New Indian Journal of Surgery

Necrotising Fasciitis of the perineum is a challenging problem to tackle with issues like rampant infections, repeated debridements and comorbidities. It is characterised by a long clinical course with majority of that time needed in wound bed preparation. External Tissue expansion for wound closure (ETEWC) is an indigenous and simple modality that involves stretching of the wound margins and helps in early wound closure while not interfering with the wound bed preparation. It involved application of hooks on the wound margin and using rubber bands to pull the opposite ends together with a dressing in situ. It acts like a dressing holder and prevents skin margin retraction while not interfering with the time taken for the wound infection to settle. ETEWC for aiding wound closure in fournier’s gangrene wound has not been reported in available literature. We wanted to report our experience with the same.

Keyword: ETEWC; Fournier’s Gangrene; Skin Stretching devices; Wound closure.

Aim: To assess the efficacy of use of Selfie stick with tripod in intraoperative photography and videography. Methods: The study was done by the Department of Plastic surgery in JIPMER, Pondicherry, India from May 2018 to July 2019. Surgeons from the department and plastic surgeons around the area were included into the study after due consent. The selfie stick with tripod for 15 different users for a period of 15 days each. The feedback was collected in a questionnaire which included video quality, audio quality and would they recommend it to their peers. Results: All 15 users found the audio and video quality satisfactory. All 15 users would recommend the use to theor collegues. Conclusion: Taking intraoperative pictures in a sterile medium is a challenge and selfie stick with tripod offers a good alternative to capture good close up images. The tripod modifications make it useful for video conferencing, demonstration and video consultation too.

Keywords: Selfie stick; Intraoperative photography; Tripod.

Introduction: Pilonidal Sinus disease is considered to be a male dominate disease which affects near about 0.7% of world young adult population. Although many treatment options are available but surgical intervention is still remained a gold standard treatment option for this disease. This study is aimed to find out better surgical procedure in terms of less complication and recurrence rate. Methods: This was a retrospective study which was carried out at Department of General Surgery, Dr M K Shah Medical College and Research Centre, Ahmedabad. Total 100 patients of which 50 patients who underwent Limberg flap procedure whereas 50 patients who underwent Secondary wound healing procedure are nalyzed. Results: In present study we have found that operative time in secondary healing procedure was significantly shorter in duration but Limberg flap procedure cures with less pain, lower rate of wound infection, less hospital stay, early returning to normal activity and low rate of recurrence of the disease. Conclusion: As a results obtained from this study we are concluding that Limberg Flap Method has shown optimal post operative outcomes as compared to Secondary healing procedure in terms of less post operative pain, low rate of wound infection, lesser days of hospitalization and low reoccurrence rate and early returning to normal daily activities. Open procedure is required lesser operative time as compared to Limberg Flap Procedure.

Keywords: Pilonidal Sinus; Limberg Flap Procedure; Secondary wound healing procedure.

Wound infections had increased the risk of amputations in Diabetic patients by 90 times. Pseudomonas aeruginosa, has been a local deterrant to wound healing by its various properties of biofilm formation, increased virulence and multi drug resistance by various methods. Unfortunately, due to its resistance to first generation spectrum of antibiotics, and its gradual increase in resistance to third generation cephalosporins, aminoglycosides etc, the need for alternative methodologies arise. Acetic acid helps in local control of the microbe by reducing the wound pH to acidic. This was an Open labelled prospective randomized control trial. Totally 80 patients with diabetic foot ulcers with culture proven Pseudomonas aeruginosa positive status were included, and non diabetic ulcers were excluded. Two groups based on simple randomization into test and control groups each containing 40 patients. The control group received traditional saline dressings. The test variables and the control variables were tabulated and compared using Chi square test. The efficacy of 3% Acetic acid in eradication of Pseudomonas aeruginosa infected diabetic ulcers was assessed. p<0.01 was considered to be statistically significant. At the end of the study, it was seen that there was complete eradication of Pseudomonas aeruginosa in 87.5% of the individuals in the test group and 62.5% of the individuals in the control group which was statistically significant (p = 0.009). Thus, in conclusion, Acetic-acid based dressings are effective for management of diabetic foot.

Keywords: Acetic acid; Pseudomonas; Dressing

Background: Anal fissure is a common and minor disorder that needs careful attention because it is a painful condition but the treatment is simple and effective. This has led to the investigation of nonsurgical treatment options that avoid permanent damage to the internal anal sphincter. Methods: The study was conducted in Geetanjali Medical College and Hospital from year 2015 to 2017, with chronic anal fissure. A comparative study of 101 cases was done between different modalities in the treatment of anal fissure. Study cases were divided into 3 groups. Treated with topical application of 0.2% glyceral trinitrate GTN, Treated with anal dilation under G.A. or spinal anaesthesia, Treated with lateral sphincterotomy under total intravenous anesthesia (T.I.V.A.) or spinal anaesthesia (S.A.). Results: A follow up of 101 patients was done for 6 weeks. 30 to 50 years of age with male and female ratio of 2.48:1. Complains of pain in anal region during defecation with blood streak on stool. History of constipation was presented in 71% patients. Out of 101 patients 81 patients could be followed up to 6 weeks. 20 lost were belonging to GTN group. 100% and 93.3% patients were relieved of pain in anal dilatation and lateral sphincterotomy as compared to 75% patients with GTN application (significant; p<0.001). Conclusion: This study concludes that pain relief is early with lateral sphincterotomy anal dilatation. Healing of fissures was early and 100% by lateral sphincterotomy only. Postoperative stay in hospital was short. Incidence of anal incontinence were present with anal dilatation and lateral sphincterotomy which was absent with GTN. Also, healing of fissure was seen in 70% patients at 6 weeks after GTN application. Lateral sphincterotomy is the best choice in terms of surgical treatment but GTN application is a good medical treatment in majority of patients and surgery can be offered to those failures with medical treatment.

Keywords: Fissure in ano; Sphincterotomy; Anal dilatation; Anal incontinence.

Amoebic liver abscess is an important cause of inflammatory space occupying lesion of liver. This study is conducted to know the clinical presentation, management and efficacy of conservative management and percutaneous aspiration in amoebic liver abscess. Materials and Methods: A total of 30 patients of amoebic liver abscess were selected for the study in Vydehi Institute of Medical Sciences and research centre, Bangalore. Their clinical presentation, lab findings and treatment in the form of conservative (abscess <5 cms ) and ultrasound guided percutaneous aspiration (abscess >5 cms) were studied. Results: The amoebic liver abscess was common in low socioeconomic middle aged male patients. Pain and fever were the most common symptoms. USG abdomen was useful in early diagnosis and assessing prognosis. Most of the abscess was solitary common in right lobe of liver. Liver function tests helps in knowing effectiveness of the treatment and the prognosis. None of the patients were positive for cysts in the stool. 27 (90%) patients were positive for anti amoebic antibody. Conservative management was effective with cavities <5 cms. Percutaneous aspiration was effective with cavities >5 cms. There was one mortality. Conclusion: Amoebic liver abscess commonly seen in young to middle aged males. Ultrasonography helps in early diagnosis. Abscess <5 cms are effectively treated by conservative management and abscess >5 cms by percutaneous aspiration. Resolution of abscess faster in patients treated by percutaneous aspiration as compared to conservative treatment.

An inguinal hernia is one of the most common problems in routine surgical practice. Uncomplicated hernia possess no difficulty as many advanced techniques are available for repair. In our set up patients present very late and with complications either because of illiteracy or ignorance of patients, In the study 38% were of middle aged (51–60 years) and 28% patients were aged between 61–80 years. 2 patients were below the age of 20 and 3 patients were above the age of 80. 96% of operative wounds were drained by negative suction drain. In 86% of cases postoperative period was uneventful and patient recovered completely. In the present study the infection rate was 12%. Seroma collection and induration were found in 1(2%) patients each. The morbidity in this group was 16%. There were no longterm-post operative complications with respect to recurrence of hernia and condition of local scar.

Keywords: Complicated Inguinal Hernia.

Background: Diabetic foot ulcers are a major cause of hospitalization which increases hospital stay because of multiple surgical procedures. The objective of this study is to compare Vacuum Assisted Closure and the conventional therapy for diabetic wounds with respect to time and wound healing and to prove the efficacy of one method over the other by appropriate statistical methods at the end of data collection. Methods: A retrospective randomized hospital based observational study of 40 patients was conducted at PSGIMSR, Coimbatore, Tamilnadu, India for a period of 24 months (January 2017– December 2018). All these 40 patients were studied and the data was statistically evaluated to determine the efficacy of vacuum assisted closure in healing of diabetic wounds and to compare it with the conventional method of treatment of diabetic wounds. The patients were divided into 2 groups, Group-A which consisted of 20 patients who received vacuum therapy (VAC), Group-B which consisted of 20 patients who received conventional dressings. Results: The patients on VAC had early appearance of granulation tissue (90% vs 60% at the end of Day 3), increased percentage of decrease in wound depth (53% vs 25% at the end of day 9) as compared to patients treated by conventional dressing. All patients developed granulation tissue by the end of Day 9. Conclusion: We thus conclude that VAC appears to be superior in the treatment of diabetic foot ulcers in terms of early appearance of granulation tissue and decrease in wound depth when compared to conventional dressings.

Keywords: VAC; DFU; Wagners classification.

Objective: To study the acceptance of Breast conservation therapy (BCT) versus Modified radical Mastectomy and the factors affecting the decision regarding the choice of surgery. Methods: 45 patients out of 135 patients of carcinoma breast were identified who were fit for BCT. All of them were counselled and educated with options available BCT and MRM along with forms which explained the decision making factors and grading according to LIKERT scale. Results: Out of 45 patients 12 patients (26.67%) accepted BCT. Fear for recurrence, fear forresurgery and cost of radiotherapy were major factors for rejecting BCT which even overruled concern regarding body image. Conclusion: BCT can be accepted as a surgical choice for early breast carcinoma by many patients if awareness about early diagnosis and factors affecting decision making are addressed.

Keywords: Breast carcinoma, BCT.

Context: Inguinal hernia repair is the most commonly performed operations. In the early 1980s, Lichtenstein popularized the tension free repair, supplanting tissue-based repairs with the widespread acceptance of prosthetic materials for posterior wall of inguinal canal. No surgeon has ideal results, and complications remain. This study was taken as the Desarda’s technique recently gaining popularity as physiological repair not using the mesh and Desarda’s technique short term outcomes not much evaluated in comparison with Lichtenstein’ repair in this region. Aims: To compare the short term outcomes and recurrence rate between Lichtenstein’s and Desarda’s technique in the following ways: Source of data: Narayana Medical College and Hospital Nellore, during 2 years from October 2014 to October 2016. Research design: A prospective experimental study. Sampling procedure: Simple random sampling technique. Sample size: A total of 60 patients were studied, 30 of these undergoing Desarda’s hernia repair and 30 undergoing Lichtenstein mesh repair. Conclusions: Desarda’s technique and Lichtenstein’s technique both are have similar rates of wound infection and post operative pain. Desarda’s technique was easy to do, has no recurrence in short term follow up period, lower operative time, less chances of post operative morbidities, lower cost, less incidence of seroma.

Keywords: Hernia; Desarda’s technique; Lichtenstein’s technique.

Introduction: Inter-professional teamwork-an important factor for patient safety. World Health Organization (WHO) introduced Surgical Safety Checklist which has shown to improve intraoperative teamwork and contribute to postsurgical safety culture by reducing surgical morbidity and mortality. Our aim is assessing the use of surgical safety checklist, its completion rate and attitude of operating room staff towards its use, barriers to implementation and methods to improve compliance. Methods: A prospective study was conducted In August 2018, a total of 262 surgeries were performed in the department of general surgery, accordingly surgeries were observed for briefing team and data collected regarding the completion of Surgical Safety Checklist (SSC). Post August questionnaires were given to operating room staff to ask their opinions regarding the checklist, beliefs and barriers. Results: Only 16.03% of the checklist were completely performed, while 55.72% remained partially complete and 28.2% were such that none of the components of checklists in the patient files were filled in; with more usage of checklist during elective procedures, 13.14% completely performed and 73.14% were partially complete. About 57.47% of checklist remained completely unused during emergency surgery. Overall, lack of briefing team was noted in >80% of time. More than 80% of people believed that usage of checklist reduces likelihood of human error and main barrier for lack of usage being lack of training and assertiveness. Conclusion: Appropriate utilization and compliance of Surgical Safety Checklist is dependent on the training of staff. It cannot be assumed that the introduction of a checklist will lead to improved outcomes unless followed. The functioning of checklist requires people to make one salient change particularly, the operating team has to pause during sign in (SI) time out (TO) and sign out (SO) phases before continuing as it just acts as a reminder at every stage of surgery. Actual usage of checklist has to be made rather than blindly filling in the box because compliance is important than the completeness of the checklist.

Keywords: Surgical safety checklist, Sign in, Time out, Sign out.

Background: The study was conducted to compare the onlay mesh repair with the preperitoneal mesh repair in adult patients with paraumbilical /umbilical hernias. Aim: The study compares the operative time, the hospital stay and postoperative complications and recurrence in onlay and preperitoneal mesh repair for umbilical hernia. It is a non randomized clinical trial. Method: 44 patients underwent mesh repair by onlay or preperitoneal. These patients were more than 18 years but less than 70 years of age. All the other hernias like groin hernia, incisional hernia, epigastric hernia, recurrent hernia and divercation of recti were excluded. A detailed history with demographic parameters were noted. Local examination and routine labs were done. After written informed valid consent patients underwent onlay or preperitoneal. In the postoperative period patients were monitored for immediate and long term complications upto 6 months. The results were statistically were analysed and tabulated into results. Results and discussion: Like most of the studies our results showed that operative time for preperitoneal is more than onlay repair. Althoughin our study the time of drain removal was almost same in contrast to the result of most studies where drain in the onlay repair group was removed before preperitoneal repair group. Patients of the preperitoneal group were discharged before the onlay group just like the result of most studies. Pain score (VAS ) showed preperitoneal group had less pain on day 3 compared with onlay group but both had similar pain score on day 1. Complications like seroma formation, surgical site infection and chronic pain was more in the onlay group as compared to preperitoneal group. There was no case of recurrence in our study. Conclusion: Umbilical hernias are less as compared to inguinal hernia and incisional hernia. Obesity remains the main risk factor and it occurs most commonly in middle age group 31–50 years. A mesh repair with non absorbable polypropelene mesh is the treatment of choice nowadays. A preperitoneal mesh repair demonstrates better outcomes in terms of hospital stay, severity of pain after day 3 and complications like seroma formation and surgical site infection as compared to onlay mesh repair. On long term follow up, a preperitoneal mesh repair shows less incidence of chronic pain and recurrence though more long term follow up warranted to validate the result.

Keywords: Umbilical Hernia; preperitoneal mesh repair; polypropelene mesh.

Background: In the era of minimal access surgery laparoscopic cholecystectomy is the gold standard of treatment for calculous cholecystitis. But laparoscopic surgery comes with its fresh set of complications. Port Site Infections (PSI) is one of the most bothersome complications that overshadow the benefits of a minimal invasive procedure and delays recovery. Atypical mycobacterial infection complicates the situation as it is difficult to diagnose and is resistant to treatment. In our institute (a tertiary level centre) the incidence of PSI was very high and we were in search of alternate methods of sterilisation for laparoscopic instruments as well as any prophylactic treatment that would prevent the development of PSI. Aims and Objectives: The aim was to study the role of low temperature gas plasma technology (STERRAD) as an appropriate method of sterilisation for laparoscopic instruments to reduce the incidence of PSI and to study the role of prophylactic port site Amikacin in preventing PSI. Methodology: This is a prospective non randomized study which was done over 15 months. During this study period patients admitted in general surgery wards of IPGME & R and SSKM Hospital with cholelithiasis were included in the study. After undergoing laparoscopic cholecystectomy they were followed up for 3 months. Results: Among the 220 cases of laparoscopic cholecystectomy done during this period a total of 30 cases of PSI were noted. There was a drastic reduction in the incidence of PSI when patients were operated using instruments sterilised by the low temperature gas plasma technology (STERRAD). In patients where surgery was done with instruments using the usual 2% glutaraldehyde sterilisation technique, prophylactic port site amikacin injection therapy reduced the incidence of PSI. Conclusion: The use of low temperature gas plasma technology (STERRAD) is an appropriate method of sterilisation of laparoscopic instruments to reduce the incidence of PSI. Prophylactic use of port site Amikacin might be another cost effective solution in preventing PSI.

Keywords: Port site infection; Sterrard; Low temperature gas plasma technology; Sterilisation of laparoscopic instruments; Port site amikacine.

Introduction: Penile fracture is rare, but it is a urological emergency that always requires immediate attention. Moreover, penile fracture has been reported more frequently in recent years. It may have devastating physical, functional, and psychological consequences if not properly managed in time. Materials and Methods: The objective of this study was to highlight the causes, clinical presentations, and outcomes of cases of penile fracture. This was a Case Series extending from November 2011 to November 2015. Every patient underwent a thorough clinical evaluation and received proper treatment. Results: In this study, 40 patients of penile fracture included, ages were 19 to 56 years. Vaginal intercourse was the most common mechanism of injury. Most of the patients (95%) were diagnosed clinically with a proper history and clinical examination. Thirty Six patients were treated surgically. The patients underwent six months of follow-up, and were evaluated with local examinations, questionnaires, and colour Doppler ultrasonography as necessary. Conclusions: Although penile fracture is an under-reported urological emergency, its incidence is increasing. It is diagnosed based on a clinical examination, but ultrasonography can be very helpful in diagnosis. Especially in cases where treatment is delayed, surgery is preferable to conservative management, because it is associated with better outcomes and fewer long-term complications.

Keywords: Penile fracture; Penis injuries; Urological emergency; Doppler ultrasonography.