic resistance and other complications and will increase the cost effectiveness of the procedure.

Keywords: Laparoscopic Cholecystectomy; Antibiotics.

The study is carried out with a broad objective of assessing relative diagnostic efficacy of clinical evaluation, FNAC and biopsy.

Method: FNAC was then performed and smears were made. Few air dried and few alcohol fixed smears were made. The technique of FNAC used in the present study is the same as described by Franzen, Zajicek. Removed lymph nodes (Biopsy sample) were analysed pathology department for further histopathological examination.

Result: Sensitivity and Specificity of FNAC in diagnosing Lymphoma was 66.66% and 100% respectively while diagnostic accuracy of FNAC in lymphomas is 100%. Sensitivity of FNAC in diagnosing Tubercular lymphadenitis is 75.92%, for Reactive lymphadenitis is 100%, for metastatic secondaries is 92.85% and for lymphomas it is 66.66%. Specificity of FNAC in diagnosing Tubercular lymphadenitis is 100%, for Reactive lymphadenitis is 91.9%, for metastatic secondaries is 100% and for lymphomas it is 100%.

Conclusion: FNAC can be deemed as a frontline investigation with further investigations onthe basis of FNAC result. However, histopathological examination remains the most dependable diagnostic tool.

Keywords: Fine Needle Cytology; Biopsy; Cervical Lymphadenopathy.

Context: Hernioplasty with use of synthetic mesh is the gold standard for Inguinal hernia repair. However high cost of synthetic mesh is the limiting factor for its use in poor resource countries. This is a study of use of mosquito net as a cheaper alternative to synthetic Prolene mesh for inguinal hernia repair.

Aims: To study safety, efficacy and cost effectiveness of Mosquito Net as compared to Prolene mesh.

Settings and Design: Comparative study by random selection, between Mosquito net and Prolene mesh for Ingunal hernia repair with 100 patients in each group. All patients underwent Lichtensteins Tension free Repair under Spinal Anaesthesia. 

Methods and Material: Comparative study between Mosquito net and Prolene mesh was done in terms of sterilization, complications and cost effectiveness.

Statistical analysis used: Proportionate test to compare Complication rate.

Results: Out of 200 Inguinal hernia repairs done, Mosquito net was used in 100 patients and Prolene mesh in 100 pateints. Sterilization was done by Routine Autoclave which did not change the properties of mosquito net. The complication rate of Mosquito net group was negligible and comparable to Prolene mesh. Also, Mosquito net is 5000 times cheaper than Prolene mesh.

Conclusions: Mosquito net is a safe, easy to sterilize and cost effective alternative to synthetic Prolene mesh in poor resource countries.

Keywords: Mosquito Net; Prolene Mesh; Inguinal Hernia.

 

Background: Peptic ulcer is one of the most common malady that affects the mankind in South India. Though lot of work had been done on the etiology of this condition, one specific etiological agent cannot be incriminated in the causation of this particular disease especially in our part of country. Peptic ulcer may produce one of the three main complications: haemorrhage, perforation or obstruction. In our study, we will be restricted to find out the magnitude of complications of peptic ulcer with special reference to the failure of conservative treatment, complications due to irregular treatment, etiological factors and various surgical treatment modalities.

Materials and Methods: The patients admitted to J.J.M. Medical College Davangere with primary diagnosis ofcomplications of peptic ulcer disease with complication and who underwent surgical management for the above was taken for this prospective study from June 2009 to June 2011. A minimum of 50 cases after applying inclusion and exclusion criteria were selected for this study and allocated alternatively to each of the clinical study. A
pretested proforma was used to collect relevant information from all the selected patients.

Results: In this prospective study of 50 cases, 35 cases (70%) of perforation, 2 cases (4%) of bleeding and 13 cases (26%) of gastric outlet obstruction were documented. Study revealed male predominance, mainly in the 3rd and 4thdecade with male to female ratio of 7.3:1. 32 (64%) patients of the study group with previous history of peptic ulcer disease, 12.5% among them who were on regular conservative treatment and the remaining 87.5% of patients taking irregular treatment came with the subsequent complications.

Conclusion: In the present era of potent PPI and anti H. Pylori treatment, medical
treatment plays a vital and pivotal role in treating expectantly majority of patients with peptic ulcer disease. Though revolutionary advances have come into lime light in the conservative management of the disease, surgical management is mandatory for patients with refractory and complicated peptic ulcer disease.

Keywords: Perforated Peptic Ulcer; Bleeding Peptic Ulcer; Gastric Outlet Obstruction; Nsaids; Smoking; H.Pylori; Proton Pump Inhibitors.

Introduction: The origin of parathyroid glands is from branchial pouches. As the fetus grows the parathyroid drift to their location near to the thyroid gland, but the final destination of the parathyroid glands are very variable. The knowledge of the location of the glands is very important in either thyroid surgery or parathyroid surgery as their identification poses a very difficult situation intraoperatively owing to their small size and the texture resembling the surrounding tissue. So the objective of this study was to revisit the knowledge on the anatomical location of the parathyroid glands.

Materials and Methods: A prospective study was conducted from 2013 to 2017 at department of general surgery, Victoria hospital, Bangalore. A total of 277 cases were studied which included cases of both thyroid surgery and the parathyroid surgery as well. The locations of both superior and inferior parathyroid on both sides were noted.

Results: The common location of the inferior parathyroid was close to the tubercle of Zuckerkandl 58% right side and 61% on the left side. The superior parathyroids were also close to tubercle but comparatively little farther than the inferior. Right side 55% and left 49%. The relation of parathyroids with lateral surface of the thyroid gland was next consistent location.

Conclusion: The surgeon must be always cautious during thyroidectomies due to the close relation of the parathyroids. The various locations of the parathyroids make them unpredictable. With some light on the key locations through this study, it can help the surgeon to locate the parathyroids with some ease and preserve them.

Keywords: Parathyroid; Tubercle of Zuckerkandl; RLN (recurrent laryngeal nerve).

Context: study of management of post acid ingestion oesophageal stricture by dilatation.

Aims: By studying 100 cases of post acid ingestion stricture to decide effectiveness of dilatation as a alternative of treatment as for transposition or replacement.

Settings and Design: This prospective clinical study was carried out on patient of 100 cases diagnose as a Oesophageal stricture due to corrosive ingestion.

Methods and Material: This prospective clinical study was carried out on patient of 100 cases diag nose as a Oesophageal stricture due to corrosive ingestion who are b/w 2 to 70 years, having Post acid ingestion oesophageal stricture patient require surgical (intervention) will be included &who haven’t pre-existence oesophageal problems(stricture, Ca, motility disorders etc.), not having congenital TE anomalies, altered renal function & other comorbidities including (DM, HTN & other medical comorbidities).

Result: out of 100 cases of post acid ingestion Grade II b injuries were present in 32% (most common) of patients. 85 patients were treated with oesophageal dilatation.

Statistical analysis used: Efficacy of conventional measure & criteria & outcome compared with criteria & results of present study to correlate with outcomes percentage of outcome of study were used & were considered success when outcome percentage were better.

Data entry and analysis: Data entry and analysis was done in Microsoft excel and frequency distribution and proportion were calculated for variable in the study.

Results: Out of 100 patients of post acid ingestion oesophagus with grad IIb and selected grade III treated with dilatation with guide wire and bougie dilator most of patients required repeated dilatation of average 4 dilatation at an interval of 1month with complication of haemorrhage in 10% and hypoxia intra-op in 6% of patients and morbidity of oesophageal perforation in only one patient with null mortality noted.

Discussion: Out of 100 patients of post acid ingestion oesophagus with grad IIb [4] and selected grade III treated with dilatation with guide wire and bougie dilator most of patients required repeated dilatation of average 6 dilatation at an different interval depending upon severity an length of injury to oesophagus by acid, with complication of haemorrhage in as many 10% of patients which was mild and managed with withholding procedure and NG tube insertion, other most common complication was hypoxia due to associated laryngeal injury which is most common associated morbidity also with 32% patients having laryngeal injury, with 1% morbidity due to rupture oesophagus and required urgent surgery, ICD insertion. Which later treated with colonic transposition with no mortality were documented with this study. Flexible fibre optic endoscopy made the assessment of upper gastrointestinal injuries accurate, safe, and reliable & practicable. Injury were graded according to modified Zargar et al classification [11], Dilatation is possible (usually 1 to 2 months ) after injury, and were done with guide wire and bougie dilator set after minimum period of 6 weeks as per criteria for intervention in post acid ingestion injury. The endoscope and over the wire dilatation technique for Oesophageal dilatation is most common, Less invasive, preferred 1st line management for less severe injury up to grade IIB and selected grade III although repeated dilatations are required in almost all patients to prevent recurrence at different intervals depending upon, concentration, amount, complaints, severity, availability of sources. Oesophageal dilation is the most common Modality, on-invasive, preferred, first line of management when possible up to grade 3 injury in selected patients Certainly good nutrition and careful peri-operation treatment are important for the healing process.

Conclusions: Dilatation relatively safe, acceptable, easy, noncomplex procedure for treatment of post acid ingestion oesophageal stricture management for grade II and selected grade III patients with acceptable complications and no mortality.

Keywords: Post Acid Ingestion; Oesophageal Stricture; Endoscopic Oesophageal Dilatation.

Aim: To study the accuracy of Clinical Examination, Ultrasonography, Cytology Parameters in the diagnosis of palpable breast lump.

Material and Methods: 81 female patients who presented with palpable breast lump who had undergone clinical breast examination , FNAC and HR-USG of breast lump and subsequent excision biopsy were included in the study. Excision biopsy was considered as a mandatory part of the workup for patients with palpable breast lump. Initially patient was subjected for clinical breast examination which included detailed history, Inspection, Palpation of breast and systemic examination. Then patient was subjected to Ultrasonography. Interpretation of sonography was performed prospectively as benign, suspicious or malignant. FNAC was done after imaging studies, the result of the palpation-guided FNAC was analysed by pathologist and reported as benign, suspicious or malignant. Following this workup, all patients underwent an excisional biopsy. The final histopathological diagnosis was compared with the result obtained by Clinical Breast Examination, Ultrasonography, and Fine Needle Aspiration Cytology examination.

Resulits: Clinical breast examination had sensitivity of 87.09%; specificity of 90.20%; positive predictive value of 84.37%; negative predictive value of 92% and accuracy of 89.02%. Ultrasonography had sensitivity of 80.65%; specificity of 94.23%; positive predictive value of 89.3%; negative predictive value of 89.1% and accuracy of 89.16%. Fine needle aspiration cytology had sensitivity of 86.21%; specificity of 100%; positive predictive value of 100%; negative predictive value of 92.9% and accuracy of 95.06%. The triad of Clinical breast examination, Ultrasonography and fine needle aspiration cytology (modified triple test) had sensitivity of 95.65%; specificity of 100%; positive predictive value of 100%; negative predictive value of 97.87% and accuracy of 98.55%.

Conclusions: We conclude that the combined triad of clinical breast examination, Ultrasonography and fine-needle aspiration cytology was highly accurate in the diagnosis of breast lumps. 

Keywords: PPV-Positive Predictive Value; NPVNegative Predictive Value; CBE-Clinical Breast Examination; FNAC - Fine-needle Aspiration Cytology; USG- Ultrasonography; Breast Lump.

Background: Acute Pancreatitis is a common surgical entity that is increasing in incidence. Gallstones and alcohol consumption remain the major contributors of
Acute pancreatitis. The disease usually follows a prolonged course with increased hospital stay, early and late complications contributing to increased patient morbidity and mortality. Traditionally the role of antibiotics is usually limited to severe necrotising pancreatitis. There is however increasing evidence to prove the role of antibiotic therapy in reducing mortality and long term morbidity in acute pancreatitis patients.

Objectives:
1. To retrospectively analyse antibiotic therapy in patients with Acute severe pancreatitis in the years
2014 - 2017 in the tertiary care hospital PSG IMSR located in Coimbatore, Tamilnadu, India
2. To analyse the role of antibiotics in patient prognosis and outcome

Type of study: Retrospective Observational study.

Duration of study: January 2014-January 2017.

Methodology: The present study was conducted in PSG Institute of Medical Sciences & Research, Coimbatore. We did a thorough retrospective analysis of case files of 900 patients with acute severe pancreatitis. Analysing the available data from case files.

Results: Of 900 patients, 411satisfied the inclusion criteris, of these 63% (n=258) of patients were started antibiotics within 48 hrs of hospital admission. The first choice antibiotics were Piperacillin tazobactum and metronidazole in 45% of cases, Fluoroquinolones and metronidazole in 12% of cases and Cefaperazone sulbactum ± metronidazole in 14% of cases. In 26% of cases a combination of imipenem + Cilastatin was used. Antibiotic use did not improve survival, nor was there any observed survival benefit when the different antibiotic agents were compared (p = 0.7 and 0.4 respectively). The timing of antibiotic use also does not appear to confer a survival benefit (p = 0.5). All patients with proven pancreatic infection died, there was not a significant difference in survival in those with extra-pancreatic infections (p = 0.2).

Keywords: Acute Pancreatitis; Necrotising Pancreatitis; Severe Acute Pancreatitis; Antibiotic Prophylaxis; Retrospective Analysis.

 

We hereby present a case series of 122 patients of renal calculi who were subjected to allopathic and herbal medicines for non surgical treatment for the same. This is a comparative observational study, comparing the efficacy of allopathic drugs with herbal medicines in terms of patient compliance, expulsion of stone and episodes of colicky pains. Results which we obtained for both pathies were comparable, however owing to longer duration of treatment in herbal medicines, compliance rate was less compared to allopathic medicines. Surgery was the last option in the treatment of these patients in whom there was no expulsion of stone.

Keywords: Renal Calculus; Stone Expulsion.

Context: The Super oxidized solution is a new concept of wound management. It has anti inflammatory effect that damage single cell organism not multicellular organism, therefore host tissues are spared.

Aims: To study the efficacy of topical SOS in Diabetic ulcers to observed Wound size, Time for appearance of healthy granulation tissue, Wound disinfection, Duration of hospital stay.

Settings and Design: Prospective, cohort & single centred, experimental study.

Methods and Material: 100 cases divided in to two groups for comparison between topical SOS and PI dressing for lower limb diabetic 
ulcers.

Statistical analysis used: p values, student t test. 

Results: in SOS and PI group patients wound assessments done on day 1,9,15 and 21 days and various wound outcome variables were compared. Patients were in the age group of 51-60 years and 68% were male. There was rapid decrease in wound size in SOS group compared to PI group at day 21, and earlier appearance of granulation tissue in SOS group. Resolution of peri wound erythema and peri wound edema was earlier in SOS group compared to PI Group. There was shorter duration of hospital stay, earlier wound disinfection and more number of patients who underwent skin grafting before 21 days in SOS group.

Conclusions: SOS with its moistening effects and cost effectiveness is safe, has faster response in wound healing and gives better efficacy as compared to the traditional Povidone Iodine solution for use as a topical / irrigant solution in wound care and in management of lower limb diabetic ulcers..

Keywords: Wound Debridement; Diabetic Foot; Super Oxide Solution.

Context: Inguinal hernias are commonly performed operations. Stoppa’s repair is one which uses large prosthetic mesh in preperitoneal plane covering myopectineal orifice. Present study is done to know the role of Stoppa’s repair in bilateral, recurrent and unilateral hernias which are at the risk of recurrence.
Aim: To study the role of Gaint Prosthetic reinforcement of visceral sac in treatment of groin hernias.

Settings and Design: Prospective, Observational study done in government Hospital.

Methods and Material: 30 cases of Bilateral, recurrent, unilateral inguinal and femoral hernias were selected. Demographic data, smoking, COPD, BPH were noted. Post op hospital stay and complications were recorded.

Statistical analysis used: Descriptive statistical analysis has been carried out in the present study.

Results: Out of 30 patients 12 had bilateral, 17 unilateral of which 5 were recurrent, 1 was femoral hernia. All were males between 41 to 60 years. 43 % of patients had associated pain with swelling in groin. Direct hernia was common. Risk factor for recurrence was smoking, COPD, BPH, Poor abdominal tone. Duration of surgery was 60 min. Post op was uneventful. Recurrences were not seen during follow up of 3 years.

Conclusions: Stoppa’s repair is effective and safe procedure hernias which are at high risk of recurrence. Procedure is simple, complications are low with lower recurrence rate.

Keywords: Stoppa’s repair; Inguinal Hernia; Femoral Hernia

Context: Benign Breast disease occurs in females from child hood, puberty to menopause It is 10 times more than breast cancer. 30% of female population suffers from breast disease. This study was undertakento evaluate the incidence and morphological features of Benign Breast Disease. 

Aims: To study various clinical presentations and management of benign breast diseases Settings and Design: Prospective study, done in the Department of General Surgery, tertiary care centre from November 2014 to April 2016.

Methods and Material: Patients of all age groups with lump, pain, nipple discharge, were selected. A detailed history was noted down in the proforma designed for the study. Patients were subjected for FNAC, HPE, Mammogram depending on need. Surgery was done as indicated. Excised specimen sent for histopathological examination. All the patients were followed up. Statistical analysis used: mean and percentages are calculated.

Results: Among 150 cases Fbroadenomas are common 44%, Fibroadenosis 41.3%, breast abscess 4%, phyllodes tumor 2.7%, galactocele 2.7%, gynaecomastia 3.3%. Mean age is 29.6 years. The right breast is more commonly involved. More common in multipara with < 6 months. Commonest presentation is lump in upper outer quadrant. Conclusions: benign lesions of breast need to be differentiated from malignancy. Approach is by triple assessment. FNAC, USG, Mammography are radiological tools. Surgical treatment, assurance, follow up is the main modality of treatment.

Keywords: FNAC; Mammography; Benign Breast Disorders.

Appendicitis remains as the disease encountered by practising surgeon. It is the most common urgent or emergent general surgical operation performed. This remains as sole reason for 300,000 hospitalizations yearly [1] upto fourteen different organisms are found in patients with perforated appendicitis. E.coli and Bacteroides frigilis are the common organisms encounterd in perforated appendicitis [2]. Our study is a prospective study which included 150 patients which were made into two groups one study and one control group where single dose and multiple doses of third generation cephalosporin were given and wound grading was done with southhamtom score. In our study with evidences available it is clear that extra doses of cefaperazone and sulbactam confer no extra advantage, as single dose can be given with much ease and offers reduced financial burden for the patient. The hospitals should make routine antibiotic protocols and keep changing it time to time in order to reduce antibiotic reistance in the current era of super bugs it is the duty of the surgeon to comply with the current standards of antibiotic care in order to reduce the complications regarding the drug resistance and complication regarding the wound infection.

Keywords: Uncomplicated Appendicitis; Third Generation Cephalosporin; Single Dose; Multiple Dose.

Background: Venous diseases are predominant causes of lower extremity venous ulcers. Inspite of effective treatment by compression therapy, these patients have psychosocial issues such as anxiety, depression, and social deprivation. These distressing symptoms are due to persistence of ulcer with exudation for longer duration, continuous pain, loss of work, and cost to the wound care.

Aims and Objectives: To study the response of skin grafting for venous ulcer plus surgical treatment for superficial varicose veins simultaneously.

Materials and Methods: 37 patients who had findings of venous ulcers along with varicose veins were selected for the study. Patients were treated conservatively for 5 -7 days followed by surgical intervention of venous ulcer and varicose veins simultaneously. The response to treatment was evaluated in terms of duration of ulcer healing and improvement of pain.

Results: The duration of hospital stay was 8-12 days (mean=9.8). The preoperative days used for ulcer bed preparation varying from 3-7 days (mean=4.2). The patients were in the age group of 40-75years (Mean= 57). Maximum patients were in the age group of 55-65 years. The duration of the ulcers was varying from 6 months to 7 years (Mean= 3.7 years). The ulcers size was varying from 2x1cm to 17x11cm. In 34 (91.89%) patients, the graft was taken completely. In 3 patient (8.1%), there was partial graft take (approx. 65-85% ulcer area). There were no cases of skin graft rejection. At the second follow up period (45 days), 32 patients were completely pain free and remaining 5 patients had partial relief.

Conclusion: There is high success rate in terms of healing the ulcer in a short duration and decreases the pain at the earliest. No recurrence of the ulcer was observed.

Keywords: Venous Ulcer; Varicose Veins; Saphenofemoral Junction; Elastic Compression Bandage.

Introduction: Recently several reports have appeared advocating the benefits of single layer extramucosal (serosubmucosal) anastomosis over conventional double layer anastomosis. The present study has been conducted to compare single layer technique with double layer anastomosis and to see cost effectiveness of suture material used and time taken for procedure.

Methods: Total 100 patients (both males and females) requiring intestinal anastomosis admitted in the Department of General Surgery, SMIMER hospital, Surat from July 2012 to November 2014 were included. In postoperative period, patient was monitored for any unexplained fever, distension of abdomen, time taken for bowel movements to come, postoperative day on which patient passed flatus and postoperative day on which patient tolerated the food. The patients were also monitored for anastomotic leak, wound infection, intraabdominal abscess.

Results: Mean time taken for anastomosis in single layer technique was 11.34±2.65 minutes and for double layer technique was 23.58±4.36 minutes. (p <0.001) Mean hospital stay in single layer technique was 11.46±2.44 days while it was 11.57±2.35 days in double layer technique. (p 0.818) Total 5 patients out of 100 cases, developed wound infections (10%) and all cases were operated in emergency.

Conclusion: Single layer anastomosis requires less time to construct, cost effective, reduces the operation time, without increase in risk of anastomotic leak and other complications. So, we came to conclude that the single layer interrupted anastomosis is equivalent to the two layer traditional intestinal anastomosis.

Keywords: Intestinal Anastomosis; Single Layer; Double Layer; Bowel Surgery.

Cholecystectomy is the treatment of choice for gall bladder stone since centuries. Bileduct injuries are associated with cholecystectomy since beginning. In last three decades gall bladder removal by laparoscopy has superseded the open method but the incidence of bile duct injuries remained same especially with beginners. This is mainly dueto misinterpretation of anatomy at calot’s triangle. The meticulous surgery for the gall bladder during cholecystectomy has prime role in prevention of bile ductinjury. We have recently use real time identification of bile duct during surgery by infra red method. This infra red technology has come in the way with more than 99% sensitivity in bile ducts identification. Indocyanine Green(ICG) is a florescent dye which is used for this purpose. Dye injected before operation is detected by a special telescope mounted on a high definition camera. This telescope emits infra red which detects ICG dye inside bile ducts. This helps in detection of biliary anatomy and prevents bile duct injuries.

Keywords: Laparoscopic Cholecystectomy; Bile Duct Injuries; Indocyanine Green Dye; Infra Red; Common Bile Duct(CBD)

Introduction: Hemorrhoids are common anal disorders. Surgical treatment required for third and fourth degree hemorrhoids. Milligan – Morgan hemorrhoidectomy is most commonly performed surgery for hemorrhoids, however in recent times several newer technique have been developed for hemorrhoids such as harmonic scalpel hemorrhoidectomy. In our study we compare outcome between two hemarrhoidal surgeries, harmonic scalpel hemorrhoidectomy and conventional hemorrhoidectomy.

Methods: This is a prospective study conducted between January 2016 to December 2016 which included 60 patients with grade 3 and grade 4 hemorrhoids. Thirty patients underwent conventional hemorrhoidectomy and another thirty patients underwent harmonic scalpel hemorrhoidectomy. Operative time, postoperative pain, length of post-operative hospital stay, wound healing duration and post-operative complications were compared between two groups.

Results: The harmonic scalpel hemorrhoidectomy group had significantly less operative time, postoperative pain, length of hospital stay, wound healing duration and less postoperative complications as compared to conventional hemorrhoidectomy group.

Conclusion: Harmonic scalpel hemorrhoidectomy is a sutureless surgery with less operative time, postoperative pain, hospital stay and faster wound healing. This makes harmonic scalpel hemorrhoidectomy a superior alternative for conventional hemorrhoidectomy with less morbidity and good patient compliance.

Keywords: Hemorrhoids; Milligan-Morgan Hemorrhoidectomy; Ferguson Closed Hemorrhoidectomy; Harmonic Scalpel Hemorrhoidectomy; Stapled Hemorrhoidopexy.

Site of peroration show a wide variability in different studies and we conducted our study to find out the prognostic outcomes based on site of perforation.

Methodology: A prospective survey of patients with acute generalized peritonitis due to hollow viscus perforation was carried out in general surgical wards of our institute during the period starting from August 2014 to December 2015. Study population consisted of 150 consecutive patients with perforativeperitonitis, which confirmed on emergency laparotomy

Results: Intra operative findings of 150 cases of perforative peritonitis were noted and the sites of perforation were confirmed. Majority were gastroduodenal perforation 109(72.66%), followed by small intestinal perforations 32(21.33%) which included 27 ileal perforations and 5 jejunal perforations. 9(6%) patients had large intestine perforation including 9 colonic perforation, 2 appendicular perforation and 1 rectal perforation. In the study group of 150 patients majority of the patients had gastroduodenal perforation (72.66%). Highest survival rate was seen among gastroduodenal perforation 83 of 109(76.75%).

Keywords: Small Intestine; Peritonitis; Hollow Viscus Perforation.

Background: The repair of inguinal hernia is the often-performed surgical operation worldwide [1]. It is the common condition among the people and affects around 27% - 43% of males and 3% - 6% of females of the world population In the present study, an attempt has been made to find the prevalence of hernia and the surgical management done in our geographical area.

Methods: The present study was retrospective, cross-sectional study from the period of 1st January 2013 to 31st December 2017. A total of 294 hernia patients were admitted in inpatient surgical ward during that period. The demographic details of all the patients were noted from the medical records.

Results: A total of 294 inguinal hernia patients undergone surgical interventions during the study period. Among which, 273 (93%) patients were male and 21 (7%) were females. The post-operative stay in hospital is almost less than 10 days as it indicates that most of the patients were discharged without any complication.

Conclusion: The male patients are predominant compared to female patients. The hernioplasty was performed in all the patients and the surgical complications are less. The exact prevalence rate may be high as some patients may either undergo a self-treatment or may not report due to the lack of complications.

Keywords: Inguinal Hernia; Prevalence; Hernioplasty; Post-operative Stay.

Introduction: Acute bowel obstruction is an emergency. It should be diagnosed early and treated promptly, if not the patient’s life may be endangered. Hence it is essential for every surgeon to have complete knowledge of this condition. 

Aims & objectives: To study clinical presentation, various etiologies and management of acute intestinal obstruction in adults.

Material and Methods: Present study was a hospital based prospective study conducted over period of 2 years. Hundred patients  admitted with acute bowel obstruction were evaluated on basis of detailed clinical history and physical examination.

Results: Presenting symptoms were pain (100%), constipation (99%), vomiting (94%), fever in 54% of the cases. Obstipation was least common symptom (40%), distension was next commonly seen sign (89%) followed by abdominal tenderness (100%). Patients with absent bowel sounds were 68%, 18% patients showed evidence of hypotension. Causes of obstruction were: adhesions (27%), obstructed external hernias (19%) followed by volvulus (15%), pseudo obstruction (3%). For postoperative adhesions appendectomy was most
common cause (44.44%) followed by gynecological operations and perforation peritonitis.

Conclusion: Abdominal pain was most common presenting symptom of acute intestinal obstruction. Most common sign of acute obstruction was tenderness followed by abdominal distention and absent bowel sounds. Small bowel obstruction was more common than large bowel. Most common cause of acute bowel obstruction in adults was adhesions followed by obstructed external hernias and Volvulus. In large bowel obstruction, malignancy was most
common cause. Most common procedure performed for acute bowel obstruction in adults was resection and anastomosis followed by adhesiolysis.

Keywords: Intestinal Obstruction; Adhesiolysis; Pseudo Obstruction.

Background: Open pyeloplasty has been the gold standard for surgical treatment of PUJ obstruction. Over the last two decades the treatment approach to PUJ obstruction has evolved from open pyeloplasty to various minimally invasive procedures. Laparoscopic pyeloplasty has developed world wide as the first minimally invasive option to match success rate of open pyeloplasty

Method: The study was carried out in our tertiary care centre between 2012 to 2015. 50 adult patients of Primary PUJ Obstruction were included in the study who underwent either Open or Laparoscopic Pyeloplasty. Patient were followed up after 4-6 weeks of surgery and outcome of surgery compared.

Results: Laparoscopic pyeloplasty appears to be a safe and effective alternative to open pyeloplasty in adults. Laparoscopic Pyeloplasty has almost similar short term outcome if renal parameters are compared. A trend toward longer operating time but shorter hospital stay with the laparoscopic approach was noted, although at this point the evidence does not indicate either technique is better than the other.

Conclusions: Laparoscopic Pyeloplasty is a technically sound operation which uses well established principles familiar to urologist. This procedure has a minimal level of morbidity, short hospital stay, better cosmesis compared to open approach. Laparoscopic pyeloplasty has emerged as the standard of care and is here to stay.

Keywords: Laparoscopic; Open Pyeloplasty; Pelviureteric junction (PUJ).