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International Surgery Journal https://ijsurgery.com/index.php/isj
International Surgery Journal (ISJ) is an open access, international, peer-reviewed surgery journal. The journal's full text is available online at http://www.ijsurgery.com. The journal allows free access to its contents. International Surgery Journal (ISJ) is dedicated to publishing research on all aspects of surgery. International Surgery Journal (ISJ) focuses on General Surgery, Robotic Surgery, Orthopedic Surgery, GI Surgery, Neurosurgery, Plastic Surgery, Cardiothoracic Surgery, Vascular Surgery, Urology, Surgical Oncology, Radiology, Ophthalmology, Pediatric Surgery, Anaesthesia, Trauma Services, Minimal Access Surgery, Endocrine Surgery, ENT, Colorectal Surgery, Laparoscopic and Endoscopic techniques and procedures, Preoperative and postoperative patient management, Complications in surgery and new developments in instrumentation and technology related to surgery. International Surgery Journal (ISJ) is one of the fastest communication journals and articles are published online within short time after acceptance of manuscripts. The types of articles accepted include original research articles, review articles, editorial, case reports, short communications, point of technique, correspondence and images in surgery. It is published monthly and available in print and online version. International Surgery Journal (ISJ) complies with the uniform requirements for manuscripts submitted to biomedical journals, issued by the International Committee for Medical Journal Editors.

Issues: 12 per year

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Print ISSN: 2349-3305

Online ISSN: 2349-2902

Publisher: Medip Academy

DOI prefix: 10.18203

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 Medip Academy en-US International Surgery Journal 2349-3305 The role of diagnostic laparoscopy in abdominal masses https://ijsurgery.com/index.php/isj/article/view/5463
Background: Diagnostic laparoscopy is an added tool that has become widely available for the assessment of abdominal masses in addition to conventional imaging. It is the best real time imaging technique due to the magnification and intense illumination provided. The aim of this work is the assessment of the impact of performing diagnostic laparoscopy at the start of operations intended for resection of an abdominal mass.

Methods: This prospective study included 40 patients admitted for surgical resection of an abdominal mass. All Patients were subjected to thorough conventional investigations followed by diagnostic laparoscopy performed prior to the start of the definitive operation. We assessed the extra time needed, complications encountered, effect on decision making and the overall benefit of laparoscopy in this context.

Results: Overall 21 patients (52.5%) did benefit from diagnostic laparoscopy somehow between upgrading the staging, affecting the laparotomy incision site and confirming feasibility of laparoscopic resection. Of the patients who proceeded to a laparotomy (n=30), diagnostic laparoscopy missed local invasion in 7 patients, which precluded the resection of the tumor in 5 of them. Only 1 complication related to diagnostic laparoscopy was encountered in the form of a port-site hematoma (2.5%).

Conclusions: While diagnostic laparoscopy doesn't carry significant added morbidity, it might save the patient an unnecessary laparotomy by altering the preoperative staging and improving the accuracy of anatomical and pathological diagnoses. Laparoscopy has its limitations mainly in the assessment of the retroperitoneal space as well as direct tumor invasion to adjacent organs and vessels.
 Hisham I. El Zanati Waleed A. Aboelwafaa Yasser M. Hamza Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 945 949 10.18203/2349-2902.isj20201370 Our management in vascular Behçet patients with ascending aorta aneurysm: 6 years' experience https://ijsurgery.com/index.php/isj/article/view/5482
Background: Ascending aortic involvement in Behçet's disease is very rare, and often accompanied by aortic root dilatation. In cases with aortic valve insufficiency without valve structure impairment, valve-sparing surgery can be performed. This study aimed to investigate the mid-term results of patients with ascending aortic involvement and selected surgical procedures according to the valve structure among those vascular Behçets disease.

Methods: A total of 13 Behçet's disease with aortic involvement operated at our center from January 2012 to 2018 was retrospectively investigated. Bentall or david valve-sparing operations were preferred according to the aortic valve status. Postoperative echocardiography and computed tomography imaging was performed periodically for aortic valve competence and pseudoaneurysm formation.

Results: Bentall procedure was performed in 7 (54%) patients, and 6 (46%) patients were undergone valve-sparing David procedure. Operative mortality was 7.7%, one patient died of major gastrointestinal bleeding 3 months after the operation. After 51±23 (ranged 23 to 94) months of follow-up, no other mortality occurred, overall survival rates were 84.6%, two patients had minimally aortic regurgitation and one patient had mild regurgitation in David procedure. In Bentall procedure, no paravalvular leakage was found during follow-up.

Conclusions: The database of our retrospective study regarding age and sex incidence, clinicopathological features and therapeutic outcome was comparable to other studies in various literatures.
 Emin C. Ata Metin O. Beyaz Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 950 953 10.18203/2349-2902.isj20201371 A comparative study between harmonic scalpel hemostasis and conventional hemostasis in total thyroidectomy https://ijsurgery.com/index.php/isj/article/view/5480
Background: Thyroidectomy is the most commonly performed procedure in endocrine surgery. Since the thyroid gland is highly vascular, therefore, rapid and absolute hemostasis is extremely required. Conventional thyroidectomy is commonly used with acceptable outcomes, however, it is time‑consuming and resulted in significant intraoperative blood loss with the possible risk of postoperative hemorrhage, injury to parathyroid glands and laryngeal nerves. The advent of focus harmonic devices was encouraging for improving safety, effectiveness, and reduction of operative time, especially in thyroid surgery. Aim of this study: The purpose of this study was to analyze the effectiveness and surgical outcomes of using ultrasonic harmonic scalpel for thyroid surgery compared to conventional techniques.

Methods: This was a prospective, randomized study in which 60 patients with various types of goiters presented for thyroidectomy. The patients were divided into two comparable groups. Group A (30 patients) included patients who had focus harmonic thyroidectomy and Group B (30 patients) included patients who underwent conventional thyroidectomy.

Results: Focus harmonic thyroidectomy showed a significant reduction in operative time, intraoperative blood loss, volume of postoperative fluid drainage and meantime for hospital stay compared with conventional thyroidectomy. There were no significant differences in the incidence of postoperative hypocalcemia, seroma, hematoma, wound infection and laryngeal nerve injury between both groups.

Conclusions: Focus harmonic thyroidectomy was a safe, effective, faster, and appealing alternative to conventional technique since it reduced the operative time, intraoperative blood loss, postoperative drainage and hospital stay with comparable postoperative complications.
 Waleed Yusif El Sherpiny Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 954 960 10.18203/2349-2902.isj20201372 Should a laparoscopic repair be the first choice in incarcerated inguinal hernia https://ijsurgery.com/index.php/isj/article/view/5695
Background: An important part of the procedures for admission to emergency surgery is incarcerated inguinal hernia repair. Minimally invasive surgical procedures have led surgeons to perform these operations laparoscopically. The aim of this study was to demonstrate the safety of laparoscopic inguinal hernia repair in patients admitted to the emergency department with incarcerated inguinal hernia.

Methods: The files of patients who underwent laparoscopic surgery for incarcerated inguinal hernia between January 2015 and June 2019 in Bandirma State Hospital General Surgery Clinic was retrospectively reviewed. Pearson Chi-Square test was used as statistical method. Version 18 of the SPSS program was used. P<0.05 was considered significant as it should be.

Results: A total of 63 patients were included in the study. The mean age was 52.8 years. A total of 64 repairs were performed on the right side in 41 (65%) cases, on the left side in 21 (33.3%) cases and on both sides in one (1.58%) case. Four (6.25%) of 63 patients had strangulation. Three of these patients (4.68%) had strangulated hernia, and one (1.56%) had strangulated and incarcerated hernia. Four patients (6.25%) presented with ileus. The mean operation time was 65 minutes (35-110 minutes). Mean duration of hospitalization was 2.4 days. The rate of minor complications was 4.68%. Only one (1.56%) major complication was iatrogenic small intestinal perforation. The mean follow-up time was 25.2 months. There was no early recurrence in patients.

Conclusions: We suggest that laparoscopic transabdominal preperitoneal hernia repair can be performed safely in emergency procedures in patients with incarcerated inguinal hernia.
 Tamer Akay Murat Akici Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 961 965 10.18203/2349-2902.isj20201014 Profile of congenital digital anomalies in children seen in two tertiary health facilities in Southern Nigeria https://ijsurgery.com/index.php/isj/article/view/5517
Background: Anomalies of the digits are among the common congenital limb anomalies seen worldwide. Whereas the majority of these digital malformations are relatively minor and require simple treatment, some of them are complex and often associated with other anomalies and systemic disorders. Reports on the occurrence of these anomalies and their treatment are scanty in our region. The study sought to evaluate the burden of these digital anomalies among paediatric patients seen in our centres and outcome of treatment.

Methods: Study was carried out as a prospective study in two tertiary health facilities in Southern Nigeria between June 2014 and May 2019. Data obtained and analyzed were the patients' gender, age, family history, type of digital anomaly, the limb/s involved, other limb anomalies, systemic disorders, treatment given, outcome, and duration of follow up.

Results: A total of 113 children with anomalies of the fingers and or toes were seen during the study period, but 104 were analyzed. They comprised, 63 (60.6%) were males and 41 (39.4%) females giving a male female ratio of 1.5:1. Polydactyly was by far the commonest digital anomaly and the upper limbs were mostly affected. Associated anomalies contributed significantly to morbidity and mortality in those cases.

Conclusions: Digital anomalies are fairly common surgical problems in our region. Though majority of cases are mild and are easily treated, the more complex ones still pose a challenge to treatment in our practice. There is need for more interest and training among surgeons in our region to improve the surgical care and outcome of treatment of these digital anomalies in our region.
 Okoro Philemon Ekemenye Otene Cletus Ikechukwu Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 966 969 10.18203/2349-2902.isj20201373 Knowledge, attitude and practice of laparoscopic surgery among medical doctors in Port Harcourt, Nigeria https://ijsurgery.com/index.php/isj/article/view/5540
Background: The use of minimal access techniques to achieve similar objectives as in open surgical procedures has witnessed a steady progress in the last two decades. The efficacy and safety of this mode of surgery has long been established. Medical doctors are not only members of the society; with their level of knowledge, their opinion is a strong mirror image of the pulse of the patients they treat. Aim of the study was to ascertain the knowledge, attitude, extent of practice, and factors affecting laparoscopic surgery among medical doctors in Port Harcourt, Nigeria.

Methods: A cross sectional study of four hundred and fourteen (414) practicing medical doctors was conducted. Using stratified sampling method, self-administered semi-structured questionnaires was distributed to respondents in Port Harcourt in 2018. Data obtained was analysed using the Statistical Package for the Social Sciences (SPSS) version 20.0.

Results: Knowledge of laparoscopic surgery among respondents was 89.6% (371). Three hundred and twelve respondents (75.4%) were willing to pay if such surgery is necessary and offered in Port Harcourt. Only 2.4%. of respondents asserted that laparoscopic surgery services are offered regularly in their hospital. Only 1 respondent (0.2%) was willing to pay ₦151,000.00 - 200,000.00 ($430 - $570) for commonly performed laparoscopic abdominal surgical procedures.

Conclusions: Willingness to accept and knowledge of laparoscopic surgery was relatively high among medical doctors, hence a high prospect for laparoscopic surgery practice in Port Harcourt is therefore likely. The practice of laparoscopic surgery seems low and willingness to pay, even among doctors seem to be a challenge.
 Rex F. O. A. Ijah Amabra Dodiyi Manuel Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 970 976 10.18203/2349-2902.isj20201374 Timing of hypocalcemia after total or near total thyroidectomy: a prospective observational study https://ijsurgery.com/index.php/isj/article/view/5530
Background: Hypocalcemia after thyroidectomy is the most common metabolic complication that prolongs the hospital stay. The aim of this study was to determine timing of hypocalcemia postoperatively and determine the safest day to discharge post-total or near-total thyroidectomy patients based on serum calcium level.

Methods: From October 2012 to January 2017, the medical records of 117 consecutive patients who underwent a total or near-total, completion or redo thyroidectomy for benign and malignant thyroid diseases in two university hospitals were prospectively analyzed. The serum calcium was measured preoperatively, on the morning on the first, second, third and fourth postoperative days and the postoperative day on which hypocalcemia developed was identified.

Results: Of the 117 patients who underwent a total or near thyroidectomy, 36 (30.7%) developed hypocalcemia, which was transient in 34 (29%) and permanent in two (1.7%) patients. The postoperative hypocalcemia was mild in 10 (8.5%) patients, and 26 (22.2%) patients developed significant postoperative hypocalcemia. Of the 36 patients who developed hypocalcemia postoperatively, the peak incidence of hypocalcemia (72.2%) was on the first postoperative day, and by the third day serum calcium measurement detected 97.3% of patients who developed hypocalcemia.

Conclusions: Postoperative serial serum calcium levels may be useful for identifying patients suitable for early discharge following total/near total thyroid surgery in hospitals that lack the facilities. Hypocalcemia peaked on the first postoperative day. However, based on serum calcium levels alone, the third postoperative day is the crucial day for deciding whether to discharge the patients.
 Mohamed O. Benkhadoura Abdulwahab M. Elbarsha Khaled K. Elgazwi Akrem I. Elshaikhy Talal K. Elkhweldi Othman H. Tajoury Jamal A. Alsharif Abdulgadir M. Abdulrahman Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 977 980 10.18203/2349-2902.isj20201375 Surgical practices during cholecystectomy in Algeria: results of a survey https://ijsurgery.com/index.php/isj/article/view/5521
Background: The cholecystectomy is one of the most practiced surgeries; the learned societies published guidelines to improve surgical practices. Guidelines are sometimes not followed, either by negligence, by lack of means or adequate professional environment. So, to know the real practices of surgeons, a survey was conducted.

Methods: An anonymous national survey involving all practicing Algerian surgeons was conducted. At the end of the survey, all data were captured and processed using the SPSS v20 software; χ2 tests were used to compare different groups of surgeons.

Results: Only 122 responses were retained, twenty-two percent of surgeons perform open cholecystectomy. No surgeon performed routinely cholangiography, 43% extracted the gallbladder using extraction disposal, 18% performed systematic abdominal cavity drainage, all surgeons send the gallbladder to histology for examination and postoperative antibiotic prophylaxis was routinely prescribed by 69% of surgeons. The average postoperative hospitalisation recommended by surgeons was 1.65 days (0-5) days. The experience of the surgeon or his position was associated with lower rates of systematic prescription of antibiotic prophylaxis, and with a lower duration of postoperative hospitalisation.

Conclusions: We recommend publication of guidelines of good practices adapted to the socio-professional and economic context of countries.
 Anisse Tidjane Nabil Boudjenan Serradj Nacim Ikhlef Soumia Benilha Noureddine Benmaarouf Benali Tabeti Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 981 985 10.18203/2349-2902.isj20201376 Evaluation of new technique of mesh fixation in laparoscopic inguinal hernia repair https://ijsurgery.com/index.php/isj/article/view/5421
Background: Hernia is a common problem of the modern world with an incidence ranging from 5 to 7%. Of all groin hernias, around 75% are inguinal hernias. Recently with the advancement in laparoscopy, endoscopic repairs seem to offer better quality of life, decreasing hospital stay and early return to work. Aim of the work was to evaluate a new technique for mesh fixation by Zein method of suturing and compare it with stapled mesh fixation in laparoscopic inguinal hernia repair transabdominal preperitoneal approach.

Methods: The study is a randomized, prospective single group study. The study was conducted after the approval of the ethical committee of the surgical department, Menoufia University. It was conducted in Menoufia University Hospital on 50 patients with inguinal hernia who were operated upon between September 2018 and September 2019 with a minimal follow-up of 6 months.

Results: Age of studied patients ranged from 27 to 55 years with mean 42.82±7.90 age/years. Regarding sex of studied patients, more than half (74%) of studied patients were males and (26%) were females. Regarding comparsion between high and low overall cost burden on the patient, it was interestingly found that high cost is associated with presence of complication like hematoma, prolonged stay in the hospital and prolonged use of antibiotics.

Conclusions: Both the use of sutures and fixation of mesh by absorbable tacks approaches are similarly effective in terms of operative time, the incidence of recurrence, complications, and chronic pain coinciding with all the available literature.
 Ahmed El Deep Ashraf A. Zeineldein Tamer A. Soltan Ahmed N. Fawzy Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 986 993 10.18203/2349-2902.isj20201377 Treatment outcome of hepatolithiasis: Nepalese experience https://ijsurgery.com/index.php/isj/article/view/5431
Background: Hepatolithiasis is a rare disease with high rate of treatment failure and recurrence. This study aims to review the burden, management and outcome from an endemic region.

Methods: A retrospective review of database of patients with hepatolithiasis managed surgically from 2015 to 2019 was performed. Diagnosis was based on the clinical findings and radiological investigations. Demographic data, clinical presentation, extent of disease and type of surgical management were evaluated. The outcome measures included immediate stone clearance, postoperative complications and follow-up.

Results: Hepatolithiasis was seen in nine (0.34%) out of 2,600 patients being evaluated for gallstone disease. Three patients were young, while the remaining six were in the middle-age group. The presenting symptoms were pain abdomen (78%) and jaundice (22%). Hepatolithiasis was located in the left, right and both ductal systems in 5, 1 and 3 patients respectively. Liver resection for unilateral disease was done in 3 patients: left hepatectomy (n=2) and left lateral segmentectomy (n=1). High bile duct exploration and bilio-enteric drainage was done in 5 patients. One patient required hepatolithotomy and T-tube drainage due to cholangitis. Complete stone clearance was achieved in 78%. Complications included surgical site infection and cholangitis in 2 patients. There was no operative mortality. Histopathology revealed recurrent pyogenic cholangitis. At median follow-up of 28 months, 7 patients are symptom-free.

Conclusions: Hepatectomy is an effective treatment when disease is confined to the left lobe. Combined surgical procedure is an acceptable option for bilateral or right-sided hepatolithiasis.
 Narendra Pandit Laligen Awale Tek Narayan Yadav Kunal Bikram Deo Shailesh Adhikary Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 994 997 10.18203/2349-2902.isj20201378 Management of complex genital fistula: experience in a tertiary sub-Saharan hospital https://ijsurgery.com/index.php/isj/article/view/5483
Background: Management of complex genital fistulae is challenging due to the cost and technical skill required. This study reports our experience in the management of patients with complex genital fistulae and to highlight the crucial role of the reconstructive urologists.

Methods: This was a retrospective review of female patients managed at a tertiary hospital in Nigeria from 2006 to 2017 for complex urinary fistulae. Data were extracted from patient case notes and the data analysed using the SPSS software.

Results: Twenty-four female patients mean age 28.9±11.1 years. Fistulae resulted from prolonged obstructed labour 10 (41.6%), caesarean hysterectomy 7 (29.2%), caesarean section and abdominal hysterectomy 2 (8.4%) respectively. The fistulae were vesicovaginal 16 (66.7%), ureterovaginal 3 (12.5%). Others were vesicocutaneous, urethrovaginal and rectovaginal. Prior attempts at repair were done in 7 (29.2%) and the number of attempts ranged from 1 to 4. Surgical procedures included direct closure in 9 (37.5%), closure and uretero-neocystostomy 7 (29.2%), uretero-neocystostomy only 3 (12.5%) closure and abdominal hysterectomy 2 (8.3%), closure and continent catheterizable neo-bladder 2 (8.3%) and 1 (4.2%) closure, abdominal hysterectomy and uretero-neocystostomy. Post-operative complications were noted in 2 (8.3%) and consisted of gynaeatresia and recurrent RVF. Repair was successful in 70.8% of patients while failed repair was recorded in 16.7% and while stress incontinence was present in 12.5%.

Conclusions: Complex genital fistulae in our practice are of obstetric origin involving the bladder, ureters and rectum. The reconstructive urologist has a crucial role the management for a favourable outcome.
 Ngwobia P. Agwu Abdullahi A. Ahmed Abubakar S. Muhammad Ismaila A. Mungadi Emmanuel U. Oyibo Mairo Hassan Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 998 1003 10.18203/2349-2902.isj20201379 Open versus laparoscopic repair of perforated duodenal ulcer: a comparative study https://ijsurgery.com/index.php/isj/article/view/5430
Background: Surgery is the mainstay of the treatment for perforated duodenal ulcer by closing the perforation with or without omental patch. There are no controversies in the surgical treatment of perforated duodenal ulcer but the best approach to surgery is still debatable. Advances in minimal access surgery has made it possible to close the perforated duodenal ulcer laparoscopically. The present study was conducted to compare the results of open and laparoscopic repair of perforated duodenal ulcer in terms of operative time, postoperative pain, hospital stay, and post-operative complications etc.

Methods: The study was conducted in Dr. V. M. Government Medical College and Hospital located in Solapur (Maharashtra) from December 2008 to December 2010. It was a prospective comparative study. Patients were randomly divided into 2 groups alternately where group A and B were operated by conventional and laparoscopic techniques respectively and their outcomes were compared.

Results: Most commonly affected age in this study was 51 to 60 years with male preponderance. Post-operative pain, analgesic requirement, wound infection, hospital stay, was significantly less in laparoscopic group as compared to open group (p<0.05).

Conclusions: Laparoscopic repair of perforated duodenal ulcer is safe and feasible in properly selected patients and has superior results as compared to open surgery.
 Santoshkumar N. Deshmukh Hirav P. Parikh Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1004 1008 10.18203/2349-2902.isj20201380 Outcomes of pleural decortication in a tertiary care hospital of Telangana state https://ijsurgery.com/index.php/isj/article/view/5804
Background: The objective of the study was to study the clinical profile, incidence of postoperative complications in patients undergoing pleural decortication.

Methods: The subjects for the study were selected from the cases admitted in a single unit of Department of Cardiothoracic Surgery, Nizam's Institute of Medical Sciences, Hyderabad during the period of 2016 to 2018 and due ethics committee approval was taken. Collection of data is done from the database including admission record, ICU charts, discharge records and follow-up records. 50 patients underwent surgery. Outcomes and complications were analyzed for 3 years duration.

Results: 50 patients were included in this study with different aetiologies that required pleural decortication. The average age of patients in our study was 34 years. Most patients in our study were male (80%) and had history of infection with tuberculosis (42%) and pyogenic (28%) infection. A few patients had history of trauma (12%). Most of the patients suffered from cough (88%), dyspnoea (74%), fever (82%) and haemoptysis (22%). The common postoperative complications we encountered were pleural air leak (37.5%) bleeding (25%) infection (25%) and recurrence (2%). Overall morbidity from pleural decortication was seen in 16 patients, and there was no mortality.

Conclusions: The most common reason for pleural decortication is still empyema thoracis secondary to infection in the developing countries. Tuberculosis is still the most common cause leading to fibrothorax requiring pleural decortication followed closely by pyogenic lung infections and trauma.
 Madhusudan Kummari Amaresh Rao Malempati Surya S. Gopal Palanki Kaladhar Bomma Chakravarthy Goutham Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1009 1014 10.18203/2349-2902.isj20201059 A study on outcome of primary closure versus open fistulectomy in low level fistula in ano https://ijsurgery.com/index.php/isj/article/view/5820
Background: Fistula-in-ano is one of the common ano-rectal disorder which causes appreciable morbidity and inconvenience to the patient. Different surgical techniques have been described in literature from time to time. Open fistulectomy though considered as the standard treatment for fistula in-ano, fistulectomy with primary closure has its merits of short hospital stay, early wound healing and lower costs. The objectives of this study was to compare the period of stay, period of healing, time period to return to daily activities and cost factor between open fistulectomy and primary closure technique.

Methods: Patients admitted in all surgical units of NIMRA Hospital, were included in the study without bias on a serial basis. This is a study comprising 50 patients over a period of 12 months from Febrauary 2019 to January 2020.

Results: The patients were divided into two equal and comparable groups. Patients who underwent open fistulectomy were classified under Group I and those who underwent fistulectomy with primary closure were classified as Group II. The patient's characteristics of the two groups were well matched.

Conclusions: In patients treated by classical method because of long time taken to heal, number of hospital visits for dressings were more and more antibiotics were prescribed when compared to cases treated by excision of fistula tract and primary closure. From this study it can be concluded that fistulectomy with primary closure is ideal for low anal fistulaures.
 Maruti Basa Karnati Prakash Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1015 1020 10.18203/2349-2902.isj20201166 Study of incidence and clinical presentation of tubercular abdominal emergencies https://ijsurgery.com/index.php/isj/article/view/5818
Background: Tuberculosis is a common surgical problem in our community. Emergency surgery is usually required and surgical procedure depends upon the location and extent of the disease. Objective of the study was to determine the incidence of abdominal emergencies due to tuberculosis.

Methods: This observational study involved 300 patients with abdominal tuberculosis admitted either as a case of acute of subacute abdominal emergencies and tract in Lal Lajpath Rai hospital Kanpur, Uttar Pradesh, India, and associated hospitals. Data was entered into Excel worksheet and analyzed using SPSS version 16.0. Detailed data of each patient was entered on a Microsoft excel. Data were presented in number and percentages.

Results: The maximum number of cases were in third decade of life, age group 21-30. There were 120 males and 180 females. Male to female ratio was 1:1.5. Most of cases not having evidence of tuberculosis. History of pulmonary tuberculosis and abdominal tuberculosis were observed in 25% and 13% of the total cases. Abdominal pain was the commonest symptoms. Generalized pain was present in 136 cases and localized pain was present in 154 cases. 186 cases were presented as subacute intestinal obstruction and 114 cases patients were presented as acute abdomen.

Conclusions: Acute abdominal condition is one of the most frequent emergencies, early diagnosis with prompt treatment is essential for a promising prognosis.
 Mahendra Kumar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1021 1024 10.18203/2349-2902.isj20201165 An analysis of factors determining the requirement of ventriculoperitoneal shunt surgery in the children suffering from posterior fossa tumour: a single centre retrospective review https://ijsurgery.com/index.php/isj/article/view/5689
Background: Hydrocephalus is a relatively common occurrence in a children suffering from the posterior fossa tumour (PFTm). However, there is a divided opinion regarding the ventriculoperitoneal shunt (VPS) surgery before the posterior fossa tumour resection in a child. For the better clinical outcome, we should be able to predict which patient will require VPS following the resection of PFTm. Purpose of our retrospective analysis is to analyse various factors that predicts the necessity of VPS following PFTm resection.

Methods: A consecutive series of twenty-six patients who underwent PFTm resection without undergoing VPS preoperatively are analysed in our series.

Results: In our series, we found that the younger age at presentation, incomplete tumour resection, longer period of artificial ventilatory support, insertion of external ventricular drain (EVD) and its duration during the postoperative period correlate the necessity of VPS following PFTm resection. However, the severity of hydrocephalus prior to tumor surgery, tumour size, anatomical location of the tumour, tumour dissemination, use of Dural grafts during closure and histopathological type do not predict the requirement of the VPS following PFTm.

Conclusions: Patients who are younger at diagnosis should be treated with utmost importance. Gross total resection should be the goal. Factors which predict the likelihood of the EVD which parallels the likelihood of postresection hydrocephalus must be prevented for the better clinical outcome.
 Mrinal Bhuyan Debadatta Saha Basanta Kumar Baishya Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1025 1030 10.18203/2349-2902.isj20201013 Ten years' experience of augmentation cystoplasty for varied indications and its outcome https://ijsurgery.com/index.php/isj/article/view/5719
Background: The aim of the study was to evaluate long term efficacy and complications of augmentation cystoplasty in patients with bladder dysfunction.

Methods: Our series comprises of 30 patients undergoing enterocystoplasty from March 2009 till December 2019. Clinical findings and investigations result along with surgical techniques used were noted for these patients. Postoperative complications along with urinary continence and renal outcome were evaluated.

Results: Mean age of patients was 7 years and their mean follow up was for 4 years. Major complications occurred in 5 patients which were successfully managed and minor complication in 8 patients. Of these 16 patients were with neurogenic bladder and 14 with non-neurogenic bladder. The primary etiology of non-neurogenic bladder was extrophy epispadias complex (10 patients), posterior uretheral valves (2 patients), anterior uretheral valve (1 patient), and bilateral ectopic ureter (1 patient). The primary etiology of neurogenic bladder was meningomyocele (4 patients), anorectal malformation with vertebral anomalies (7 patients), partial sacral ageneis (4), nonneurogenic neurogenic bladder (1 patient). Relative continence was achieved in 97%. The preoperative serum creatinine and blood urea nitrogen (BUN) at the time of bladder augmentation (termed creatinine-1 and BUN-1)and the serum creatinine and BUN at the last follow up after bladder augmentation (termed creatinine-2 and BUN-2)were sought and compared using chi square test showed statistically significant improvement (p<0.01).

Conclusions: Augmentation cystoplasty is a necessary and safe procedure to increase the functional capacity of small contracted and poorly compliant bladder and allows patients to achieve relative continence and preserves renal function.
 Hemangi R. Athawale Shivaji B. Mane Natasha Vagheriya Prathamesh More Taha Daginawala Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1031 1035 10.18203/2349-2902.isj20200999 Mortality from necrotizing fasciitis: a cross-sectional study https://ijsurgery.com/index.php/isj/article/view/5720
Background: Necrotizing fasciitis refers to the rapidly progressive inflammation of the fascia, with secondary necrosis of subcutaneous tissues. Due to the high mortality, it is considered a surgical emergency, needing timely diagnosis and appropriate treatment with early debridement. The aim of the study was to analyse the clinical profile of patients with necrotizing fasciitis so as to determine the mortality and the risk factors associated with mortality and other poor outcomes.

Methods: This retrospective cross-sectional study was conducted in a tertiary hospital in Kerala, from January 2016 through January 2018. 175 cases were identified through the ICD codes for necrotizing fasciitis and Fournier's gangrene in the discharge and death registers; and data were obtained about these patients. The data were analyzed to assess the study objectives.

Results: In this study mortality was found to be 22.7%. Diabetes mellitus was found to be the most common co-morbid disease and had a significant association with increased risk of amputation. Mixed growth (type I NF) was the most common microbiological isolate and Pseudomonas was the most common gram-negative isolate. 4 cases of MRSA were recorded. Klebsiella infection was found to have increased risk of undergoing limb amputation. 7.4% of the patients required amputation during hospital stay for infection control.

Conclusions: Necrotizing fasciitis has a high mortality. Diabetes mellitus was found to be the most common co-morbid disease. Increased blood glucose and low serum albumin had a significant association with an increased risk of amputation. Proper control of these factors is essential to reduce mortality from this condition.
 Patric Paul Induprabhayadev Prabhakaran Meer Chisthi Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1036 1041 10.18203/2349-2902.isj20201036 Factors responsible for left atrial clot formation in patients with mitral stenosis and normal sinus rhythm https://ijsurgery.com/index.php/isj/article/view/5728
Background: The objective of the study was to investigate the factors responsible for left atrial (LA) clot formation in patients with mitral valve stenosis in normal sinus rhythm.

Methods: 79 patients (43 males and 36 females) were included in the study. 9 patients with mitral stenosis in normal sinus rhythm had LA clot or LA smoke in echocardiography included in Group A and rest of 70 patients in Group B. LA size, gradient across mitral valve and mitral valve surface area was studied and compared in patients with or without LA clot/smoke.

Results: Mean LA size was 4.8 (±0.5) and 4.6 (±0.7) in group A and B respectively with (p=0.304) and mean valve gradient was 11.6 (±2.8) and 10.6 (±3.5) in group A and B respectively with (p=0.507), the difference was not significant in both. Mean mitral valve area was 1.01 (±0.3) and 1.12 (±0.5) in group A and B (p=0.36), the difference was not significant.

Conclusions: Study concluded that there was no significant difference in LA size, valve gradient and mitral valve area in patients with or without LA clot having mitral valve stenosis in normal sinus rhythm. Patients with LA clot warrant measures to prevent thromboembolic episodes.
 Pranay Suresh Mehsae Mohammad Abid Geelani Sayyad Ehtesham Hussain Naqui Soumyaranjan Das Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1042 1044 10.18203/2349-2902.isj20201011 Correlation of coagulation markers with axillary lymph node metastasis in breast malignancy: a tertiary care centre study in North India https://ijsurgery.com/index.php/isj/article/view/5743
Background: Breast cancer is the most common female cancer worldwide representing nearly a quarter (25%) of all cancers. Search for a marker which can predict lymph node metastasis in clinically negative axilla has been a matter of research for long. The present study is an attempt to evaluate role of coagulation makers with special reference to D-dimer and factor 7 and 8 in patients of carcinoma breast in predicting lymph node metastasis in carcinoma patients.

Methods: The study was a prospective study conducted in 50 diagnosed patients of carcinoma breast in whom D dimer levels and factor 7 and 8 levels were measured at the time of commencement of the treatment and at six weeks after surgery.

Results: Most of the patients in the study group were in the age group 41-70 (80%) years. 22% patients were of early Breast cancer. The reduction in D-dimer, factor VII and factor VIII value after 6 weeks of surgery were significant (p value 0.0001 for all three).

Conclusions: D-dimer and factor VII were found to be an independent predictive factor for lymph node metastatsis, thus providing as a safe, easy, objective and convenient supplement to sentinel node biopsy in assessing metastatic disease in axilla. Combined- with other biomarkers, it may prove to be an alternative to sentinel node biopsy in assessing metastatic disease in axilla. Significant postoperative decrease in D-dimer, factor VII and factor VIII may provide objective criteria to assess completion of surgery.
 Vaibhav Srivastava Nandan Rai Shabi Ahmad Vikram Singh Shirish Kumar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1045 1050 10.18203/2349-2902.isj20201163 A clinical study on varicose veins of lower limb, surgical management and functional outcome at a tertiary care hospital of South India https://ijsurgery.com/index.php/isj/article/view/5761
Background: Varicose veins defined as dilated, tortuous, subcutaneous veins ≥3 mm in diameter, measured in the upright position with demonstrable reflux. Though the history of varicose veins dates prehistorically, the advances in diagnosis and new management modalities gained attention recently. The aim of the present study was to study the clinical profile, risk factors and their association, different types of surgical procedures employed and complications associated with varicose veins.

Methods: A one year observational after ethical committee approval was conducted by department of general surgery at ACSR Medical College. Cases fulfilling the inclusion criteria were clinically examined and duplex ultrasound colour Doppler was performed for diagnosing the varicose veins and findings of site of incompetence was noted. All the cases were operated and followed up for six months period. The results were tabulated and analyzed in Microsoft Excel for any corrections.

Results: Eighty cases with 66.25% males and 33.75% females with mean age of 40.24 years and majority (40%) were in 41 to 50 years group. 60% of cases had varices in right limb and long saphenous vein was involved in 52.5% of cases.85% had dilated veins, perforator incompetence was noted below the knee in 30% of cases. 41.25% of cases saphenofemoral flush ligation with stripping of long saphenous vein. Wound infection was the common postoperative complication.

Conclusions: Operative line of management should be the first line of treatment even though conservative management relieves the symptoms but always requires a definitive management.
 Bandaru Nageswara rao Ramachandra Pushpalatha Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1051 1055 10.18203/2349-2902.isj20201072 Spectrum of elective pancreatic surgeries with short term outcomes at a tertiary hospital in North India https://ijsurgery.com/index.php/isj/article/view/5762
Background: Pancreatic surgeries have undergone substantial changes over the last few decades and are now being attempted by many surgeons not limited to specialised centres. The study has attempted to document the indications for elective pancreatic surgeries and its outcomes in terms of morbidity and mortality.

Methods: This observational study included 42 patients over a period of 12 months. The data were recorded in a predesigned proforma to assess the indication for elective pancreatic surgery, to describe the number and kind of pancreatic operation undertaken and to evaluate the short-term outcome of various pancreatic surgeries in terms of complications, morbidity and mortality.

Results: Authors studied 42 patients, who underwent the elective pancreatic surgeries for various indications in hospital. Histopathological studies revealed that the majority (50%) were carcinoma of the head of pancreas. Pancreaticoduodenectomy (PD) was done in all the sixteen cases. The most important complications of PD were delayed gastric emptying (DGE) (50%), surgical site infection (SSI) (43.7%), post pancreatic haemorrhage (PPH) (31%), post-operative pancreatic fistula (POPF) (25%) and intra-abdominal abscess (IAA) (12.5%). Of the 26 patients operated for benign conditions of pancreas, 19 (73%) had pancreatic pseudocyst, in majority of cases as a sequela of alcohol induced pancreatitis. Partington Rochelle procedure was the commonest surgical procedure in chronic pancreatitis.

Conclusions: Carcinoma of head of pancreas was the most common periampullary malignancy necessitating major pancreatic resections. DGE, POPF and PPH were the most common and significant post-operative complications.
 Hema Rana Jitendra Prasad Ray Babar Rehmani Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1056 1060 10.18203/2349-2902.isj20201164 A study of collagen dressing versus conventional dressings in burns at tertiary health care centre https://ijsurgery.com/index.php/isj/article/view/5766
Background: Worldwide, burn injury is a problem and cause intense pain, biological dressings like collagen as it forms physiological interface prevents infection effective for burn wound healing. The objective of the study was to study of collagen dressing versus conventional dressings in burns at tertiary health care centre.

Methods: This was a cross sectional study carried out in the Department of Surgery during September 2018 to September 2019. Out of 50 patients, 25 were enrolled to collagen treatment group (group A) and remaining into conventional treatment group i.e. (group B). The statistical analysis was done by unpaired t-test and chi-square test.

Results: Average less time required for granulation tissue to appear p<0.001, df=48, t=4.56); average less time requires for sterile wound swab culture (weeks) (p<0.05, df=48, t=3.45); less discomfort score (0-10) (p<0.001, df=48, t=6.78); less dressing removal pain score (0-10) (p<0.0001, df=48, t=9.87); less average time required for complete healing (days ) (p<0.001, df=48, t=7.79).

Conclusions: It can be concluded that collagen dressings were superior to conventional dressing in wound healing of burns.
 Paritoshsingh B. Thakur T. Ramachandrudu Anant Arunrao Takalkar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1061 1064 10.18203/2349-2902.isj20201073 Step up approach for the management of late presentation of pancreatic trauma patients https://ijsurgery.com/index.php/isj/article/view/5773
Background: Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities and these injuries are often overlooked in cases with extensive multi-organ trauma. Our study was conducted to evaluate the outcome of a step-up approach in the management of pancreatic trauma patients with late presentation.

Methods: The study included 15 patients who presented with grade III AAST delayed presentation of pancreatic trauma from September 2017 to 2019. In our step-up approach 2 staged procedure was done, firstly laparotomy with necrosectomy along with closure of proximal pancreatic duct with external drainage of pancreatic duct, in second stage Roux-en-Y pancreaticojejunostomy was done to drain the remnant pancreas as a definitive procedure 3 to 6 months after initial procedure.

Results: In our study, blunt trauma abdomen (83.30%) (n=10) was the most common mode of injury. The main reason for delay in diagnosis of pancreatic trauma was delayed presentation of patient (83.3%) (n=10). Total of 4 patients were admitted to intensive care unit (ICU) at the time of admission. 10 patients underwent both the stages of step up approach management among which one patient had pancreatic fistula as a complication (n=1) (10%) and one patient had post-operative abscess as a complication (n=1) (10%). No mortality was noted in our study.

Conclusions: The step-up approach discussed above proves to be beneficial towards management of patients with delayed presentation of pancreatic trauma in our setting.
 Shabi Ahmad Vikram Singh Vinod Kumar Pandey Shirish Kumar Tabrej Alam Prakhar Pratap Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1065 1070 10.18203/2349-2902.isj20201058 Role of emergency coronary artery bypass grafting in the era of percutaneous interventions https://ijsurgery.com/index.php/isj/article/view/5776
Background: In acute coronary syndrome, prompt restoration of myocardial blood flow is essential to optimize myocardial salvage and decrease mortality. Coronary artery reperfusion, if performed in a timely manner improves clinical outcomes compared to no reperfusion. Fibrinolysis and percutaneous interventions can restore blood flow in an acutely occluded coronary artery in most of the patients; but in a few subset of patients coronary artery bypass grafting (CABG) is needed to effectively restore blood flow.

Methods: A retrospective study was conducted among all CABGs performed during March 2016 - February 2018. During this period, 366 CABGs were performed and 57 patients underwent emergency CABG as per the inclusion criterias. Pre-operative, intra-operative and post-operative data was analysed of these patients. Patients were divided into four groups based on the time of surgery from the time of onset of myocardial infarction.

Results: 57 patients underwent emergency CABG with males constituting 94.7% of the study population. 78.9% of them had an ejection fraction less than 35%. 52% presented with low cardiac output status, 10% needed intra-aortic balloon pump support and 15% required mechanical ventilation prior to surgery. All patients received an average of 2.8 grafts. Mortality was 5%

Conclusions: Immediate surgical revascularisation of patients presenting with acute MI is feasible. Emergency CABG not only treats the culprit lesion but also achieves complete revascularization and offers a clear advantage for patients. The optimal timing of CABG for patients with acute MI remains difficult to establish.
 Venugopal Ramarao Chandana N. C. Sunil P. K. Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1071 1076 10.18203/2349-2902.isj20201171 Role of diagnostic laparoscopy in chronic abdominal pain https://ijsurgery.com/index.php/isj/article/view/5154
Background: Chronic idiopathic pain syndromes are amongst the most challenging and demanding conditions to treat across the whole age spectrum. Despite these patients having undergone numerous diagnostic work-ups, their pain remains a challenge to all known diagnostic and treatment methods.

Methods: To evaluate role of diagnostic laparoscopy in chronic abdominal pain a prospective observational study was done. The present study was conducted on patients with undiagnosed chronic abdominal pain coming to the Department of Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune. 75 patients with chronic abdominal pain who attend the General Surgery Department (OPD) were included in the study. Patients were included in the study after taking their voluntary informed consent. The categorical variables were assessed using Pearson chi-square. The quantitative variables were assessed using T-test. The test was considered significant only if the p value comes out to be less than 0.05.

Results: Based on the findings of the study after performing diagnostic laparoscopy for 75 patients with chronic abdominal pain it was found that most common finding was of appendicitis (32%) followed by abdominal Koch's (24%) and post-operative pain relief using VAS showed p value of less than 0.05 at 3 months of follow up post diagnostic laparoscopy.

Conclusions: The present study concluded that laparoscopy is an effective diagnostic role in evaluating patients with chronic abdominal pain, in whom conventional methods of investigations have failed to elicit a certain cause. The advantage of diagnostic laparoscopy over non-invasive methods is the ability to perform therapeutic procedure at the same time in cases of chronic abdominal pain. Diagnostic laparoscopy is safe, cosmetically better and having less morbidity.
 Anuradha Dnyanmote Neha Srivastava Debabrata Gope Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1077 1081 10.18203/2349-2902.isj20201035 Soft tissue reconstruction of low voltage electric burn injuries of the thumb and first web space by the first dorsal metacarpal artery island flap: a three-year study from Eastern India https://ijsurgery.com/index.php/isj/article/view/5841
Background: Complex soft tissue defects of thumb and first web space are a reconstructive challenge. Low voltage electric burns of the hand commonly result in localised and deep soft tissue destruction. The first dorsal metacarpal artery flap (FDMA) is an attractive local flap option to reconstruct these. This study illustrates our experience with the same.

Methods: Between March 2014 and February 2017, 16 patients with complex soft tissue defects of thumb and first web space resulting from low voltage electric burns underwent reconstruction with the FDMA flap and subsequent structured hand therapy. In the follow up visits objective assessment of hand function included tests of mobility using Kapandji Score, sensory evaluation with static 2 point discrimination and cortical reorientation. The Subjective Satisfaction Score was used to ascertain the patient's overall perception of aesthetic and functional outcome.

Results: Majority (43.75%) of the patients had defects involving the thumb IP joint. No case of complete flap failure was noted. In a mean follow-up of 11.5 months the reconstructed thumb showed return of good protective sensation as well as mobility. Though cortical reorientation was complete in only 18.75 %, it did not substantially impede hand functioning. All patients were satisfied with the functional and aesthetic result.

Conclusions: In cases of low voltage electric burn injuries the FDMA flap is a reliable reconstructive option for small to moderate sized complex defects of thumb and first web space. It has minimal donor site morbidity and can be accomplished in a relatively simple single stage procedure.
 Madhumita Gupta Prabir Kumar Jash Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1082 1088 10.18203/2349-2902.isj20201169 Evaluation of changes in serum lipid profile and fasting blood glucose levels in patients with gall stone disease before and after cholecystectomy https://ijsurgery.com/index.php/isj/article/view/5674
Background: There is paucity of information regarding the effects of cholecystectomy on serum lipid profile parameters and blood glucose levels in the patients of cholelithiasis. Therefore, this study was undertaken to compare some serum lipid parameters and blood glucose levels in patients of cholelithiasis and effect of cholecystectomy on the same.

Methods: The study was conducted on 50 patients of cholelithiasis who were admitted in Surgery department, MLN Medical College over a period of one year and were planned for cholecystectomy. Complete lipid profile (which included total cholesterol, triglycerides, high density lipoproteins (HDL) cholesterol, low density lipoproteins (LDL), very low density lipoproteins (VLDL) and atherogenic index) and fasting blood glucose was evaluated pre-operatively and post-operatively on the 3rd, 7th and further after 1 month of cholecystectomy.

Results: Out of 50 patients, maximum of 38% were in their 4th decade with females constituting 82% of total. There was significant elevation in fasting blood glucose and HDL cholesterol on 3rd, 7th and 30th day post-cholecystectomy as compared to pre-operative values (p value<0.0001). Triglyceride and VLDL cholesterol elevated on 3rd and 7th day but it significantly decreased one-month post-cholecystectomy as compared to pre-operative levels (p value<0.0001). However, LDL, total cholesterol and atherogenic index significantly decreased on 3rd ,7th and 30th day post-cholecystectomy.

Conclusions: Cholelithiasis is an important cause associated with significant pathological changes in many lipid profile parameters, which will return towards normal after cholecystectomy. This normalization will be a time dependent phenomenon with long term beneficial effects.
 Raj Kumar Vikram Singh Shabi Ahmad Mayank Singh Anshul Singh Nandan Rai Shirish Kumar Abhinav Agarwal Gaurav Mittal Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1089 1094 10.18203/2349-2902.isj20201012 Scrotal hitch: a novel technique to reduce post-operative scrotal oedema in inguinal hernia surgeries: a pilot study https://ijsurgery.com/index.php/isj/article/view/5358
Background: Inguinoscrotal swellings are the most common presenting complaints in the surgical out patient department and surgeries for the same are the most commonly done elective procedures.However meticulous the surgeon is, there is always some amount of scrotal oedema. Our study is intended to use a simple and novel technique by applying a scrotal hitch after the surgery to prevent the scrotal oedema. The aim of the study was to evaluate the effectiveness of a scrotal hitch in reducing the scrotal oedema and pain postoperatively.

Methods: In this study all subjects undergoing inguinal hernia surgeries at undergoing at R.L. Jalappa Hospital, Kolar from June 2019 to August 2019 were included. Of the 60 subjects, 30 in group A were given scrotal hitch and subjects in group B were given scrotal support alone. The incidence of scrotal oedema and postoperative pain and development of any complications will be compared in both the groups.

Results: A total of 60 subjects were included in this study. Mean age of patients in group A is 45.63±21.745 and group B is 41.43±24.579. 2 patients with scrotal hitch developed scrotal edema whereas 6 patients developed scrotal edema in group B. The post-operative pain score was lower in patients with scrotal hitch.

Conclusions: Scrotal hitch is a simple and effective technique in preventing post-operative oedema and pain. The results of this study would encourage surgeons to take up this simple procedure to prevent the commonest complication of inguino-scrotal surgeries.
 Raadhika Raja P. N. Sreeramulu Vikranth Suresh N. Srinivasan D. Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1095 1098 10.18203/2349-2902.isj20201043 Comparative study of laparoscopic and open surgery in management of 50 cases of liver hydatid cyst https://ijsurgery.com/index.php/isj/article/view/5847
Background: Echinococcosis is caused by parasite called Echinococcus granulosus and Echinococcus multilocularis. The modern treatment of hydatid cyst of the liver varies from surgical intervention to percutaneous drainage or medical therapy.

Methods: This clinical study was done on 50 patients who had liver hydatid disease admitted in Sir T Hospital, Bhavnagar from August 2013 to February 2016. Patients were divided into two groups consisting of 25 cases in each. Group A: managed by open surgery. Group B: managed by laparoscopic surgery. All patients followed up for 6 months after surgery.

Results: The mean operative time in Group A was 65.2 minutes (range 35-100 minutes) while in Group B it was 76.32 minutes (range 50-100 minutes). Group B patients were mobilised early and resumed duty very fast then Group A. The mean duration of stay in hospital was 12.4 days (range 4-20 days) in Group A and 6.2 days (range 4-12 days) in Group B. Wound infection seen in 16% in Group A and 0% in Group B. General complication rate was 32% in Group A and 8% in Group B. No recurrence noticed in either group during follow up.

Conclusions: Overall laparoscopic management of liver hydatid cyst is cost effective in terms of early mobilization, early discharge and early resumption of work along with cosmetic benefit.
 Vikram B. Gohil Swarnim U. Thakur Smit M. Mehta Firdaus A. Dekhaiya Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1099 1105 10.18203/2349-2902.isj20201170 Surgical management and post-operative complications in abdominal tuberculosis patients https://ijsurgery.com/index.php/isj/article/view/5834
Background: Abdominal tuberculosis is a diagnostic and therapeutic challenge in resource limited countries. The vague clinical presentation is a barrier to early diagnosis. Aim of the study was to highlight the role of operative procedures and post-operative complications in patients suffering from abdominal tuberculosis.

Methods: This is a descriptive study of abdominal tuberculosis cases, which were operated in the Department of Surgery, Lal Lajpath Rai hospital Kanpur, Uttar Pradesh, India, and associated hospitals. Informed and written consent was obtained from each patient prior to commencement of the study. Detailed data of each patient was entered on a Microsoft excel. Data were presented in number and percentages.

Results: Most of the patient's lumps were present in right ileac fosa, 70.37% followed by lymph node mass. Rolled omentum and appendicular showed minimum percentage of cases. In operative finding on exploratory laparotomy, the most common site of involvement was ileocaecal, and less commonly involved site in abdomen tuberculosis are duodenum and appendix. Surgical procedures, intestinal resection in the form of right hemicolectomy (21 cases), small bowel resection (58 cases). Appendicectomies were done only in 3 cases. Post-operative complications were found in 64 cases. Most of the complication developed in patients those were operated in emergency.

Conclusions: Most of the surgeons were preferred conservative surgery rather than extensive resection of the active lesion. Commonest post-operative complication was broncho pulmonary complication.
 Mahendra Kumar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1106 1110 10.18203/2349-2902.isj20201168 Transhiatal oesophagectomy: a single unit study https://ijsurgery.com/index.php/isj/article/view/5871
Background: Oesophageal cancer is a common gastrointestinal malignancy in our country and transhiatal oesopahgectomy is popular choice of surgery for lower oesophageal cancers. This study aims at identifying the feasibility and effectiveness of this surgery in our setting.

Methods: This prospective study was performed in Department of Surgery, SDM College of Medical Sciences and Hospital, Dharwad, India. It included a total of 10 cases operated during the study period. Various pre-operative, intra-operative and post-operative parameters were observed and results tabulated.

Results: In our study dysphagia (90%) was the most common presenting complaint and tobacco, either smoked (40%) or chewed (40%) formed a common risk factor. Lower oesophageal growths (80%) were more common than mid oesophageal (20%). The preferred incision was midline (80%) and average duration of surgery was 351min and average blood loss was estimated to be 521 ml. There was one mortality and a R0 resection in 90% of the cases with 10% positive for local lymphnodal malignant spread.

Conclusions: Our statistics are not very different to the studies compared, and we believe they will only improve. We propose transhiatal oesophagectomy to be a practical and affective tool in a surgeon's armamentarium, which certainly can be a formidable treatment modality in sub-carinal oesophageal cancer.

 Sameer Ahmed Mulla Srinivas Pai Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1111 1115 10.18203/2349-2902.isj20201381 Tension free, mesh free inguinal hernia repair: a prospective study of Desarda's technique https://ijsurgery.com/index.php/isj/article/view/4722
Background: The Desarda repair for inguinal hernias is a new tissue-based technique. Application of the external oblique muscle aponeurosis in the form of un-detached strip has been established as a new concept in tissue-based hernia repair.

Methods: A prospective study was conducted among 126 cases with 148 inguinal hernias repaired by Desarda's technique for a period of 3 years in Dr. B. R. Ambedkar Medical College and Hospital, Bangalore, Karnataka, India. The details pertaining to duration of hospital stay, pain, ambulation and complications were recorded.

Results: The mean age of the patients was 38.4 years. Mean operating time was 62.5 min for unilateral and 123 min for bilateral hernias. About 97.8% patients were ambulatory within 6.42 hours and were freely mobile within 19.26 hours after surgery. About 96.4% patients returned to work within 6-14 days. About 91.26% patients were discharged on same day. The mean hospital stay duration of the patients was 1.11 days. Postoperative pain on movement out of bed was described as mild and tolerable in 92.6% patients on day 1. Two patients had seroma that subsided on its own. There were no long-term complications, recurrence of the hernias or chronic groin pain.

Conclusions: The results of this new technique (Desarda repair) using continuous absorbable sutures appear promising. The continuous suturing saves time and just one packet of suture material without mesh saves cost.
 Hosni Mubarak Khan B. S. Ramesh Viraja Bobburi Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1116 1121 10.18203/2349-2902.isj20201382 Open versus laparoscopic appendicectomy: a prospective comparative study https://ijsurgery.com/index.php/isj/article/view/5428
Background: Open appendectomy has been the gold standard for the treatment of acute appendicitis since its introduction by Charles Mc Burney in 1889.The introduction of laparoscopic surgery has dramatically changed the field of surgery. Various studies showed conflicting results about the superiority of laparoscopic approach over open for treatment of acute appendicitis. Present study is conducted to determine any possible benefits of the laparoscopic approach over open surgery.

Methods: The study was conducted in Dr. V. M. Government Medical College and hospital located in Solapur (Maharashtra) from September 2017 to September 2019. It is a prospective comparative study. Patients were randomly divided into 2 groups alternately where group A and B were operated by conventional and laparoscopic techniques respectively and their outcomes were compared.

Results: Mean age of patients in open and laparoscopic appendicectomy group was 29.67 years and 31 years respectively. Post-operative pain, wound infection and hospital stay was significantly more in open group as compared to laparoscopic group (p<0.05).

Conclusions: From the results of our study we conclude that laparoscopic appendicectomy has superior results as compared to open appendicectomy.
 Santoshkumar N. Deshmukh Abhilash P. Pawar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1122 1126 10.18203/2349-2902.isj20201383 Safety and efficacy of percutaneous nephrolithotomy in paediatric age group: our 3 year experience in Western Rajasthan https://ijsurgery.com/index.php/isj/article/view/5839
Background: Percutaneous nephrolithotomy (PCNL) has become a well-established procedure for the management of pediatric renal calculi. Paediatric PCNL has been performed using both adult and paediatric instruments. Objectives: To evaluate the safety, efficacy and complications using the Modified Clavien scoring system (MCSS) in children undergoing PCNL using adult sized instruments.

Methods: All patients less than 16 years old were analyzed retrospectively in Western Rajasthan undergoing PCNL procedure at Dr. SN Medical College and Hospital from April 2016 to March 2019. All PCNL procedures were performed in prone position under general anaesthesia with fluoroscopic guidance and using adult size instruments. All the demographics, surgical data and perioperative information were collected.

Results: Total 112 patients with 120 renal units (8 patients with bilateral stones), (66 boys and 46 girls), with a mean (range) age was 10.01±4.02 (2-16) years. The mean (range) stone size in our study was 28.94±1.10 (20-50 mm). Overall, stone-free rate after PCNL was 95%. Twenty five (25) children (20.8%) had operative complications; 23/25 (92%) had, Clavien grade I in 15 (60%), grade II in 8(32%) and all managed conservatively. 2 patients had hydropneumothorax, managed with ICD tube. Stone size, operative duration and haemoglobin drop were significantly associated with complications on Univariate analysis (p<0.05).

Conclusions: In paedriatric age group PCNL is considered safe with MCSS showing grade I and grade II complications in majority (92%) of patients.
 Pradeep K. Sharma Shekhar Baweja Vikas Aggarwal Pawan Katti Rupesh Nagori M. K. Chhabra Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1127 1132 10.18203/2349-2902.isj20201384 Early surgical management in pancreatic ascites on a background of chronic pancreatitis https://ijsurgery.com/index.php/isj/article/view/5638
Background: Pancreatic ascites can occur as a complication of acute or chronic pancreatitis. In majority of cases, it is associated with pseudocyst or duct disruption. Management is initially conservative with paracentesis with nutritional support. Early surgery has been recently contemplated as primary management for pancreatic ascites.

Methods: A prospective study was done over a duration of three years from November 2017 to October 2019 in patients of chronic pancreatitis presenting with pancreatic ascites. All patients underwent pancreatic protocol contrast enhanced computed tomography abdomen and magnetic resonance cholangiopancreatography, duct diameter and main pancreatic duct (MPD) disruption site. pseudocyst site was identified. After optimizing patients, early surgery was planned. Surgeries included either lateral pancreatic jejunostomy, if MPD were dilated. Pancreaticogastrostomy, cystogastrostomy or cystojejunostomy, if there was pseudocyst with extraneous impression over stomach or on mesocolon, and distal pancreatectomy (and/or) splenectomy.

Results: Out of 20 cases of pancreatic ascites, 6 were of acute pancreatitis and conservatively managed and 14 were subjected to early primary surgery. 8 out of 14 patients underwent LPJ. 2/14 underwent pancreaticogastrostomy. 2/14 underwent cystogastrostomy and 1/14 underwent spleen preserving distal pancreatectomy. 1/14 underwent distal pancreatectomy and splenectomy. None of the patients had postoperative recurrence of pancreatic ascites. One patient developed Postoperative intra-abdominal collection which was drained. Mortality was 2/14 (14.2%), one died immediate postoperatively and another succumb to Pulmonary embolism on post-operative day-4. Pain scores were significantly reduced post-operatively.

Conclusions: Primary early surgery directed towards primary pathology, as guided by MPD status, in selected patients with chronic pancreatitis with ascites leads to faster recovery of patient.
 Thiruvarul Muthukumarasamy Kanchan Ashok Sachanandani Sakhtivel Harikrishnan Jeswanth Satyanesan Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1133 1137 10.18203/2349-2902.isj20200998 An assessment of the factors affecting surgical decision making: a multi institutional study https://ijsurgery.com/index.php/isj/article/view/5490
Background: Decision making is a complex process, especially when guidelines are lacking. Surgeons then turn to other factors to help guide them make these decisions. This study is an attempt to understand these factors which play a role in the decision making process of surgeons.

Methods: A prospective qualitative study was conducted amongst consultant surgeons and surgical residents from various institutes across Bangalore. The questionnaire was sent out to these surgeons and responses were recorded using Google Forms. A total of 158 responses were received and analyzed.

Results: 69.2% of surgeons felt that patient preferences influence their decision making process. Age of the patient and medical comorbidities played a role in the decision making process of 95.5% and 94.2% of the surgeons respectively. 91% of the surgeons agreed that their age and experience has a strong influence on the decisions made by them. The institution of work and availability of tools mattered to 61.7% and 80.1% of the surgeons respectively.

Conclusions: Factors such as patients' age, comorbidities, preferences, surgeon's institution of study, institution of work, experience, and institutional factors influence the decisions made by surgeons. Further study is needed on the larger scale to fully understand the various factors playing a role in the final decision making process.
 Prem Kumar Anandan Sindhu Sivakumar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1138 1142 10.18203/2349-2902.isj20201388 A comparative study of surgical site infection after single dose of preoperative antimicrobial prophylaxis versus multiple doses of antimicrobials in clean and clean contaminated abdominal surgeries https://ijsurgery.com/index.php/isj/article/view/5484
Background: The advent of antimicrobial therapy has offered an important adjuvant to the prevention of surgical infection. In spite of vast accumulation of research and review published there are still conflicting views. Some study shows multiple doses require for the eradication of microorganisms in the wound. While numerous authors have reported that single dose of an appropriate antibiotic is effective, but there has been no direct comparison of one dose against three doses regimens. Objective was to study about effect and safety of single dose of antibiotic against routine multiple dose regimens in clean and clean-contaminated abdominal surgeries.

Methods: Patients recruited in the study according to specific inclusion and exclusion criteria. The participants were divided in two groups: group I and group II. Group I was given single dose of injection cefotaxime. While another group was given 5 days course of injection cefotaxime and injection amikacin or injection ciprofloxacin and injection metronidazole. Postoperative wound was assessed by Southampton wound grading system.

Results: The rate of wound infection on 3rd day was for 16.30% for group I and 13.82% for group II. The infection rate decrease on 7th post-operative day and it was 13.04% for group I and 11.7% for group II.

Conclusions: Long course of antibiotic as prophylaxis has no added advantage. Good operative technique plays a major role in preventing infections. Single dose antibiotic regimen has comparable infection rate for clean surgical cases and it saves lot of money in this era of cost containment.

 Haresh Vala Maulik A. Vaja Ajit B. Gohil Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1143 1147 10.18203/2349-2902.isj20201386 Clinical study of sterile collagen (Biofil) particles in the management of chronic non healing ulcers and their comparison with saline dressings https://ijsurgery.com/index.php/isj/article/view/5489
Background: Chronic non healing ulcers are a challenge to the patient and health care professional. They require special care and intensive treatment often for prolonged periods. These ulcers do not generally heal with conventional types of treatment within a reasonable time period and need special types of treatment like collagen particles, vacuum dressing, chemical debridement etc. The aim of the study was to compare the effect of sterile collagen particles with saline dressings in treatment of chronic non healing ulcers.

Methods: 30 test subjects were dressed using sterile collagen particles and 30 controls using saline gauze on day 2 and every 3rd day. The condition of the ulcer was followed up using the Bates-Jensen wound assessment score (BJWA score).

Results: BJWA score was significantly lesser at 4th week in test group. The p value was 0.00021. Test group mean score was 17.23 and for control group it was 21.467. BJWA score was significantly lesser even at 8th week in Test group. The p value was 0.00026. Test group mean score was 12.47 and control group it was 17.43. This signifies that healing rate is better in test group compared to control group.

Conclusions: Comparing the components in BJWA score we can conclude from our study that; collagen dressings are superior to saline dressing in all type of ulcers and irrespective of gender and age of a person. The best response was seen in non diabetic ulcer without Saphenofemoral incompetence who are non smokers.
 Vipul Metta Prabhat B. Nichkaode Sunil V. Panchbhai Sai Charan Aishwarya Purohit Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1148 1152 10.18203/2349-2902.isj20201387 A hospital based cross sectional study on surgical profile of patients with chronic leg ulcers https://ijsurgery.com/index.php/isj/article/view/5472
Background: Treatment of chronic leg ulcer is not easy. Appropriate diagnosis and proper treatment are the cornerstone for successful outcome. To study the profile of patients with chronic leg ulcers.

Methods: Hospital based observational study was carried out in 108 cases. All patients coming to surgery OPD in our set up with chronic leg ulcers of duration of more than 6 weeks were advised admission if they were willing for the same. Then detailed history was recorded. Detailed examination of venous system was done for varicosities, incompetent perforators, sapheno-femoral or poplitio-femoral junction incompetence. In case of patient's peripheral vascular diseases, detailed examination of arterial system was done. Descriptive statistics like frequencies and percentage for categorical data, mean and SD for numerical data has been depicted.

Results: Majority of study subjects were in age range of 60 to 70 years. percentage of male patient (76.9%) was higher than that of the female (23.1%). 43.5% of participants with ulcer on left side and 56.5% participants had ulcer on right side. 47% of participants had complaints between 7 to 8 weeks. main etiological factor was infective etiology in 38.9% patients. 54.1% ulcers were found in lower 1/3rd of the leg. About 88.9% cases had positive culture. The most common organism grown was of pseudomonas in 45.8% cases.

Conclusions: The most common etiology of chronic leg ulcer in this study is infective followed by traumatic ulcer. The most common associated condition found in chronic leg ulcer is diabetes mellitus.
 Archana L. Thakur Meghraj J. Chawada P. T. Jamdade Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1153 1157 10.18203/2349-2902.isj20201385 Comparative study of closed versus open lateral internal sphincterotomy in the management of chronic anal fissure https://ijsurgery.com/index.php/isj/article/view/5492
Background: Anal fissure is a painful tear in distal anal canal extending from just below the dentate line to anal verge. Patient presents with pain during or after defecation and passage of bright red blood per anus. Various studies investigating chronic anal fissures show a large variation in healing rates for different modalities. The present study was carried out to evaluate effectiveness of closed versus open lateral internal sphincterotomy in treatment of patients with chronic anal fissure.

Methods: A prospective study was conducted in the Department of Surgery, Pt. B.D. Sharma PGIMS, Rohtak. Group A and group B included 20 patients each with chronic anal fissure and managed by closed and open lateral internal sphincterotomy respectively and effectiveness was evaluated with regards to fissure healing, pain reduction, recurrence and incontinence after surgical treatment.

Results: The mean pain scores on visual analogue scale at end of 1 week in group A and group B was not found to be statistically significant, whereas it was found to be statistically significant at 3 week and at 6 weeks. Delayed healing was seen in 1 patient of group B, whereas no patient in group A had delayed healing or absence of healing postoperatively.
Conclusions:There was a significant difference between closed and open methods of lateral internal sphincterotomy in terms of relief in post-operative pain but as a whole both techniques did not show any statistically significant difference in terms of fissure healing, postoperative complications or recurrence at 3 months.

 Anand R. Bansal Manish Bansal Ankit Bhardwaj Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1158 1161 10.18203/2349-2902.isj20201389 Clinical study of fistula in ano with special reference to its surgical management https://ijsurgery.com/index.php/isj/article/view/5621
Background: The present study was undertaken to evaluate the results of "Lay open method" fistulectomy technique in treating fistula-in-ano in terms of relief of symptoms, healing of wound, recurrence rate and post-operative complications.

Methods: Total 45 cases with definite history of fistula and clinically diagnosed cases of fistula in ano selected for the study. A final diagnosis was made after proctoscopic examination under anaesthesia during operation and by histopathological examination after completion of operation. In all the patients, lay open method fistulectomy was done. Post-operative period was closely monitored and all the cases were meticulously followed for a variable period of time.

Results: The common fistulas were low anal type (80%). External opening was mostly located in the posterior mid zone (44.44%). Internal opening was found in 30 cases (66.66%) during per rectal digital examination while proctoscopic examination revealed internal opening in 26 cases (57.77%). Pain (22.22%), retention of urine (8.88%) were the commonest immediate as well as incontinence (1; 2.22%) and recurrence (1; 2.22%) were the delayed post-operative complications. 90% of cases had a satisfactory healing of their wounds within 21 days. Excellent results were achieved in 77.77% cases and only one case of recurrence (2.22%).

Conclusions: Encouragingly high success rates were achieved in our patients, but this series comprised a very small number of patients in a short period of time with limited amenities; also follow up of very short duration and irregular for which a definite conclusion is difficult to arrive at.
 Sivaji Sankar Ghose Mili Das Chowdhury M. Y. Dharmamer Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1162 1168 10.18203/2349-2902.isj20201403 C reactive protein as a prognostic indicator of severity in patients with acute pancreatitis https://ijsurgery.com/index.php/isj/article/view/5498
Background: Acute pancreatitis ranges from a mild illness to a severe disease with high morbidity and mortality. Severity affects the treatment and outcome. The existing scoring systems for assessment of its severity require are time consuming and expensive. This study was an attempt to evaluate the effectiveness of C-reactive protein (CRP) as a prognostic indicator and a marker of severity of acute pancreatitis.

Methods: This was a prospective observational study conducted between among 50 patients diagnosed with acute pancreatitis. The Ranson's score and CTSI was calculated for these patients. CRP levels were measured 48 hours after the onset of symptoms. They were observed for the development of local and systemic complications, and outcome. These were compared with the CRP values. Pearson coefficient was used to study the correlation between the variables. A p value of less than 0.05 was considered to be statistically significant.

Results: 30 of the 50 patients had no local complications. 14 patients (28%) had peripancreatic collection and 6 (12%) had pancreatic necrosis. 24 of the 50 patients had systemic complications (48%). 25 patients had mild disease and 25 had severe disease as evidenced by the Ranson's score. These 25 patients with severe disease also had raised CRP (p<0.05). There was no statistically significant correlation between the CTSI and CRP values. 4 patients with CRP values more than 400 succumbed to the illness.

Conclusions: CRP can serve as an inexpensive alternative to the conventional severity assessment methods for the prediction of severity and outcome of patients with acute pancreatitis.
 Bharath Nayak Ganesh Srinivas Nanjangud Masana Setty Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1169 1173 10.18203/2349-2902.isj20201391 The risk factors of laparoscopic and open repair surgery of inguinal hernia in a tertiary care center https://ijsurgery.com/index.php/isj/article/view/5505
Background: The purpose of the present study to investigate the incidence of inguinal hernia and risk factors of laparoscopic and open repair surgery.

Methods: The present study contained 3 bilateral,17 right-sided and 7 left-sided hernia in the laparoscopic group and 2 bilateral, 19 right-sided and 6 left-sided hernia in open repair group. A total of 54 patients had an inguinal hernia, 27 underwent open repair and 27 underwent laparoscopic to open repair.

Results: The age group of patients of open repair is 51-60 years, whereas 41-50 years in laparoscopic repair. The mean age was 47 years in open repair against 43 years in the laparoscopic repair.

Conclusions: Among them, eight patients from open repair (1-COPD, 3-asthma,1-hypertension, 3-smoking) and five patients with the laparoscopic repair (2- COPD, 2-asthma, 1-hypertension) had one of the above-mentioned risk factors.
 Ashish Goenka Mahesh Ijjapawar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1174 1178 10.18203/2349-2902.isj20201392 Open and laparoscopic transabdominal preperitoneal approach for inguinal hernia: our single institution experience https://ijsurgery.com/index.php/isj/article/view/5510
Background: Trans abdominal preperitoneal (TAPP) a novel approach for inguinal hernia was introduced by Arregui (1991) and Dion in early 1990's has brought the revolutionary change in the era of hernia surgery over open preperitoneal inguinal hernia repair procedure introduce by Stoppa. Based on this we have done single institution retrospective study of TAPP and open preperitoneal procedure for inguinal hernia.

Methods: This study was single institution retrospective study, where we have analyzed the data of 93 male and 7 female patients out of which 50 underwent standard TAPP procedure and 50 patients who underwent open preperitoneal procedure for inguinal hernia, with median 1 year of follow up. Their data analyzed for demographics, surgical site occurrence and short terms recurrence.

Results: 100 patients with mean age of 55 years, median ASA of 1, ratio of left: right: bilateral for open 18:30:2 and for laparoscopic 26:20:4. Mean time for surgery was 102.3 min for open and 142.4 mins for TAPP. There was surgical site infection in 3 patients operated by open procedure and 2 patients in TAPP procedure. 4 patients from open procedure group and no one with TAPP group developed seroma which were managed conservatively and resolved at 6 weeks and 8 weeks. One recurrence in TAPP group patient at the 1 week follow.

Conclusions: Open preperitoneal repair is hence a technique as effective as laparoscopic hernia repair with a minimal learning curve, ability to be performed under regional anaesthesia and cost effective. It can hence be used to carry out inguinal hernia repairs effectively in rural areas.
 Bhushankumar A. Thakur Vivek Mukhamale Snehal Deotale Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1179 1185 10.18203/2349-2902.isj20201393 Role of antibiotics in elective clean surgeries: limiting its use to single shot preoperative dose https://ijsurgery.com/index.php/isj/article/view/5528
Background: Conventional antibiotic therapy during operation not only increases the financial burden on patient, not only increases chances of adverse reactions among them but also not effective in reducing the infection rate after surgery. Single dose prophylactic antibiotic or maximum 24 hours dosing during or before surgery was found to be equally effective. Objective was the to study utility of single shot antibiotic prophylaxis in patients undergoing surgery

Methods: This prospective study includes 100 clean elective surgical cases randomized to groups of 50 each. Single dose prophylactic antibiotic was given to cases in the study group and conventional antibiotic therapy was given to cases in the control group. Study group cases received Injection Ceftriaxone in the dose of 2 gm intravenously. This was given at induction or half an hour before the incision was given. Second dose was given if there was delay in starting the surgery for more than three hours. Dose of the antibiotic was adjusted for children, underweight and obese persons. For cases in the control group. Injection ceftriaxone 1 gm was given intravenously twice a day for three days. Surgical site infection incidence was recorded.

Results: Both the groups were comparable for age, sex, diagnosis and hence the type of surgery performed. The incidence of fever, redness, swelling and wound discharge which are the signs of surgical site infection after surgery was not found to be statistically significantly different. Management protocol was also not significantly different after the surgery.

Conclusions: Single shot antibiotic before surgery is equally effective in reducing the incidence of surgical site infections (SSIs) compared to conventional antibiotic therapy.
 P. T. Jamdade Meghraj J. Chawada Apurva Samant Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1186 1190 10.18203/2349-2902.isj20201394 Hospital based randomized prospective study outcomes in colorectal surgery after bowel preparation https://ijsurgery.com/index.php/isj/article/view/5531
Background: Research of so many years from the procurable world data has shown that the reasons for most colorectal cancers occur due to change in life style the type of diet, smoking as well as the influence of the surrounding environment in which man lives and increasing age with only a minority of cases associated with genetic disorders. Colorectal cancer is the third most commonly diagnosed cancer. In the first half of the 20th century, mortality from colorectal surgery often exceeded 20%, mainly attributed to sepsis.

Methods: The randomized prospective study was conducted on 202 colorectal cancer patients in the department of Colorectal division of General and Minimal Invasive surgery" Sher-i-Kashmir Institute of Medical Sciences, Srinagar.

Results: Mean age of patients in Group 1 (with no mechanical bowel preparation (NMBP)) was 51±18.15 years while as same was 50±17.76 years for Group 2 (with mechanical bowel preparation (MBP)). Age range for Group 1 was 16-87 years and16-85 years for Group 2. Regarding outcomes, wound infections were 6.1% and 3.8% in Group 1 and Group 2 respectively. While disruption of anastomosis were 2.0% and 3.8% in group A and B respectively.

Conclusions: Statistically no gross difference in terms of morbidity and mortality was found between the use of mechanical bowel preparation versus no use of mechanical bowel preparation in elective colorectal surgery. Elective Colorectal Surgery can safely be performed without enduring MBP in it as it does not possess any sorts of benefits.
 Altaf Hussain Bhat Gh Hussain Mir Sajad Ahmad Bhat Muzaffar Ali Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1191 1194 10.18203/2349-2902.isj20201395 Cell cannibalism: a diagnostic and prognostic marker of breast cancer https://ijsurgery.com/index.php/isj/article/view/5541
Background: Cell cannibalism (cytophagocytosis) is defined as a tumor cell within a tumor cell, such that smaller tumor cells are found in the cytoplasm of larger tumor cells with crescent shaped nuclei. Aims and Objectives were to study the cytomorphological characters of cell cannibalism in primary and metastatic breast cancer, to correlate the histologic type and grade of tumors with positive rate of cannibalism and to study the role of Cannibalism as an independent prognostic factor in breast cancer.

Methods: The study was conducted during the period of July 2003 to June 2005 in the Department of Surgery and Pathology, JNMCH, Aligarh. A total of 42 cases were included in the study. A minimum of 3 FNAC smears per case were assessed for cytophagocytosis. Presence of metastasis was also noted to establish the cytological grade and aggressiveness of the tumor.

Results: Out of 42 cases, significant cannibalistic activity was noted in 30 (71.42%) cases. All grade III (33.4%) breast tumors were found positive for cytophagocytosis (4.28/smear), while the rate was much lower (2.33/smear) in grade II and (1.63/smear) in grade I tumors. LN metastasis was confirmed by histopathological examination in all high grade tumors showing significant cannibalistic activity.

Conclusions: Cannibalism in breast carcinoma is an indicator of both the anaplastic grade and invasiveness. The rate of cytophagocytosis may have a prognostic significance.
 Mir Mohsin Haroon Rashid Zargar Mohammad Amanullah Khan Rana Sherwani Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1195 1198 10.18203/2349-2902.isj20201396 Can difficulties in laparoscopic cholecystectomy be anticipated preoperatively: evaluation of a scoring system https://ijsurgery.com/index.php/isj/article/view/5544
Background: Laparoscopic cholecystectomy is often associated with intra operative difficulties leading to increased intra and post-operative morbidity. Accurate prediction of a difficult laparoscopic cholecystectomy can reduce the complication rate, rate of conversion and overall medical cost. This study was an attempt to validate a scoring system developed to predict difficult laparoscopic cholecystectomy.

Methods: 100 patients undergoing laparoscopic cholecystectomy were included. Details such as age, sex, BMI, previous surgical history, history of hospitalisation for biliary disease, sonographical wall thickness, pericholecystic collection and presence of impacted stone were noted. With these, pre-operative score was calculated using the scoring system. Intra operative details and complications were noted and were classified as easy, difficult and very difficult. Student t test and chi square test was used to test the difference of significance (p<0.05).

Results: Male sex, higher BMI, a history of previous surgery, a history of prior hospitalisation for biliary disease, a palpable gall bladder, a thickened gall bladder wall, impacted stone and pericholecystic collection all had a statistically significant accurate prediction of the difficulty in laparoscopic cholecystectomy. The mean duration of surgery was 62.7±33.15 minutes. The scoring system developed by Randhawa et al predicted difficult laparoscopic cholecystectomy with a sensitivity of 77.8%, specificity of 78.1%, positive predictive value of 66.7% and a negative predictive value of 86.2%.

Conclusions: The proposed scoring system predicted difficult laparoscopic cholecystectomy with a sensitivity of 77.8%, specificity of 78.1%, positive predictive value of 66.7% and a negative predictive value of 86.2%.

 Sachin . Srinivas N. Masanashetty Sindhu S. Devaprashanth M. Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1199 1203 10.18203/2349-2902.isj20201397 Modified retrorectus procedure for repair of midline incisional hernias https://ijsurgery.com/index.php/isj/article/view/5550
Background: Incisional hernias develop after abdominal operations. Primary closure procedures carry high recurrence rates. Prosthetic repairs with different modifications have reduced the recurrence rates and are the procedures of choice for incisional hernia repair.

Methods: Our study is a prospective study conducted on 30 patients of midline incisional hernia. Hernia repair was done by modified retrorectus technique with in which the mesh is placed between the rectus abdominis muscle and the posterior rectus sheath.

Results: In our study, the hernia defect ranged from 25-40 cm2.The mesh size used ranged from 15×15 to 30×20 cm. Mean duration of hospital stay was 9.9±2.3 days. Operative time ranged from 90-150 minutes. Follow up period ranged from 3-15 months. There were no post-operative complications in 73.3% cases. Seroma formation occurred in 10% cases and wound infection was seen in 10% cases. One patient developed mesh infection which required partial removal of mesh. There was no recurrence, no mortality, no bowel injury or adhesion obstruction. Wound related complications and morbidity was higher in patients with risk factors and comorbidities like diabetes, obesity, anaemia, COPD, hypoalbuminemia and patients on steroids.

Conclusions: The retrorectus technique for the repair of midline incisional hernia using polypropylene mesh is a safe and durable procedure with excellent long-term results, minimal comorbidities and least recurrence rates and is an open procedure of choice for the repair of large incisional hernias.
 Javed A. Mir Sanober M. Masoodi Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1204 1211 10.18203/2349-2902.isj20201398 Outcome of early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy for patients with acute cholecystitis https://ijsurgery.com/index.php/isj/article/view/5551
Background: This prospective randomized study was undertaken to to assess the outcomes of early versus delayed cholecystectomy for patient's acute cholecystitis.

Methods: 70 patients with acute cholecystitis were prospectively randomized to either an early laparoscopic cholecystectomy (n=35) or a delayed laparoscopic cholecystectomy group (n=35). The mean operative time, conversion rate, total hospital stay, intra-operative and post-operative complications, average hospital cost were evaluated between the two groups.

Results: A total of 70 patients were enrolled, 35 patients in each group. There was no significant difference in the conversion rates (early, 8.57% vs delayed, 5.71%) and postoperative complications (early, 25% vs delayed, 20%). At the cost of an increased operating time (early, 81 minutes vs delayed, 78 minutes) and blood loss (early, 180.33ml vs delayed, 108.00 ml), early laparoscopic cholecytectomy significantly shortened the total hospital stay (early, 1.5 days vs. delayed, 7.95 days) and average hospital cost (early 9240 INR vs delayed, 12251 INR).

Conclusions: The safety and efficacy of early and delayed laparoscopic cholecystectomy for acute cholecystitis were comparable in terms of morality, morbidity and conversion rate. However early laparoscopic cholecystectomy allows significantly shorter total hospital stay and reduction in days away from work at the cost of longer operating time and blood loss and offers definitive treatment at initial admission. Moreover it avoids repeated admissions for recurrent symptoms has both medical as well as socioeconomic benefits and should be the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy.
 Zahid Mohd Rather Nighat Ara Majid Mohd Nazrull Islam Raja Waseem Mohd Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1212 1217 10.18203/2349-2902.isj20201399 A study of prognostic score for predicting the outcome in cases of traumatic brain injury https://ijsurgery.com/index.php/isj/article/view/5556
Background: Glasgow coma scale (GCS) and the Glasgow outcome scale help us with confident predictions after 24 h following the injury, but not on admission. The IMPACT and CRASH studies provided new methods for performing prognostic studies of traumatic brain injury. And this prognostic scoring system has been studied in our study.

Methods: This is an observational prospective cohort study performed at the department of surgery, Gandhi medical college and Hamidia hospital, Bhopal on 87 patients during a period of 2 years. A preformed pro-forma was filled for each patient after 6 hours of resuscitation which included all the details of the patients like name, age, sex, CR no., and GCS after resuscitation, mode of injury, the clinical evaluation score used by IMPACT trial and neurological finding, management details, CT scan was done as soon as possible for all patients and findings were included in the pro-forma. The final outcome was recorded at the time of discharge.

Results: Among Patients with mean total prognostic score of 0-4, 97% patients discharged without deficit, 3% discharged with deficit with no mortality. Among score of 15-20, only 7 % can be discharged without deficit and 7% could be discharged without deficit, while 86 % patient died.

Conclusions: The mean total prognostic score of discharged groups was significantly lower than the patients in discharged group. We concluded that this prognostic model helps us to individually identify patients who will succumb to death and early need for surgical intervention.
 Sudhir Singh Pal Ashay Rathore Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1218 1222 10.18203/2349-2902.isj20201400 Alvarado score and computerized tomography scan as impact indicator in intervening negative appendectomy rate https://ijsurgery.com/index.php/isj/article/view/5578
Background: The objective of this study is to study the impact of combined use of Alvarado score and computed tomography (CT) scan on negative appendectomy rate.

Methods: This prospective observational study comprising of patients presenting with clinical features of appendicitis admitted to department of general surgery, VIMSAR, Burla from November 2017 to October 2019, where Alvarado score and ultrasonography (USG) findings are mismatching each other. Alvarado scores calculated and categorized in 2 groups as negative (score <4) and positive (score ≥4). These patients were also subjected to USG and categorized as negative (USG -ve) and positive (USG +ve). Those patients having discrepancy in both the findings were subjected to CT scan. On histopathological examination, inflamed appendix in 63 (97%) patients and non-inflamed in 2 (3%). Rest patients were either discharged (both -ve) or operated (both +ve).

Results: Total 84 patients showed discrepancy between Alvarado score and USG findings and are subjected to CT scan abdomen and pelvis. CT scan was positive for appendicitis in 65 cases (where appendectomy done) and negative for appendicitis in 19 cases (where the diagnosis is different). patient. Thus, negative appendectomy (NAR) is 3% in this study.

Conclusions: Alvarado score and ultrasonography could not be used as absolute tool in doubtful and equivocal cases, where combined use of CT scan with Alvarado score and USG has definitely has an edge by diagnosing the differentials and reducing NAR followed by reduction in cost and length of hospital stay.
 Braja Mohan Mishra Pramit Ballav Panigrahi Sandeep Mishra Abinasha Mohapatra Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1223 1228 10.18203/2349-2902.isj20201401 Bedsore is a curse in disguise: capturing the zeitgeist https://ijsurgery.com/index.php/isj/article/view/5582
Background: Development of a bedsore is always avoidable still its worldwide prevalence fluctuates between 0%-56%. Bedsores are maximally observed in patients who are on long term care, in intensive care, immuno-compromised or on home care.

Methods: In a tertiary care center-JK hospital, Bhopal, a longitudinal observational study was done for a duration of 3 years, on all registered in-patients, to understand the trend of bedsore rates on monthly basis.

Results: In our study, even though, on yearly basis, average of rates is showing a declining trend in favorable manner yet higher statistical analysis (ANOVA test p value = 0.054) has decrypted the non-significant results.

Conclusions: Timely and appropriate prophylactic interventions are needed to overcome the increased bedsore rates. Checklist based surveillance and monitoring should be a pressing priority. Cochrane reviews are also suggestive of incorporation of organizational changes, risk assessment tools, wound care teams and education to reduce the incidence of pressure ulcers.
 Anand Yadav Rituja Kaushal Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1229 1233 10.18203/2349-2902.isj20201402 Evaluation of the role of pre-operative albumin and its post-operative drop in the prediction of outcomes of emergency laparotomy https://ijsurgery.com/index.php/isj/article/view/5497
Background: Laparotomies are commonly performed surgeries in an emergency setting. The complications associated with these are a result of the activation of the surgical stress response, the magnitude and duration of which are proportional to the surgical injury. Albumin is an important negative phase reactant. This study was an attempt to evaluate the effectiveness of measurement of pre-operative albumin and the post-operative drop in albumin levels in the prediction of post-operative morbidity and mortality following laparotomy.

Methods: Albumin levels of 50 patients undergoing emergency exploratory laparotomy in Victoria Hospital were measured pre and post operatively. The percentage drop in albumin levels was noted. The outcomes were noted and classified according to Clavein Dindo Classification. Unpaired t-test and ANOVA test was used for statistical analysis. A p value of <0.05 was considered statistically significant.

Results: 62% of the patients had hypoalbuminemia preoperatively. 58% of patients had post-operative complications. The mean preoperative albumin levels for patients without complications was 3.83 while that for patients with complications was 2.78 (p<0.05). The mean percentage drop in albumin values was 9.66% for patients without complications while it ranged from 14.79 (Clavein Dindo 1) - 24.27 (Clavein Dindo 5) for patients with complications (p=0.047). A negative correlation was noted between the preoperative albumin values and the duration of hospital stay while the drop in albumin levels showed a positive correlation with the duration of hospital stay.

Conclusions: Measurement of albumin levels pre-operatively and in the immediate post-operative period following laparotomy can prove as a useful tool and an early indicator of morbidity and mortality following laparotomy.
 Devaprashanth Mohan Kumar Sindhu Sivakumar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1234 1237 10.18203/2349-2902.isj20201390 Comparison of split skin thickness graft survival in diabetic and non-diabetic ulcer https://ijsurgery.com/index.php/isj/article/view/5678
Background: Split skin grafting is widely used surgical procedure for the treatment of ulcers. Graft survival depends on number of factors like vascularity, wound infection etc, diabetes is associated with endothelial dysfunction, neuropathy, wound infection which collectively affect the graft survival. Objective of this study was to compare the amount of graft uptake, the post-operative complications and survival of split thickness skin graft in diabetic and non-diabetic ulcer.

Methods: In our prospective comparative study total 112 patients with ulcer were included of which 56 were diabetic and 56 were non-diabetic. All of t7hem underwent split skin grafting as part of their wound management. Comparison was made between two groups in terms of amount of graft uptake, post-operative wound infection, revisional surgery, donor site infection.

Results: Compared with non-diabetics, diabetics have significantly less graft uptake (p<0.001). out of 56 patients in diabetic group 4 (66.7%) underwent revisional surgery, out of 56 patients in non-diabetic group 2 (33.3) patients underwent revisional surgery (p value is <0.68) which is statistically insignificant. 3 (60%) out of 56 in diabetic group developed post-operative graft infection, 2 (40%) out of 56 in non-diabetic group developed graft infection (p=1, not significant). One patient in the study developed donor site infection. Among 112 cases, only 1 case had donor site infection with diabetic.

Conclusions: Diabetes is associated with poor graft uptake and post-operative complication rates in patients undergoing split skin grafting.
 Yamanur P. Lamani M. Amarnath Reddy E. B. Kalburgi B. S. Suhas Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1238 1242 10.18203/2349-2902.isj20201404 Predictive factors for intraoperative excessive bleeding in Grave's disease https://ijsurgery.com/index.php/isj/article/view/2888
Background: Grave's disease frequently results in and is the most common cause of hyperthyroidism. It also often results in an enlarged thyroid. It also known as toxic diffuse goiter, is an autoimmune disease that affects the thyroid. This study evaluates all the factors that cause intra-operative blood loss and how it affects the grave's disease.

Methods: This study was conducted on 100 patients with Grave's disease, who underwent thyroidectomy during the period from May 2010 to April 2016.

Results: The majority of patients were females which constitute about 76.3% with a median age of 33 years. The median period between the onset of the disease and operation was 15 months. Weight of thyroid in grams was 40. Post-operative hospital stay was 3 days. Univariate analysis revealed that the strongest correlation of amount of intraoperative blood loss (AIOBL) was noted with the weight of thyroid (p<0.001). Additionally, AIOBL was correlated positively with the period be- tween disease onset and surgery (p<0.001) and negatively with preoperative free T4 (p<0.01). Occurrences of postoperative complications, such as recurrent laryngeal nerve palsy or hypoparathyroidism, and postoperative hospital stay were not correlated with AIOBL.

Conclusions: For Grave's disease, for excessive bleeding during surgery, a large goiter presented as a predictive factor, and transfusion of blood should be considered in cases in which goiter weighs more than 200 g.
 A. Srinivas Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1243 1246 10.18203/2349-2902.isj20201405 Ultrasound abdomen as a tool to predict difficult cholecystectomy https://ijsurgery.com/index.php/isj/article/view/5872
Background: Laparoscopic cholecystectomy is a commonly performed procedure in general surgical practise, which can sometimes be tedious and can have high morbidity. Ultrasound abdomen is a routinely performed radiological investigation for every case of cholecystectomy. This study intends to find correlation between the ultrasound findings and the perceived difficulty during surgery.

Methods: This is a prospective study of 100 patients who underwent cholecystectomy after a preoperative ultrasound. Difficult cholecystectomies were defined and sonographic findings and intraoperative difficulties recorded and tabulated.

Results: Fifty one cholecystectomies were classified as difficult cholecystectomy (20 converted to open procedure and 31 took more than 90 min to complete laparoscopically). The commonest ultrasound finding that was encountered was multiple calculi (62%) followed by gallbladder (GB) wall thickness of >4 mm (33%), stone size >1 cm (22%), contracted GB (17%), intrahepatic biliary radicals (IHBR) dilatation (15%) and the least common finding was empyema of the gallbladder seen in 7% of the cases.

Conclusions: This study is a reflection of surgeries performed by a single team over 3 years which included 100 cases. It was started with an idea to identify the findings on a preoperative ultrasound that predicted a difficult cholecystectomy (laparoscopic or open). In our experience we found that empyema GB, pericholecystic fluid, IHBR dilatation and wall thickness of GB are excellent predictors of a difficult cholecystectomy.
 Sameer Ahmed Mulla Srinivas Pai Dishita Shetty Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1247 1250 10.18203/2349-2902.isj20201406 The anatomical site of perforation peritonitis and their microbiological profile: a cross-sectional study https://ijsurgery.com/index.php/isj/article/view/5503
Background: Initiation of early appropriate antibiotic therapy influences the outcome of perforation peritonitis, which otherwise is delayed till culture reports are available. The knowledge of microbial profile and sensitivity of peritoneal fluid culture with respect to the anatomical site of perforation peritonitis will help in initiation of early appropriate antibiotic therapy in the post-operative period.

Methods: A cross-sectional study conducted from January 2017 to December 2017 where intraoperative peritoneal fluid sample in patients of perforation peritonitis was subjected to culture (aerobic and anaerobic) and sensitivity and results analysed with respect to anatomical site of perforation.

Results: 50 patients were studied. The most common site of perforation was ileum (32%) followed by appendix (18%) and stomach (18%). In aerobic culture, the culture positivity rate was highest in colonic perforation (100%) and least in gastric perforation (44.4%). The most common organism isolated in all sites of perforation peritonitis was E. coli followed by Klebsiella spp. In anaerobic culture, although facultative anaerobes were isolated, no strict anaerobe was isolated. The most sensitive antibiotics covering all isolated organisms were gentamycin (p=0.006), colistin (p=0.018), piperacillin and tazobactum (p=0.022).

Conclusions: The predominant differential normal flora according to site of gastrointestinal tract was not reflected in the peritoneal fluid culture of patients with perforation peritonitis and E. coli was the most common organism isolated in all sites of perforation peritonitis. The antibiotic sensitivity profile showed the increasing resistance against third generation cephalosporins. Aminoglycosides, piperacillin and tazobactum, meropenem and colistin showed a significant antimicrobial activity against organisms isolated from cases of perforation peritonitis.

 Lohith P. R. K. Jindal Deepak Ghuliani Rajshekar P. Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1251 1257 10.18203/2349-2902.isj20201407 Clinical study and management of hydrocephalus in children https://ijsurgery.com/index.php/isj/article/view/5429
Background: Hydrocephalus is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain. Hydrocephalus can occur at any age, but it is more common in infants. Long-term complications of hydrocephalus can vary widely and are often difficult to predict and may result in significant intellectual, developmental and physical disabilities. Ventriculoperitoneal shunt remains mainstay of treatment even today as it is easily available and inexpensive.

Methods: The study was conducted in Dr. V. M. Government Medical College and Hospital located in Solapur (Maharashtra) from September 2016 to 2018. It was a prospective descriptive study. 30 cases up to the age 14 years with diagnosis of hydrocephalus undergoing VP (ventriculo-peritoneal) shunt surgery were included in the study.

Results: Aqueductal stenosis and tuberculous meningitis were the commonest causes of congenital and acquired hydrocephalus in children respectively. Shunt infection and shunt obstruction were the commonest post-operative complications required shunt revision. Low birth weight and other associated congenital anomalies increased the mortality rate.

Conclusions: VP shunt placement has been the main treatment modality for hydrocephalus. VP shunts procedures are associated with complications and morbidity. Number of revision shunt procedures, low birth weight, associated congenital anomalies adversely affected the final surgical outcome.
 Santoshkumar N. Deshmukh Ashishkumar T. Yadav Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1258 1262 10.18203/2349-2902.isj20201408 A clinical study of various presentations of intestinal tuberculosis, evaluation, management and its complications https://ijsurgery.com/index.php/isj/article/view/5821
Background: Abdominal tuberculosis includes tuberculous infection of gastrointestinal tract, mesentery, lymph nodes and omentum, peritoneum and solid organs like liver and spleen. The initial clinical presentations are nonspecific and no single laboratory investigation is pathognomonic. Bacterial culture and tissue histopathology though confirmatory are time consuming, and immunological tests though rewarding is expensive. Moreover, abdominal tuberculosis with an acute abdomen presents as an enormous challenge to the surgeon.

Methods: This one-year prospective observational study of 25 patients who presented with intestinal tuberculosis at the Department of General Surgery, NIMRA Medical College from February 2019 to January 2020. The causes of intestinal tuberculosis were determined along with clinical profile and were monitored for outcome based on the morbidity and mortality.

Results: Among the 25 patients, all had intestinal tuberculosis on the basis of operative findings and histopatholoigcal reports. Age of the patients ranged between 9 to 70 years; majority (75%) were in the age group of 20 to 40 years. Female to male ratio was 1.7:1. The commonest operative findings were hyperplastic ileocaecal tuberculosis (16%), followed by strictures (20%), and perforations (24%). The overall mortality was 8% due to sepsis and septic shock.

Conclusions: Intestinal tuberculosis is a common problem presenting to general surgical units in the developing countries, often in an acute form. A high index of suspicion, proper evaluation and therapeutic trial in suspected patients is essential for an early diagnosis, in order to minimize complications.
 Maruti Basa Karnati Prakash Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1263 1269 10.18203/2349-2902.isj20201167 Outcomes following transaortic septal myectomy in hypertrophic cardiomyopathy https://ijsurgery.com/index.php/isj/article/view/5809
Background: The objective of the study was to evaluate effect of myectomy and its impact on survival for a period of one year and to identify the co-morbid conditions that would increase the risk of surgery.

Methods: The study was conducted on the patients admitted in a single unit of department of cardiothoracic surgery, NIMS, Hyderabad during the period of 2014 to 2018. The study was a retrospective observational study. 21 patients were enrolled in the study after approval from institute ethics committee. All the patients between 7 to 70 years who underwent septal myectomy were included in the study.

Results: Out of the 21 patients underwent modified Morrows myectomy 16 (76.2%) were male and 5 (23.8%) were female. The most common presenting symptom was dyspnea (81%), followed chest pain (76%), palpitations (62%) and syncope (38%). 5 (24%) patients had a family history of sudden cardiac death. Preoperative beta blockers were used by 15 (72%) patients. 11 patients had severe mitral regurgitation, out of which 8 patients underwent valve replacement and 3 underwent mitral valve repair. The mean preoperative left ventricular outflow tract obstruction gradient was 86.86 and the mean postoperative gradient was 23.47. 3 patients had implantable cardioverter defibrillator insertions. All patients had symptom relief.

Conclusions: Surgical treatment of hypertrophic cardiomyopathy through transaortic septal myectomy is safe and effective method to relieve left ventricular outflow tract obstruction. Mitral valve replacement can be done for cases with structural defect of mitral valve. Early detection and intervention in patients with family history of sudden cardiac death would reduce the risk of death and ensure long term survival.
 Madhusudan Kummari Amaresh Rao Malempati Surya S. Gopal Palanki Kaladhar Bomma Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1270 1276 10.18203/2349-2902.isj20201060 Metaplastic breast carcinoma with chondrosarcomatous differentiation: an unusual disease with a worse prognosis https://ijsurgery.com/index.php/isj/article/view/5735
Metaplastic breast carcinoma (MBC) has an incidence of <1% of all breast cancers and MBC with chondrosarcomatous differentiation is even more rare, <0.1% of all cases. The World Health Organization have classified MBC into pure epithelial-type and mixed epithelial and mesenchymal type. The epithelial-type MBC is sub-classified into squamous cell carcinoma, adenosquamous carcinoma and adenocarcinoma with spindle cell differentiation; mixed type MBC is sub-classified into carcinosarcoma and carcinoma with osseous and chondroid metaplasia. Metaplastic carcinomas of the breast are characterized by large tumour size and rapid growth, and they are usually estrogen receptor, progesterone receptor, and HER2/neu negative and tend to have a worse prognosis than other triple negative breast cancers. There is a noteworthy increased risk of tumour recurrence and a worse prognosis with MBC compared with invasive lobular carcinoma and infiltrating duct carcinoma. We report a case of metaplastic carcinoma with extensive chondroid differentiation that is chondrosarcoma and chondroid metaplasia along with classic infiltrating duct carcinoma with involvement of ipsilateral axillary lymph nodes.
 Samuel Lalhruaizela Bhupendra Mehra Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1277 1279 10.18203/2349-2902.isj20201000 An unusual presentation of pancreatic serous cystadenoma https://ijsurgery.com/index.php/isj/article/view/5771
Pancreatic cystic neoplasms (PCNs) are predominantly benign entities which represent almost 50 percent of all cystic lesions of the pancreas. PCNs are often an incidental finding on abdominal imaging and are not indicated for surgical resection unless they show evidence of malignant transformation or become symptomatic due to mass effect. This report examines an unusual presentation of a PCN, in a 70 years old female with sudden onset abdominal pain, who was found to have spontaneous intraabdominal haemorrhage secondary to a benign PCN. Emergency laparotomy was performed and a distal pancreatectomy or splenectomy were required to achieve haemostasis. Incidence of spontaneous haemorrhage in a benign PCN is a rare but serious complication.
 Alexandra O. Stathis Samuel C. Kuo Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1280 1282 10.18203/2349-2902.isj20201074 Gallbladder perforation with concomitant liver abscess: a case report with a review of treatment options https://ijsurgery.com/index.php/isj/article/view/5564
Gallbladder perforation (GBP) management is still controversial in regards to time (early vs. interval), first procedure (surgical vs. drainage) and technique (laparoscopic vs. open). This is the case report of an adult patient with GBP Niemeier type II, complicated with a concomitant hepatic abscess. The patient was treated medically and with laparoscopic drainage of abscess and pyocholecistolithiasis. She was scheduled shortly after for endoscopic retrograde cholangiopancreatography, and posteriorly for definitive treatment with laparoscopic cholecystectomy 1 month later. Satisfactory postsurgical outcome, with uneventful 1-month follow-up.
 Alejandro Quiroga Garza Milton Alberto Muñoz Leija Juan Manuel Valdivia Balderas Santos Guzmán López Rodrigo E. Elizondo Omaña Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1283 1285 10.18203/2349-2902.isj20201409 Non-endoscopic management of a giant ureterocele: a case report in resource poor African hospital https://ijsurgery.com/index.php/isj/article/view/5665
Ureterocele is a cystic dilatation of the distal sub mucosal part of the ureter. It is a congenital anomaly that may co-exist with other anomalies. It has an incidence 1 in 4000 live births. Patients present with symptoms at paediatric age or may remain asymptomatic till adulthood. Our 30 year old female patient was assessed for a giant orthotropic right ureterocele with obstructive uropathy, in a hospital that has no modern facilities for endoscopic treatment. She then had successful open surgical repair of the ureterocele with satisfactory outcome. Minimally invasive endoscopic treatment options remains the gold standard. Patients from poor resource regions can as well be treated successfully by open surgical repair like our index case presented.

 Usman Mohammed Tela Babatunde David Olajide Abdu Mohammed Lawan Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1286 1288 10.18203/2349-2902.isj20201410 Parotid sialolithiasis with Stenson's duct stricture: a rare case report https://ijsurgery.com/index.php/isj/article/view/5592
Sialolithiasis is the most common disease that affects the major salivary glands and occurs mainly in the submandibular gland (80-90%), and to a lesser degree in the parotid gland (5-20%). In literature many papers have been published regarding the parotid calculi and their treatment. However, data on salivary duct strictures management is less with variable opinion. We present a case of 45-year-old female with swelling of right parotid for 6 months, USG showed duct calculi with sialadenitis and sialogram showed large duct calculi with high grade strictures. Duct calculi was removed by intra-oral approach and parotidectomy was done as endoscopic management of strictures failed. This was highlighted case as parotid duct calculi along with high grade strictures are rare.
 Mohammed Raza Mohit Gupta Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1289 1291 10.18203/2349-2902.isj20201411 Incidental isolated renal mucormycosis in immunocompetent patient: a rare and atypical presentation https://ijsurgery.com/index.php/isj/article/view/5473
Mucormycosis is a group of clinical syndromes resulting from infection by one of a group of related filamentous fungi. It is an opportunistic fungal infection that rarely occurs in immunocompetent individual. Isolated involvement of any organ is rare and only a few cases of renal mucormycosis have been reported. We present a case report of atypical presentation of a case of renal mucormycosis in a healthy adult with no predisposing factors. A 48 year non diabetic immunocompetent patient underwent right nephrectomy for painful non-functioning kidney. Biopsy showed chronic pyelonephritis with broad non-septate hyphae suggestive of mucormycosis. Post op followup of patient is normal. Mucormycosis of kidney causes extensive infarction and necrosis due to direct angioinvasion and vascular thrombosis leading to fulminant acute renal failure. The disease mimics pyogenic infection leading to delay in diagnosis and hence resulting in high mortality. High index of suspicion is needed for early diagnosis. Urine and blood cultures are usually sterile. Characteristic CT findings include diffuse enlargement of the kidney with absence of contrast excretion and multiple low-density areas in the renal parenchyma representing fungal abscess. Whenever suspected, FNAC or biopsy is strongly advocated as no imaging can confirm the diagnosis. Nephrectomy or debridement of necrotic tissue along with IV Amphotericin B consist the principal treatment. Renal mucormycosis presenting an indolent course and found incidentally after nephrectomy is extremely rare. In an incidentally found mucormycosis, the role of further investigations to find the source and the role of antifungals have to be further studied.
 Deepak Ghuliani Rajshekar Puttaswamy Kartik Sahni Reena Tomar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1292 1295 10.18203/2349-2902.isj20201412 Renal artery aneurysm misdiagnosed as renal cell carcinoma https://ijsurgery.com/index.php/isj/article/view/5477
Renal tumors are best diagnosed by contrast-enhanced computed tomography (CECT) abdomen along with history and physical examination. In case of suspicious lesions in respect to location like lesion arising from the bifurcation of renal artery and close to major vessels with all features suggesting of tumor with absent contrast enhancement and absent color flow on Doppler study should be further investigated keeping other possibility of Renal artery aneurysm with thrombus mimicking as renal tumor. CT angiography should be done in every case of suspicious lesion because this will change the further management protocol from Nephrectomy in case of renal tumor to kidney preserving minimally invasive procedure for renal artery aneurysm. Like in this case diagnosis of Renal cell carcinoma was made on the basis of CECT abdomen findings and managed further as per the management protocol for renal tumor but intraoperatively found renal artery aneurysm. On conclusion every suspicious lesion of kidney should be further investigated for renal artery aneurysm so that kidney preserving procedure could be planned preoperatively.
 Shashi . Rajdeep Singh Manu Vats Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1296 1297 10.18203/2349-2902.isj20201413 Hydatid cyst of broad ligament: a rare case report https://ijsurgery.com/index.php/isj/article/view/5502
Hydatid cyst is a parasitic disease caused by tapeworm Echinococcus. It affects the liver and lung most commonly, but may rarely affect fallopian tube, broad ligament and other structures. One such peculiar case is where a 17 years old female presented with a rapidly growing cystic mass in lower abdomen, clinically suspicious of ovarian mass or mesentric cyst. Investigations failed to identify the nature. On laparotomy, excision of the mass was done. Suprisingly histopathological examination identified the lesion as hydatid cyst arising from the broad ligament. Patient responded well to surgical excision followed by albendazole administration. Female genital tract hydatidosis is a rare entity and in most cases the involvement is secondary. Primary hydatid disease of female genital tract is even very rarer and generates considerable diagnostic difficulty.
 Ajay Gujar Jayant Pednekar Nida Khan Anurag Tiwary Rohith Pillai Karna Chheda Pragati Singhal Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1298 1300 10.18203/2349-2902.isj20201414 Angiomyofibroblastoma of scalp: a rare soft tissue tumour at an unusual site https://ijsurgery.com/index.php/isj/article/view/5539
Angimyofibroblastoma is a very rare, benign mesenchymal soft tissue tumour which involves the vulvovaginal area of females of reproductive age group. These tumours are usually slow growing and painless which has a very low tendency for local recurrence. In women it is common in female genital tract, vulva, and posterior perivesical space. In men it occurs in spermatic cord. Here a report of 47 year old male patient from VMKV Medical College and Hospital, Salem was presented with a swelling in the posterior aspect of scalp from 6 months with no any associated symptoms. A preoperative diagnosis of dermoid scalp was made and patient was subjected for excision.
 Sajid Hussain Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1301 1303 10.18203/2349-2902.isj20201415 Primary ileal volvulus: a rare cause of small intestinal obstruction https://ijsurgery.com/index.php/isj/article/view/5543
A 50-year-old lady presented to us in the emergency department with history of acute abdominal pain and vomiting since the past 24 hours. Abdominal examination showed tenderness and guarding in the hypogastrium, lumbar and right iliac fossa region. Initial diagnosis of ruptured appendicitis was considered but exploratory laparotomy gave us an intra-operative surprise. Small bowel volvulus is extremely rare in clinical practice and their symptoms are usually nonspecific. The diagnosis is typically confirmed at surgery most of the time just like in this case. No etiology of this volvulus was found in this patient. Ileal volvulus carries a significant risk of mortality. Awareness of this condition among surgeons will help to reduce the morbidity and mortality associated with this unusual form of intestinal obstruction.
 Syed Faizan Amit Kumar C. Jain Durganna Thimmappa Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1304 1306 10.18203/2349-2902.isj20201416 A rare case of symphalangism of bilateral interphalangial joint of thumbs: a case report https://ijsurgery.com/index.php/isj/article/view/5555
Symphalangism is rare congenital disorder characterised by ankylosis of interphalangeal joints of hands and feet. The fusion can involve the proximal or the distal joints; however, involvement of the proximal interphalangeal joints is more common. There may other associated skeletol and non-skeletol abnormalities. Here the author reports a 14 year old girl with symphalangism involving the interphalangeal joints of the thumbs of bilateral hand. She did not have any functional impairment and hence no medical or surgical intervention was performed. As involvement of thumbs is very rare condition, author would like to report it.

 Anil Kumar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1307 1309 10.18203/2349-2902.isj20201417 Delayed presentation of diaphragmatic hernia as acute intestinal obstruction due to an old penetrating trauma: a rare case report https://ijsurgery.com/index.php/isj/article/view/5571
Acquired diaphragmatic hernias (ADH) are uncommon following penetrating thoraco-abdominal injuries. This is a case report of ADH with bowel obstruction following an old penetrating abdominal trauma without any signs and symptoms of respiratory distress.

 Prakash Biswas Neha Yadav Rachith Sridhar P. K. Bhatia Binoy Patel Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1310 1312 10.18203/2349-2902.isj20201418 Transitional cell carcinoma of the renal pelvis masquerading as renal tuberculosis https://ijsurgery.com/index.php/isj/article/view/5737
We report a case of transitional cell carcinoma of the right renal pelvis mimicking the signs, symptoms and radiological findings of renal tuberculosis (TB). She had been diagnosed initially for urinary tract infection and radiological diagnosis initially was more towards renal TB and urine cytology and cultures were normal. Specific investigations for tuberculosis all showed negative results. But as neoplasia could not be ruled out by ureterorenoscopy due to presence of multiple ureteric strictures, decision was taken for an exploratory surgery. During surgery it was found that there was a tumour in the upper pole of kidney involving the renal pelvis and was found to be papillary transitional cell carcinoma on histopathological examination.
 Samuel Lalhruaizela Zothansanga Zadeng Lal Hruaitluanga Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1313 1316 10.18203/2349-2902.isj20201015 The era of robotics: dexterity for surgery and medical care: narrative review https://ijsurgery.com/index.php/isj/article/view/5532
Robots are man-made machines; created to increase the performance of an action. They are either autonomous or semi-autonomous in the hands of the user. The medical field has evolved and revolutionized over the decades. It is the hour of the robot-assisted medical care to successfully change the clinical scenario of patient care. Employment of robotics in diverse fields of medical care has increased the effectiveness of the treatment and in return the effectiveness of the healthcare professionals. Our aim is to emphasize the advances in robot-assisted procedures over their comparable facets and highlight the unresolved challenges of robotics in medical care for the near future.
 Shivaramakrishnan Balasubramanian Jayakumar Chenniah Gurumurthy Balasubramanian Venkataram Vellaipandi Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1317 1323 10.18203/2349-2902.isj20201057 Stump appendicitis: an uncommon dilemma https://ijsurgery.com/index.php/isj/article/view/4394
Stump appendicitis is one of the rare delayed complications post appendectomy with a reported incidence of 1 in 50,000 cases. Stump appendicitis can present as a diagnostic dilemma if the treating clinician is unfamiliar with this rare clinical entity. The purpose of this paper is to review current data on stump appendicitis and analyse published cases.
 Chirag Pereira Leo F. Tauro Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1324 1326 10.18203/2349-2902.isj20201419 Management of chronic anal fissures: a narrative review https://ijsurgery.com/index.php/isj/article/view/5768
Anal fissures are often encountered in surgical practice in both sexes. It is a distressing disease impacting quality of life and causes profound morbidity among those affected. If left untreated, it may lead onto perianal abscess or even malignancy in long standing cases. Surgery is the gold standard management for chronic anal fissures. Recently the widespread use of pharmacologic agents for chronic fissures has increased. The management of chronic anal fissures has migrated to an era of multifaceted approach. This narrative review looks into various studies spanning over a period of 16 years. Various articles were shortlisted and analyzed for efficacy of various treatment methods, their impact in hospital stay, quality of life improvement, recurrence rate and complications among various treatment methods. We concluded from this review, that open lateral internal sphincterotomy is still the gold standard method of treatment for chronic anal fissure. Among pharmacological agents, 2% diltiazem has the best effectiveness with good compliance rate. Modern surgical techniques like VY plasty can be reserved for special situations. We do not recommend the practice of manual anal dilatation.
 Hariharan Sritharan Naren Kumar Ashok Kumar Mohamed Ismail Syed Ibrahim Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1327 1331 10.18203/2349-2902.isj20201420 Therapeutic approach to epidermoid cyst https://ijsurgery.com/index.php/isj/article/view/5861
Epidermoid cyst is one of the commonest cutaneous swelling treated by a general surgeon. It is usually misnamed as a sebaceous cyst. Understanding the anatomical origin and pathogenesis of the cyst is pivotal for diagnosis and successful treatment. The etiopathogenesis, clinical features and surgical approach is presented in this paper.
 Ketan Vagholkar Suvarna Vagholkar Copyright (c) 2020 International Surgery Journal 2020-03-26 2020-03-26 7 4 1332 1334 10.18203/2349-2902.isj20201421