Journal of Surgery Archives

Prevalence of Low-Lying Pubic Tubercle in Patients Undergoing Inguinal Hernia Repair in a Tertiary Care Center

2024-09-27T05:52:36+00:00

Background: Delayed diagnosis of inguinal hernia can present directly as an emergency and result in high morbidity and mortality. Hence, surgical tradition advocates timely detection and elective repair wherever possible.

Throughout history, researchers have been searching for identifiable predisposing factors associated with inguinal hernia development, trying to answer an age-old question: 'Can inguinal hernia development be predicted?' for its early identification and tailored management.

Studies have shown a definite relationship between the occurrence of inguinal hernia and pelvic anatomy. Low-lying pubic tubercle is reported as an important and measurable risk factor.

Objective: The objectives were to detect the prevalence of low-lying pubic tubercle in patients with Inguinal Hernia and analyze the risk factors.

Methodology: This study was a prospective observational study done in Tribhuvan University Teaching Hospital (TUTH) for a duration of 1 year after ethics committee clearance. About 71 patients who met the inclusion criteria were enrolled in the trial after providing written informed consent in accordance with the Institution Review Board's format. Statistical Package for Social Sciences (SPSS) software version 25 was used for data analysis.
Results: In our study, the prevalence of low-lying pubic tubercles was high among patients with inguinal hernia.
Conclusion: Anthropometric measurements like low-lying pubic tubercle can be a predisposing for inguinal hernia development.

A Comparative Study to Compare Results of Treatment of Incompetent Perforators by Laser Versus Foam Sclerotherapy in Chronic Venous Insufficiency Patients

2024-08-27T08:26:41+00:00

Introduction: Patients of chronic venous insufficiency (CVI) of the leg can present with lower limb pain or heaviness, subcutaneous edema, skin changes such as hyperpigmentation with or without dermatitis and in advanced cases with ulcer in the gaiter area. Various modalities are now available for the treatment of CVI, namely endovenous thermal ablation, foam sclerotherapy, open surgical technique (stripping, phlebectomy, subfascial endoscopic perforator surgery and modified Linton procedure for the incompetent perforators.
Methods: In this study, adult patients of primary chronic venous insufficiency (C3-C6) diagnosed by venous duplex USG were enrolled. In both groups, the great saphenous vein (GSV) and short saphenous vein (SSV) were ablated by endovenous laser therapy. However, in group A, incompetent perforators were treated by endovenous laser ablation and in group B, they were treated with ultrasound-guided Foam sclerosant injection (0.5% Polidocanol). Patients were followed up for a period of 6 months.
Results: Technically all the incompetent perforators were feasible to puncture the perforators and to do the procedure. Anatomical closure rate of treated incompetent perforating veins In Group A at 1, 3 and 6 months was 68.33, 63.33 and 60.0%, respectively, while in Group B it was 65.95, 61.72 and 57.0%, respectively (statistically insignificant. Pain in group A at 1-month was mild (50%) and at 3 months only 10% and absent at 6 months, while in group B 50, 20% and absent at 6 months. Hyperpigmentation in group A was 06.66, 01.66 and absent at 1, 3, and 6 months, respectively, while in group B it was 10.63 and 04.25% and absent, respectively.
Conclusion: USG-guided endovenous laser ablation (EVLA) and Foam sclerotherapy are both technically feasible but the closure rate for treated perforators is almost the same for both techniques. In 6 month follow up, we found that EVLA is slightly better than foam sclerotherapy for the treatment of perforators but statistically insignificant.

Bowel Injury in Laparoscopic Cholecystectomy- A Surgical Challenge

2024-08-09T07:38:51+00:00

Laparoscopic cholecystectomy has become the gold standard for the surgical management of gallbladder diseases, including cholelithiasis and cholecystitis, due to its minimally invasive nature and favorable outcomes. Despite its widespread adoption and overall safety, complications can still occur. One such complication, albeit rare, is bowel injury, which can lead to significant morbidity and potentially life-threatening conditions if not promptly recognized and managed. Bowel injuries during laparoscopic cholecystectomy can arise from various mechanisms, including direct trauma from surgical instruments, thermal injury from electrocautery devices, or as a consequence of extensive adhesiolysis. The clinical presentation of bowel injury may vary, ranging from immediate recognition intraoperatively to delayed symptoms postoperatively, such as abdominal pain, peritonitis, or sepsis. Given the potentially severe outcomes, surgeons must maintain a high index of suspicion and be prepared to address these injuries promptly. In this case report, we describe a rare instance of a small bowel injury sustained during laparoscopic cholecystectomy in a 31-year-old male. We detail the intraoperative identification and management of the injury, the subsequent post-operative complications, and the successful surgical interventions that led to the patient’s recovery. This case underscores the importance of early detection and prompt intervention in managing bowel injuries during laparoscopic procedures and contributes to the existing knowledge on this critical issue.

Strangulated Spigelian Hernia: A Diagnostic Challenge with Rare Case Report

2024-08-14T03:29:58+00:00

Background: Spigelian hernia, is a rare abdominal wall anomaly with an incidence of 0.1-2%, was initially documented by Josef Klinkosh in 1764. This hernia protrudes through the Spigelian aponeurosis, a continuation of the transversus abdominis muscle’s aponeurosis situated between the rectus abdominis muscle’s lateral border and the linea semilunaris. They primarily occur within the spigelian hernia belt, a region below the umbilicus delineated by the anterior superior iliac spines. These are often misdiagnosed as lateral incisional hernias (eg, port site hernia).There’s no clear sex predilection, and most patients are diagnosed in the fifth or sixth decade of life.
Methods: A 56-year-old woman presented with acute onset and severe abdominal pain persisting for four days, accompanied by bilious vomiting. She had history of intermittent pain and swelling in left abdomen for more than 20 years and had undergone Hysterectomy with bilateral salpingo-oophorectomy 11 years earlier. Clinical examination revealed a palpable 5x5 cm lump in the left iliac fossa, with tenderness and mild erythema of overlying skin. Non-contrast abdominal CT confirmed a bowel loop protruding through an abdominal wall defect.
Results: Exploratory laparotomy revealed a gangrenous ileal segment of about 10 cm and segmental resection followed by anastomosis by single layer interrupted technique was done.
The patient recovered well during a 5-day hospital stay and continued follow-up without complications.
Conclusion: This case report emphasizes the importance of diagnosing spigelian hernia with increased risk of strangulation in patients with prior abdominal surgery. A high index of suspicion is needed for early diagnosis resulting in better outcomes.

Traditional 4-Port Versus Reduced Port Laparoscopic Cholecystectomy

2024-07-07T07:07:49+00:00

Introduction: Laparoscopic cholecystectomy is one of the most commonly performed surgeries worldwide by general surgeons. Improvisations, also in terms of reduction in the number and size of ports have been attempted for the same, seeking advantages of the same above the conventional four-port laparoscopic cholecystectomy.
Objective: To evaluate the advantages & efficacy of reduction in the number of ports for laparoscopic cholecystectomy.
Methods: A descriptive study of 100 cases from the Dept of General Surgery, Silchar Medical College & Hospital, Silchar, Assam, over a period of one year were analyzed.
Results.: A study of 100 patients with a female: male ratio of (18:7), of which 9 underwent 1-port LC, 52 underwent 2-port LC, 39 underwent 3-port LC. The mean operating time for 1, 2 & 3-port LC were 57.88, 42.2 & 35.68 minutes, respectively (p = 0.883) for conversion of reduced ports to conventional 4-port LC or open cholecystectomy, indicating no positive association between the number of ports & conversion. The mean number of doses of analgesia required in 3, 2 & 1-port LC were 2.23, 2.03 & 1.44 doses, respectively (p = 0.018). The mean number of post-operative days stay was 1.16, 1.04 & 1.11 days, respectively (p = 0.170), and the number of days taken for return to daily was 1.16, 1.04 and 1, respectively.
Conclusion: It was observed that the age for the prevalence of gallstone disease was most common between (21–30) years, the duration of surgery increased with the decrease in the number of ports, and the conversions were not associated with the number of ports used & so were the complications. The number of doses of analgesics required was lesser with a lesser number of ports. There was no significant difference in the duration of hospital stay. The number of days required to return to routine activities was earlier, with a lesser number of ports. The was excellent cosmesis in all the 3 types of reduced ports.
Our study showed similar results of Cassera et al., in terms of post-op complications, & pain were similar in with a decrease in the number of ports; Chow et al. showed shorter post-operative stay, which is not so in our study, which showed no significant duration of post-operative stay; Podolsky et al. expired technical difficulty with a reduction in a number of ports, which is similar to our study, where the duration of surgery increases with reduction of ports. There were certain limitations to this study including sample size being small and being from a single region is not representative of the entire community around the world. All the surgeries were performed keeping in mind the benefits that could be incurred for the patients at no added cost. There is a possibility of bias.

Giant Gall Bladder Stone Mimicking as a Gall Bladder Mass: A Diagnostic Challenge Between Gall Bladder Carcinoma and Xanthogranulomatous Cholecystitis

2024-08-27T08:17:43+00:00

Giant gallstones, although a rare phenomenon, pose significant diagnostic challenges, particularly when they mimic gall bladder carcinoma (GBC). Gallstones larger than 5 cm or weighing over 70 g are categorized as giant gallstones and are often associated with increased risk for conditions such as GBC, Mirizzi’s syndrome, and xanthogranulomatous cholecystitis (XGC). This case report presents a woman in her mid-40s with symptomatic gallstone disease, where preoperative imaging and elevated serum CA 19-9 levels raised suspicion of GBC. However, intraoperative findings revealed a giant gallstone mimicking a gallbladder mass, with subsequent histopathology confirming XGC. This case highlights the complexities in distinguishing between GBC and XGC due to their overlapping clinical presentations and imaging findings. It underscores the importance of thorough radiological evaluation and high clinical vigilance in managing such cases, as early and accurate diagnosis is crucial for determining the appropriate surgical approach and optimizing patient outcomes.

Correlation of Pulse oximetry with SOFA scores for evaluation of tissue perfusion in emergency surgery patients

2023-07-17T15:37:38+00:00

Introduction - Worldwide, every year, millions of people require emergency abdominal surgeries, which are urgent and time-critical to treat high-mortality diseases. Post-operatively, patients require continuous monitoring of the vitals and early diagnosis of post-operative complications and management for suitable outcomes of the patient. Pulse oximetry is a noninvasive method of monitoring a person’s oxygen saturation.
Physiologic compensatory mechanisms such as peripheral vasoconstriction limit the use of heart rate and blood pressure measurement as indicators for mild central tissue hypoperfusion and hypoxia in early settings. Hypotension is a late marker of hypoperfusion and almost 30% of circulatory volume may be lost before hypotension occurs. Therefore, early recognition of tissue hypoperfusion and hypoxia before the onset of tachycardia or hypotension is of prime importance in the prevention of hypoperfusion and hypoxia-induced organ failure.
AIM - Serial correlation between SpO2, perfusion index and SOFA score both preoperatively and post-operatively with the ultimate outcome of the patient.
Method - A total of 48 patients requiring emergency abdominal surgery of non-traumatic cause were considered. Vital parameters were assessed and documented. Blood samples were collected under aseptic conditions and deposited in the hospital lab. ABG was done using an ion-selective electrode in an ABG analyzer. SOFA scores of individual patients were calculated.
In our study, patients with uneventful recovery had a mean pre-operative SpO2 value of 95.75% and SOFA score value of 1.5 and post-operative value 97% and 1.13, respectively. On the other hand, patients who died (n = 7) in the post-operative period had mean pre-operative SpO2 values of 87.71% and SOFA scores of 7.29 and post-operative values of 86.57% and 13.71, respectively, at the end of 72 hours.
Result - Preoperatively, compared to uneventful recovery, the mean SOFA score was significantly high in patients who require reservoir bag (p ≤0.001), invasive ventilation (p = 0.028), only ionotropic support (p <0.001), ionotropic support plus ventilation (p <0.001), requiring renal replacement therapy (p <0.001) and in patients who died (p <0.001).
Preoperatively, compared to uneventful recovery, mean SpO2 was significantly low in patients who require reservoir bag (p = 0.002), invasive ventilation (p = 0.003), only ionotropic support (p = 0.003), ionotropic support plus ventilation (p = 0.003), required renal replacement therapy (p <0.001) and in patients who died (p <0.001).
Post-operatively, the mean SOFA score, compared to uneventful recovery, was significantly high in patients who require reservoir bag, invasive ventilation, only ionotropic support, ionotropic support plus ventilation, required renal replacement therapy and in patients who died.
Conclusion - Pulse oximetry is widely used for monitoring peripheral oxygen saturation (SaO2). By alerting the surgeon about the onset of hypoxemia or diminished perfusion, pulse oximetry can lead to the rapid institution of supportive treatment even before organ dysfunction begins to happen. Derangements of pulse oximetry parameters will occur several before the SOFA score is raised. Therefore, on the basis of pulse oximetry findings, quick corrective measures can be undertaken to prevent possible serious complications.
Physiologic compensatory mechanisms such as peripheral vasoconstriction limit the use of heart rate and blood pressure measurement as indicators for mild central tissue hypoperfusion and hypoxia in early settings. Hypotension is a late marker of hypoperfusion and almost 30% of circulatory volume may be lost before hypotension occurs. Therefore, early recognition of tissue hypoperfusion and hypoxia before the onset of tachycardia or hypotension is of prime importance in the prevention of hypoperfusion and hypoxia-induced organ failure.

In the pathophysiology of sepsis-generated organ dysfunction, the basic flaw lies in poor tissue perfusion and cellular oxygenation.
This sets off the cascade of metabolic and biochemical events which leads to organ dysfunction after a few hours or days. The key
to successful management of such patients lies in controlling the sepsis source and the earliest possible recognition of perfusion
and oxygenation deficit before organ dysfunction starts to take place.