New Indian Journal of Surgery

Burn trauma remains a difficult problem because of the difficulties in treating the victims, prolonged treatment, the high mortality rate, and sometimes unacceptable results of treatment. Pediatric burns account to nearly a fourth of all the burn injuries around the world. Because of emphasis on early resuscitation, the mortality due to hypovolemic shock has come down drastically. Majority of burn related deaths are due to sepsis. There is a wide range of organisms that can lead to sepsis in burn patients. Burn sepsis due to spore bacteria is rare but one should keep the possibility as one of the causes of sepsis in pediatric burn cases.

Keywords: Burn; Septicemia; Spores

Injury to gallbladder is rare in the set up of penetrating trauma caused by firearm injury. Here we reported a case of a 23-years-old male with an alleged history of firearm injury to abdomen received in a state of shock. On evaluation, NCCT shows pneumoperitoneum with hemoperitoneum and Grade II renal injury on the right side. On exploration, we found gallbladder perforation through its neck along with liver laceration involving segment IV, V, VI and right perinephric hematoma for which patient underwent cholecystectomy and entry wound was debrided. Purpose of reporting was the rarity of gallbladder injury in penetrating abdominal trauma and difficulty in preoperative diagnosis.

Keyword: Gallbladder perforation; Penetrating abdominal trauma; Gunshot injury.

Introduction: Pesticides and insecticides are easily accessible in India as a predominantly agrarian population reside. This has resulted in unregulated selling of these compounds and is often the cause of poisoning due to accidental, suicidal or homicidal motive. Though commonly ingested, people do find innovative ways to administer these compounds. Such instances are scarcely described in medical literature let alone the prescribed management. Case Report: We present a case of suicidal parenteral injection of pyrethroid ester insecticide (Deltamethrin) into left upper limb. Initially the patient and relatives tried to masquerade it as a case of an insect bite but the clinical features painted a suspicious picture. Conclusion: This rare case account is the first description of parenteral deltamethrin poisoning and portrays the management of such a patient and reviews literature pertaining to parenteral pesticide poisoning. Our case management yielded successful salvage of the involved limb with fasciotomy, multiple debridement and NPWT followed by skin grafting with a considerable lengthy hospitalization for the patient and laborious treatment on the part of treating physicians.

Keywords: Parenteral poisoning; Injection; Pyrethroids; Deltamethrin; Organophosphates; NPWT; Limb salvage; Upper limb.

Aim: To prospectively study the different surgeries and their outcome in management of Chronic pancreatitis. Method: Patients were investigated with transabdominal Ultrasound and then with contrast enhanced computerized tomography (CECT). Other investigations like Magnetic resonance cholangiopancreaticography (MRCP), Endoscopic Retrograde Cholangio Pancreaticography (ERCP) were used when appropriate. Patients underwent surgery for chronic pancreatitis. Results: Mean ± SD of Hospital stay for Freys is 9.7 ± 0.53 days, for Partington - Rochelle is 9.06 ± 0.6 days, for Begers is 11.66 ± 0.57 days and for Whipples is 14.4 ± 0.54 days. Mean ± SD of VAS postop 6 months of Freys is 1.73 ± 1.19, for Partington - Rochelle is 1.31 ± 0.47, for Begers is 1.33 ± 1.1 and for Whipples is 2.6 ± 1.9. Mean ± SD of VAS postop 1 year of Freys is 1.6 ± 1.3, for Partington - Rochelle is 1.12 ± 1.4, for Begers is 0.66 ± 0.57 and for Whipples is 2.6 ± 1.94. Mean ± SD SF 36 postop 1 year of Freys is 78.96 ± 14.6, for Partington - Rochelle is 81.1 ± 13.6, for Begers is 85.3 ± 7.76 and for Whipples is 85.6 ± 10.9. Conclusion: Operative time of Whipples procedure is greater than that of Begers, Freys and Partington Rochelle procedures in decreasing order. Blood loss of Whipples procedure is greater than that of Begers, Freys and Partington Rochelle procedures in decreasing order. Duration of hospital stay in whipples procedure is greater than that of Begers, Freys and Partington Rochelle procedures in decreasing order.

Keywords: Abdominal pain; Chronic pancreatitis; Magnetic resonance cholangiopancreaticography; Endoscopic Retrograde Cholangio Pancreaticography.

This is a review of 100 cases of undescended testes operated at the Indian Institute of Medical Science and Research, Warudi, over a period of 5 years. In the cities, these patients present early, usually soon after birth or in infancy but in a rural setup, the presentation is late, sometimes very late and sometimes for a different reason like hernia. As a result of late presentation, the incidence of atrophy in the undescended testes is high. Keywords: Testis; Undescended; Atrophy; Orchidopexy.

Background: Of all abdominal hernia, inguinal hernia is the most common hernia presenting in groin part of abdomen and open inguinal hernioplasty (Lichtenstein hernia repair) is one of the most commonly performed general surgery. Surgical site infections (SSIs) are the most common complications secondary to hernia repairs. Use of antibiotic prophylaxis in open inguinal hernioplasy (Lichtenstein hernia repair) is a conflicting issue for prevention of SSI. In the present study we compared the rate of postoperative wound infections in patients of antibiotic prophylaxis group and placebo group so that unnecessary use of antibiotics could be avoided. Method: The present study was a prospective randomized controlled study of 100 cases of open inguinal hernioplasty (Lichtenstein hernia repair) which was done over a period of 15 months from April 2017 to June 2018. 50 patients in antibiotic group received antibiotic ceftriaxon 1 gm and another 50 patient in placebo group received no antibiotic. Results: Mean age of patients was 45.86±15.49 years in antibiotic group and 43.14 ± 15.44 years in placebo group with range of 18–70 years. All the patients were males and most of the patients were from rural area (78%). Totally 3 patients developed surgical site infection (3%). In antibiotic group, one patient with superficial SSI and in placebo group, two patients, one with superficial SSI and another with deep SSI were noted (p value =0.557). Conclusion: There was no clear benefit of administering prophylactic systemic antibiotics for open inguinal hernioplasty (Lichtenstein hernia repair) as use of prophylactic antibiotics did not significantly reduced the incidence of wound infections. 

Keywords: Antibiotic Prophylaxis; Inguinal Hernioplasty; Surgical site infections (SSIs).

Introduction: The management of ulcers is expensive and economic burden it throws on our expanding geriatric population is tremendous. Thus it is paramount to carefully evaluate the efficacy of different wound dressings and a cost-benefit analysis to optimize health care spending. A hydrocolloid dressing is a water type of dressing that contains gel-forming agents in an adhesive compound laminated into a flexible, water-resistant outer layer. Some formulations contain an alginate to increase absorption capabilities. These are self adhesive and available with or without an adhesive border and in various thicknesses and precut shapes for such body areas as the sacrum, elbows and heels. Objective: To establish the role of Hydrocolloid dressing in wound management and also its superiority with other methods. Methods: This is comparative randomize study in which we will take 200 cases. We will applied hydrocolloid dressing in group A (100 cases of ulcers) while remaining group B (100 cases) will be applied conventional dressing and during study time of period we will compare both groups and see which dressing is superior. Results: In this study, comparison of wound dressing done between hydrocolloid dressing and conventional dressing by various measures such as early granulation tissue, decrease hospital stay and early skin grafting, which conclude that hydrocolloid dressing is more efficacious than conventional dressing. Conclusion: Hydrocolloid dressing helps in making healing process faster in such way making ulcer with early healthy granulation tissue, so patient undergone early in skin grafting and hospital stay will be decreased.

Keywords: Hydrocolloid dressing; Conventional dressing; Ulcer.

Introduction: Pleural empyema is a collection of pus in the area between the lungs and the inner surface of the chest wall that is caused by microorganisms, usually bacteria. Prompt evacuation of the infected fluid along with appropriate antibiotics is the mainstay treatment; however, Decortication may be performed with percutaneous chest tube placement. Objective: The objective of the study is to determine the clinical outcomes of surgical decortication as first line treatment of choice in pleural empyema. Material and Method: The study is an observational retrospective analysis of 100 patients who presented with empyema and were treated either with open drainage or surgical decortications as the first line of treatment at Dhiraj General Hospital, Gujarat. Results: Out of 100 patients with empyema 27 underwent open drainage and 73 with surgical decortications. Surgical decortications showed a better treatment success rate in all study subjects (68/73 patients, 93%) compared with open drainage (20/27 patients, 74%, p<.001 for method comparison). After a propensity scored matching surgical decortications resulted in a better outcome versus open drainage, hence surgical decortication was the best predictor of treatment of success. Conclusion: The first treatment of choice for pleural empyema is critical determinant of ultimate therapeutic success. After adjusting for confound variables, surgical decortication is the optimal first treatment of choice in advanced empyema.

Keywords: Pleural empyema; Decortication; Tuberculosis.

Context: Fistula-in-ano is a condition that has been described virtually from the beginning of medical history. A fistula is usually the result of a previous crypt abscess or glandular infection in the area which has been drained inadequately and not fully healed. This results in persistent or intermittent discharge of pus, blood or mucus. There is not usually much pain, although an abscess can sometimes recur. Fistulotomy is one of the common surgical procedures wherein a probe is passed through the entire fistulous track, incision is made over the probe to cut and lay open the fistulous track. In Fistulectomy, a probe is passed through external opening up to the internal opening, fistula is opened along the probe using a knife, and fibrous tract along with unhealthy granulation tissue is excised. The aim of the study is to compare the operation time, postoperative wound size, postoperative pain, recurrence, anal incontinence and quality of life in both the groups. Materials and Methods: This comparative study was conducted from 2017 to 2018 that was conducted on 60 consecutive patients diagnosed to have low fistula-in-ano. 30 patients underwent fistulotomy and 30 patients underwent fistulectomy. Parameters related to surgery, postoperative period and follow up were observed, tabulated and analyzed. Results: Mean operative time was (11.63 mins) in fistulotomy when compared to fistulectomy which was (12.17 mins). Postoperative wound size was (2.51 cms) in fistulotomy when compared to fistulectomy (2.80 cms). Postoperative pain on day 1 and on day 3 was less in fistulotomy compared to fistulectomy. The quality of life was better following fistulectomy compared to fistulotomy due to more rate of recurrence in fistulotomy group. Conclusions: Fistulectomy can be considered a better procedure for a low anal fistula owing to lesser postoperative recurrence.

Keywords: Fistulectomy; Fistulotomy; Fissure-inano.

Introduction: Acute appendicitis is one of the most commonly encountered surgical conditions with a lifetime incidence of 7–9%. Early diagnosis with prompt surgery is the preferred treatment option to prevent complications. Conventional appendicectomy has been the gold standard for the treatment of acute appendicitis. The major benefits to patients undergoing laparoscopic appendectomy are early hospital discharge, reduced postoperative pain, decreased wound infection, Early return to full activity and a better cosmetic scar. Aim: To compare the efficacy of laparoscopic approach over conventional appendicectomy in emergency uncomplicated acute appendicitis. Material and Methods: The present interventional clinical study was carried out at teaching government hospital during December 2014 to November 2016 and total 178 patients underwent appendicectomy. The study subjects were the patients who have undergone emergency appendicectomy for uncomplicated acute appendicitis, all with modified Alvarado score >7. Results: Out of total 178 patients 130(73.03%) underwent Conventional Appendicectomy and 42(23.59%) had laparoscopic appendicectomy. The mean duration of surgery was longer in laparoscopic group than conventional group and the difference was statistically significant. Liquid diet and solid diet were started earlier in laparoscopic group than conventional group. The postoperative pain was less in laparoscopic group as compared to conventional group. In the laparoscopic appendicectomy group, 3(7.14%) patients had wound discharge, 3 patients had burning micturition (7.14%). While in the conventional appendicectomy group, 13(9.55%) patients had wound discharge and wound dehiscence was seen in 5(3.67%) patients. The mean postoperative hospital stay was longer in laparoscopic group than conventional group. The difference was statistically significant. It was found that laparoscopic appendicectomy was costlier than conventional appendicectomy. Limitation of Our Study: Long-term complications of both laparoscopic and conventional appendicectomy could not be studied. Conclusion: The present study shows that laparoscopic appendicectomy provides benefits over conventional appendicectomy in terms of a shorter hospital stay, less postoperative pain, earlier resumption of oral feeds and reduced wound infection rate. Although the above–mentioned benefits were at the cost of significantly longer duration of surgery and higher cost associated with laparoscopic approach over conventional appendicectomy also feasibly in teaching government hospital is also a hindering factor.

Keywords: Appendicectomy, Conventional, Laparoscopic, Acute appendicitis.

Context: Intestinal obstruction is one of the commonest diagnoses at admission in a neonatal surgical unit. The aim was to study various types of neonatal intestinal obstruction to determine pattern of presentation, diagnosis and their outcomes excluding anorectal malformation. Materials and Methods: This retrospective study was conducted from January 2012 to January 2013. Data were collected from hospital records and analyzed for age, sex, religion, demographic location, birth history, mother’s age, birth weight at admission, the maturity of neonates, the age of presentation, spectrum of anomalies, associated anomalies, types of operation and their outcomes. Results: Out of 150 neonates admitted under surgical care, 150 neonatal intestinal obstructions were operated. Most common was Hirschsprung’s disease 42(28%), followed by meconium ileus 26(17.3%), jejunoileal atresia 20(13.3%), malrotation of gut 18(12%), duodenal atresia 9(6%), idiopathic pyloric stenosis 9(6%), necrotizing enterocolitis 13(8.67%) and others 13(8.67%). Survival rate among them were in, idiopathic hypertrophic pyloric stenosis 100%, Hirschsprung’s disease 86%, meconium ileus 85%, malrotation of gut 79%, duodenal atresia 66.6% and necrotizing enterocolitis 66%. Among them highest death incidence were found in duodenal atresia 33%, necrotizing enterocolitis 33% whereas least in idiopathic pyloric stenosis, meconium ileus, jejunoileal atresia and malrotation of gut. Conclusions: Neonatal surgical outcome depend on many factors, it require dedicated surgical care as well as supportive infrastructure and manpower, early diagnosis and intervention are the crucial factors in improving operative outcome in neonatal surgery.

Keywords: Neonates; Intestinal obstruction; surgery; outcomes.

“Pain” is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. There is both the physiologic and affective nature of the pain experience. Inadequate pain control, apart from being inhumane, may result in increased morbidity or mortality. Despite this overwhelming rationale for effective postoperative pain control, the clinical reality is unfortunately, still far from satisfactory. As the importance of postoperative pain relief is undebated, there is a need for an effective protocol in the care of all postoperative patients. In our hospital, we follow a “feedback” pain protocol, in which the VAS pain scale is used to record pain at least once a day, or more depending on the analgesia frequency, with a follow-up after 15 to 45 min to see the level of pain relief, and to receive drug orders for further analgesia if the pain relief is not adequate. The aim of this audit is to find the level of compliance to this protocol, and its effectiveness. The main reason being that there is no standard protocol for postoperative pain management widely being practiced. The surgeons are the ones who are managing the postoperative pain. This audit will determine the effectiveness, and the adherence to protocol, which will suggest whether there is a need for a change in the protocol, or adherence. Objectives being to ensure that the analgesia protocol is followed in all postoperative patients and to ensure that atleast 95% of those who receive the analgesia protocol, has a VAS score of less than 3 in their first two postoperative days.

Keywords: Postoperative pain; Pain protocol; Feedback protocol; Institution

Gallstone disease is one of the most common biliary pathology. It is estimated that gallstones affect 10–15% of the population in the western societies. Approximately 1–2% of asymptomatic patients will develop symptoms requiring surgery per year, making cholecystectomy one of the most common surgeries performed by the general surgeons. Traditional open cholecystectomy (OC) has more postoperative pain due to excessive dissection and lengthy muscle dissection. Hence laparoscopic cholecystectomy (LC) was introduced which revolutionized the treatment of gallstone disease. Though, these advances have markedly reduced postoperative pain and hospital stay, etc. they are associated with high cost, long, learning curve and also postoperative complications. Incidence of CBD injury is found to be high in LC compared to conventional cholecystectomy. The advent of Mini Lap cholecystectomy (MLC) has brought down the cost, hospitalization stay early return to work, etc. Hence in resource poor countries, MLC is an acceptable alternative too LC, as it is done through a small 5–6 cm incision. The advantages of performing cholecystectomy through a minimal incisions controversial. In view of the above the present study is taken up to evaluate the efficacy of Mini lap cholecystectomy.

Keywords: Mini lap cholecystectomy; cholelithiasis.

Aim: The repair of zone II flexor tendon injuries is an evolving topic in hand surgery. It was hypothesized that variability would exist within the hand surgeon community in treatment of zone II flexor tendon repairs in surgical material used, surgical technique, and postoperative rehabilitation protocol. Methods: A single-answer multiple-choice survey was distributed to the 12 plastic surgery trainees of a tertiary care center. Surgeons were asked questions about surgical technique, suture type, common complications, postoperative management, and the factor that plays the largest role in guiding their surgical preferences. Responses were compared with current medical evidence. Conclusions: This study demonstrates that the majority of respondents are performing zone II flexor tendon repairs in accordance with the best currently available evidence, although there is variability with respect to suture material, surgical technique, and rehabilitation protocols.

Keywords: Zone II; Flexor tendon repair; Trainees.

Background: Cholelithiasis is a common cause of morbidity among Indians with female predominance and its treatment has shown a decisive shift from open to minimally invasive surgery, prevalence rate ranging from 10 to 20%1 most of them are asymptomatic for a long time. With advent of laparoscopic cholecystectomy (LC) apart from shift from open cholecystectomy (OC) to laparoscopic cholecystectomy (LC) is benefit of decreased hospital stay, lesser postoperative pain and early return to normal activity. LC is cosmetically better when compared to OC. But some difficulty of LC in early phase of surgical practice is long operative time and increased incidence of biliary leakage. Methods: A prospective study of 50 cases of gall stone carried out in district hospital Kalaburgi which was attached to ESIC Medical College Kalaburgi, between October 2017 and November 2018 with aim of comparing open cholecystectomy and laparoscopic cholecystectomy. Patients are divided randomly into two groups: group A underwent laparoscopic cholecystectomy and group B underwent open cholecystectomy. Pros and cons of both procedures is explained in detail to the patient. Result: Duration of surgery is longer in OC than LC, 75.10 minutes versus 45.15 minutes, mean duration of postoperative pain 18 hours in group A and 30 hours in group B patients, the mean period of hospital stay was 1.8 days in group A and 4.5 days in group B patients, and postoperative food resumed in 1.2 days in group A and 2.5 days in group B and surgical site infection is higher in group B than group A. Conclusion: Minimal invasive surgery laparoscopic cholecystectomy (LC) is better than open cholecystectomy (OC) as first choice interms of less postoperative pain, less hospital stay and fewer incidence of surgical site infection and early return to work.

Keywords: Cholelithiasis; LC (laparoscopic cholecystectomy); OC (open cholecystectomy); Minimal invasive surgery.

Background: Necrotizing fasciitis is an uncommon life-threatening soft-tissue infection characterized by rapidly progressing inflammation and necrosis of subcutaneous fascial tissues and it represents a subset of all necrotizing soft-tissue infections (NSTIs). The common pyoderma does not extend beyond the skin (epidermis and dermis) and include erysipelas, impetigo, etc. Necrotizing fasciitis is often underestimated because of the lack of specific clinical findings in the initial stages of the disease. Methods: This was a prospective observational study in which 200 patients presenting with symptoms suggestive of necrotizing soft tissue infections in general surgery department, Sri venktaeshwara Medical College, Tirupati from March 2017 to Oct 2018 were taken for the study. Results: In patients with severe soft tissue infections, LRINEC SCORE based on laboratory parameters is an easy and reliable predictor to diagnose necrotizing fasciitis. In developing countries like India, where in resources are limited, LRINEC score will greatly help in predicting necrotizing fasciitis.

Keywords: Necrotizing fasciitis; LRINEC score; Soft tissue infection.

Abdominal wall hernias are very commonly encountered surgical problems faced by general surgeons and have attracted surgical skills and expertise. Innumerable number of studies have been done with varying results by experts. In this medical college hospital we have taken up a prospective study of all the adult ventral abdominal hernias (excluding inguinal hernias) in relation to age and sex distribution, clinical presentation, risk factors, complications as well as their management protocol adopted in our institution.

Keywords: Ventral hernias; Prospective study.

Introduction: Post-mastectomy pain syndrome (PMPS) is typically a chronic neuropathic pain, which can develop shortly after, or up to several months after surgery (BCS and MRM) and can persist for years. There is some evidence that chronic pain and sensory abnormalities do decrease over time. The study was aimed to assess frequency and intensity of chronic pain in the breast area and ipsilateral arm in already treated breast cancer patients. To study the demographic and clinical characteristics affecting the development of chronic pain and to assess the effect of chronic pain on the quality of life in post-treatment breast cancer patients. Materials and Methods: This was a cross-sectional study conducted at a tertiary institute in South India. The study included breast cancer patients older than 18 years attending the oncology clinic within the study period, who have undergone breast surgery and completed their treatments at least 6 months before and were free of disease at the time of interview. Pain characteristics were assessed in detail using the Short Form McGill Pain Questionnaire (SF-MPQ). Quality of life was assessed using the Functional Assessment of Cancer Therapy-Breast (FACT–B) questionnaire (Tamil/English version). The comparisons of domain scores were carried out by using independent student’s t test. The comparison of domain scores and overall score of FACT-B in relation to histological grade was carried out by using one-way Analysis of Variance. The association of pain with menopausal status, post-treatment duration, comorbidities, age at diagnosis, clinical stage of disease, histological grade, type of surgery, quadrant involved and postoperative complications were assessed by using χ2 test. All statistical analyses were carried out for two-tailed significance at 5% level of significance. Results: A total of seventy post-treatment breast cancer patients participated in the study. Postoperative pain was experienced by the majority of women with a VAS score of 4 to 6. The character of chronic pain was assessed using Short Form McGill Pain Questionnaire. The intensity of chronic pain was VAS 4 to 6 in 30 out of 31 patients. On comparing patients with chronic pain, there was no association noted to age, menopause, comorbidities, type of tumor, type of procedure, postoperative complication, adjuvant received and post-treatment duration. Quality of life scores in the subscales varied from 47 to 63% of their maximum scores. The mean Trial outcome index (TOI), FACT-G score and FACT-B overall score were 50%, 61% and 82% of their maximum scores respectively. On comparing women with and without chronic pain, the mean Breast Cancer Subscale (BCS) score was found to be higher and statistically significant in the latter. Though mean scores of FACT-B domains were higher in patients who underwent modified radical mastectomy, no statistically significant difference was found. On comparing quality of life scores and adjuvant therapy, it was found that all domain scores except SWB and BCS scores were significantly higher in patients who received both chemotherapy and radiotherapy than those who received radiotherapy alone. Conclusion: This preliminary work suggests that the severity of acute postoperative pain may predict future chronic pain. Aggressive treatment of acute post-operative pain may therefore decrease the incidence of chronic pain. Surgeons should be aware that younger women may be at a higher risk of developing chronic pain syndromes after breast cancer surgery. Further studies are needed to determine whether more careful surgery and radiotherapy can diminish the incidence of these symptoms.

Keywords: Chronic pain, Breast cancer, Quality of life.