Journal of Surgery Archives

A Rare Presentation of Obstructed Inguinal Hernia with Sac Containing Appendix and Loop of Ileum (Amyand’s and Maydl’s Hernia)

Santosh Singh — 2026-08-04

Background: Obstructed inguinal hernias are common surgical emergencies, but simultaneous presence of the appendix and a loop of ileum within the same hernial sac is exceptionally rare. The coexistence of Amyand’s hernia (appendix within the sac) and Maydl’s hernia (two loops of bowel forming a “W” configuration) is seldom reported.

Case Presentation: A 52-year-old male presented with irreducible right inguinal swelling and features of intestinal obstruction. Ultrasonography revealed an obstructed right inguinal hernia with decreased vascularity of the sac contents. Emergency surgery revealed the hernia sac containing the appendix and a loop of ileum, with gangrenous right testis due to compromised vascular supply. Right orchidectomy and Right Inguinal Herniorrhaphy were done. The postoperative period was uneventful.

Conclusion: The coexistence of Amyand’s and Maydl’s hernias is an extremely rare occurrence. Early surgical exploration remains the key to diagnosis and successful management.

Varicose Veins: Recent Updates in Pathophysiology, Diagnosis, and Management

Ajay K Khanna — 2026-08-04

Varicose veins are one of the most prevalent vascular disorders encountered in practice worldwide. It was regarded as a cosmetic concern, but it has been found that varicose veins are a chronic progressive condition associated with significant morbidity and reduced quality of life. This review deals with the current understanding of varicose veins and particular emphasis is placed on emerging non-thermal, non-tumescent ablative techniques and updated classification systems. The endovenous thermal ablation, mechanochemical ablation, and cyanoacrylate-based closure are critically appraised along with conventional surgical and sclerotherapy approaches.

CBD Injury During Cholecystectomy: Prevention, Early Recognition, Management and Ethical Disclosure

Amit Srivastava — 2026-08-04

Common bile duct (CBD) injury remains one of the most feared complications of cholecystectomy. Although uncommon, its consequences may be devastating when recognition is delayed or when repair is attempted without adequate expertise. This manuscript summarises the key deliberations of a surgical panel discussion on CBD injury, with emphasis on prevention, intra-operative warning signs, classification-based management, post-operative detection, delayed repair, referral principles and ethical disclosure to attendants. The central message is that most bile duct injuries arise from misinterpretation of anatomy rather than lack of knowledge. Prevention therefore depends on disciplined adherence to safe cholecystectomy principles, including B-SAFE orientation, identification of Rouviere’s sulcus or the R4U line, proper dissection of the hepatocystic triangle, demonstration of the critical view of safety and an intra-operative pause whenever anatomy is uncertain. If injury is suspected, the surgeon should classify the injury, avoid hazardous repair, drain when necessary and refer early to a centre with hepatobiliary expertise. Early recognition, minimal intervention and timely referral remain the cornerstones of good outcomes.

Prognostic Scoring and Risk Factor Analysis in Perforated Peptic Ulcer Disease: A Tertiary Centre Study

Harshit Sharma — 2026-08-04

Background: Perforated peptic ulcer disease (PPUD) is a global health issue with significant morbidity and mortality. This study aims to investigate predisposing factors for PPUD and evaluate the efficacy of the Peptic Ulcer Perforation (PULP) score in predicting patient outcomes at a tertiary care center in Uttar Pradesh.
Methods: This prospective cross-sectional study was conducted over one year and included 53 patients diagnosed with a perforated peptic ulcer. Data on demographics, clinical presentation, comorbidities, laboratory results, and intraoperative findings were collected. The PULP and American Society of Anesthesiologists (ASA) scores were calculated for each patient. Outcomes, including postoperative complications and mortality, were analyzed. Statistical analysis was performed using chi-square and independent t-tests, with a p-value of <0.05 considered significant.
Results: The study population was predominantly male. Mortality was significantly associated with advanced age (p = 0.027), with 57.14% of non-survivors being over 60 years old. Comorbidities such as diabetes mellitus and hypertension were significantly more common in non-survivors (p = 0.029). Non-survivors had significantly higher heart and respiratory rates and lower systolic blood pressure. Laboratory findings revealed that non-survivors had significantly higher total leukocyte counts, urea, creatinine, and INR levels (p <0.05). Postoperative complications like ARDS, leak, and sepsis were significantly more frequent in the non-survivor group (p <0.001). Higher PULP and ASA scores were strongly correlated with increased mortality (p <0.001).
Conclusion: Advanced age, comorbidities, physiological instability, renal dysfunction, and coagulopathy are key predictors of mortality in PPUD. The PULP score is a reliable and effective prognostic tool for risk stratification. Early identification of these risk factors and prompt intervention are crucial for improving clinical outcomes.

Role of Ultrasound Elastography for Predicting Malignancy in Suspicious Thyroid Nodules: A Prospective Study

Mohd Rashid — 2026-08-04

Background: Accurate preoperative differentiation between benign and malignant thyroid nodules remains challenging, particularly in patients with indeterminate fine-needle aspiration cytology (FNAC). Ultrasound elastography (USE) has emerged as a promising, non-invasive diagnostic modality for assessing tissue stiffness and predicting malignancy. This prospective study evaluated the diagnostic performance of qualitative and semiquantitative ultrasound elastography in solitary thyroid nodules and assessed the feasibility of surgeon-performed elastography.

Methods: A prospective study was conducted on 135 patients with solitary thyroid nodules (1–5 cm) who underwent thyroid surgery. All patients underwent conventional ultrasonography with American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS), qualitative elastography using the Asteria colorimetric score, semiquantitative elastography using strain ratio, FNAC, and histopathological examination, which served as the reference standard. Diagnostic performance of individual and combined elastography parameters was analyzed.

Results: Histopathology confirmed malignancy in 38 (28.1%) and benign disease in 97 (71.9%) patients. The incidence of malignancy increased progressively with higher colorimetric scores and strain ratios. Qualitative elastography demonstrated a sensitivity of 80.4%, specificity of 68.0%, and accuracy of 68.6%, whereas semiquantitative elastography achieved a sensitivity of 78.9%, specificity of 84.5%, and accuracy of 84.2%. Combining both elastography techniques improved diagnostic performance, yielding a sensitivity of 73.3%, specificity of 85.5%, negative predictive value of 89.2%, and overall accuracy of 84.8%. Surgeon-performed elastography demonstrated diagnostic performance comparable to radiologist-performed examinations.

Conclusion: Ultrasound elastography is a valuable adjunctive tool for predicting malignancy in solitary thyroid nodules. Combined qualitative and semiquantitative elastography provides high diagnostic accuracy and negative predictive value, potentially reducing unnecessary diagnostic thyroid surgery, particularly in patients with indeterminate cytology.

Ten Surgical Commandments of Totally Extraperitoneal Inguinal Hernia Repair: A Stepwise Technical Roadmap for Safe and Reproducible Surgery

Rajat Qanoongo — 2026-08-04

Background: Totally extraperitoneal (TEP) inguinal hernia repair is an established laparo-endoscopic technique that applies the principles of posterior preperitoneal mesh reinforcement without entering the peritoneal cavity. Despite well-recognised advantages in selected patients, the technique is limited by a narrow working space, unfamiliar posterior groin anatomy, and a learning curve that may predispose to technical errors.
Objective: To present a structured, anatomy-based set of ten operative commandments for TEP repair that can be used as a practical roadmap for training, intraoperative standardisation, and quality assurance.
Technique: The operative sequence is organised around safe retrorectus access, stable pneumo-extraperitoneum, medial Retzius dissection, lateral Bogros dissection, identification of all potential hernia sites, careful parietalisation of cord structures, achievement of the critical view of the myopectineal orifice, adequate mesh deployment, selective fixation, and desufflation under direct vision.
Conclusion: A reproducible TEP operation depends less on isolated manoeuvres and more on consistent exposure of the entire myopectineal orifice. The proposed commandments translate key anatomic concepts into a stepwise checklist that may reduce missed hernias, inadequate mesh overlap, neurovascular injury, and mesh displacement.