Indian Journal of Surgery最新文献

Introduction

We describe a tissue-based repair technique for primary ventral hernia. We use the anterior rectus sheath as a flap from across the opposite side to cover and strengthen the suture repair in patients with small primary ventral hernia.

Patients and Methods

Patients with primary ventral hernias of 1 to 3 cm defect width were included in this series. We created a rectangle-shaped anterior rectus sheath flap (ARS). The ARS flap was rotated medially to cover the closed hernia defect. The patients operated with this technique were evaluated for postoperative pain, surgical site infection, seroma, hematoma, skin necrosis, hospital stay, readmissions, chronic pain, and recurrence.

Results

We studied eight patients (six men and two women), seven of whom had an umbilical hernia and one epigastric hernia. Two patients had chronic liver disease with ascites and infected hernia. One was an obstructed hernia. The mean defect width was 2.1 cm (range 1.2 to 2.5), and the mean operative time was 40 min (range 30–50 min). The mean pain score on a scale of 1 to 10 on postoperative day one was 2 (range 1–3). The median follow-up period was 14 months (range 12–47). In the postoperative period, none of the patients had surgical site infection, seroma, hematoma, skin necrosis, readmission, chronic pain, or recurrence.

Conclusion

The anterior rectus sheath flap repair gives strength to the simple suture closure in patients with small primary ventral hernia. It is suitable for repair when the mesh is not desired. However, further studies are needed to throw more light on this promising technique.

Abstract

This study is to evaluate intraoperative and postoperative outcomes of hand-assisted laparoscopic colectomy (HALC) and open colectomy in the management of patients needed to removal total colon or colorectum. A systematic literature search with no limits was performed in PubMed and the Cochrane Library. Estimated blood loss, operative time, length of hospital stay, and post-operation complications including ileus, wound infection and leak were extracted. Six researches reporting a total number of 271 patients who underwent HALC or open surgery within restorative proctocolectomy (RPC) or total abdominal colectomy (TAC) were included. There was a significant difference between HALC and open surgery groups in the estimated blood loss (mean difference (MD) = 93.44, 95%CI [51.33, 135.54], p < 0.0001), operative time (MD = − 41.17, 95%CI [− 54.41, − 27.94], p < 0.00001) and length of hospital stay (MD = 1.56, 95%CI [0.24, 2.88], P = 0.02). In the terms of post-operation complications, the incidence of ileus (OR 1.27, 95% CI [0.55, 2.95], P = 0.57) and wound infection (OR 1.21, 95% CI [0.53, 2.79], P = 0.66) were similar between the two groups. HALC could have more effect and safety over open surgery in patients underwent RPC and TAC.

Primary tracheal tumour is a relatively rare condition. Resection of tracheal tumours is challenging as airway is shared between anaesthesiologist and surgeon for providing maximal surgical access while ensuring patent airway and oxygenation at the same time. We report a case of tracheal mass located below the vocal cord almost occluding the tracheal lumen. Awake fibreoptic-guided flexometallic endotracheal tube was placed for initial ventilation; subsequently, another flexometallic endotracheal tube was placed through an incision in the trachea below the tumour for ventilation during resection of tumour. The patient was successfully managed under general anaesthesia through our meticulous preparation and keen vigilance.

Free fibular flap has been widely used for head and neck reconstruction. However, studies on donor-site complications after free fibular flap are lacking. This study aims to systematically review the morbidity of early and late donor-site complications following FFF transplantation for head and neck reconstruction. A systematic search was conducted in PubMed, EMBASE, Cochrane Library, Web of Science, and MEDLINE databases until April 2023. Weighted means was calculated to pool the morbidity of complications. Finally, 34 studies were included. The weighted mean morbidity of common early donor-site complications was wound dehiscence (8%), necrosis (4%), delayed healing (27%), infection (6%), total skin graft loss (1%), and partial loss (11%). Late donor-site complications included chronic pain (14%), limited range of ankle motion (16%), ankle instability (6%), reduced muscle strength (24%), toe weakness (24%), claw toe (19%), gait abnormality (19%), sensory deficit (26%), numbness (28%) and limitations in walking (19%), running (31%), and upstairs (20%). High morbidity of early and late donor-site complications following FFF surgery was observed. Thorough preoperative assessment and flap design are crucial to minimize complications risk. Further studies are warranted to investigate other potential influencing factors and provide more specific treatment suggestions.

There are quite a lot of studies investigating preoperative factors that might be used to predict postoperative hypocalcemia (PH) in thyroidectomized patients; however, there are less studies in parathyroidectomized patients, especially in patients who underwent single parathyroid adenoma excision by using the focused surgical approach. In this study, our aim was to determine whether any preoperative clinical, laboratory, or ultrasonographical feature anticipates PH in parathyroidectomized patients due to primary hyperparathyroidism (PHPT). All patients who operated for PHPT between 2019 and 2021 were retrospectively evaluated. Patients undergoing single parathyroidectomy by using the focused surgical approach were included in the study. Demographic, clinical, ultrasonography, and histopathology results were noted and compared in patients with and without early PH within 4 days after surgery. Of 181 parathyroidectomized patients, 98 underwent focused parathyroidectomy for single parathyroid adenoma. PH was observed in 36 (36.7%) patients. Patients with PH were younger compared to without PH (p = 0.018). Gender distribution and the presence of osteoporosis were comparable. Nephrolithiasis was less prevalent in the hypocalcemia group (p = 0.034). Preoperative levels of calcium, phosphorus, magnesium, parathyroid hormone, alkaline phosphatase, and 25 OH vitamin D were similar in the two groups. Fractional excretion of calcium (FECa) was lower in the PH group (p = 0.045, p = 0.001). Ultrasonographic and histopathologic diameters and volumes of parathyroid lesions were not different in both groups (p > 0.05 for all). In the multivariate analysis, only being 50.5 years old or younger and without nephrolithiasis were found to be associated with PH (p = 0.016, p = 0.026). Patients younger than 50.5 age and without nephrolithiasis might require closer follow-up for the development of early PH.

Anomalous low insertion of cystic duct (LICD) is present in 10.4% of cases. Its preoperative detection is possible with MRCP (95% accuracy). Commonly they present as post-cholecystectomy cholangitis ( Mirizzi's syndrome). Only few small case reports are available in the literature to serve as a guideline for its management. We present the management of 35 cases of LICD done by a single surgeon in the last 10-year period. Thirty four out of 35 cases were post cholecystectomy. We streamlined our surgical management depending on biliary dilatation (cut off 1 cm). Open or laparoscopic CD clearance after slitting CD vertically and obliterating the CD pouch with sutures including the common wall + / − choledocho-duodenostomy if bile duct is more than a centimetre. We did open surgery in 20 cases and laparoscopic in 15. Our follow up duration was 2 months to 3 years with a serial ultrasound and LFT yearly. No recurrence of symptom and/or stricture was noted in all cases except one case had pancreatic duct stones in ampulla that required ERCP. Our 30-day mortality was 1/35 cases (3%) due to severe CRE sepsis. LICD presenting as Mirizzi’s syndrome is a complex surgical problem. We recommend MRCP in all cases. With our surgical approach either open or laparoscopic, by obliterating the CD pouch + / − biliary bypass can cure this problem forever, but we need much larger studies to establish a care pathway for LICD.

The Supreme Court of India has directed the National Medical Commission to find out the rationality of conducting live surgical workshops during medical conferences several times without any clear guidelines or directives. Whilst live surgical workshops are great learning tools for young surgeons, there exists a risk of a breach of patient confidentiality and safety. Do the pros outweigh the cons is to be addressed. The time may be ripe to explore other options like live operations on simulators with the scenario manipulated by Artificial Intelligence (AI), to make it more a real, challenging experience for surgical trainees.

Abstract

Segmental absence of the intestinal musculature (SAIM) is a rare clinicopathological entity in childhood. The etiology of SAIM has not been fully elucidated. Cases of SAIM are mostly documented in neonate and adult population. A 10-year-old girl was admitted to our clinic with the complaint of acute abdominal pain that was not relieved on medical management. Ultrasound abdomen showed diffuse thickening of duodenum, jejunum, and transverse colon wall. There was fluid collection in the left lower abdomen. In view of unrelieved abdominal distention, acute abdominal pain, and intestinal obstruction, a midline laparotomy was performed. Fibrous bands were compressing the jejunum with a small jejunum segment that appeared ischemic and was resected. Histopathological examination of this jejunum segment was reported as SAIM—a clear cut histopathological picture of mucosa and sub-mucosa with no muscularis propria was seen.

This study is to compare different substitutional urethroplasties in female urethral stricture (FUS). FUS constitutes 4–13% of patients, with voiding symptoms, commonly treated by urethral dilatation or internal urethrotomy with a poor success rate. A urethral reconstruction is a viable option. We compared the results of different substitutional urethroplasty for the stricture urethra in females. Symptoms identified FUS. Urethral calibration (unable to pass 8 Fr catheter) and urinary flow rate of less than 12 ml per second were taken as inclusion criteria. Substitution urethroplasty was performed using vaginal ventral onlay flap vaginal dorsal graft (n = 8), dorsal buccal mucosa (n = 8), and labial skin grafts (n = 4) over 3 years. Twenty patients with urethral stricture were identified (mean age of 49.9 years). We found a good stream immediately after removing the catheter in all vaginal flap patients with post-void dribbling. With the three vaginal graft patients (75%), six buccal mucosa graft patients (75%), and two patients (50%) in the labia minora graft, 14 Fr catheter calibration is accessible in all patients except 50% of patients of the labia minora group on 1st follow-up. They require repeated dilatation. Uroflowmetry at six months showed normal flow in all vaginal flap/ graft patients and buccal mucosa grafts, while only 50% of labia minora grafts showed mild improvement. Urethroplasty using dorsal onlay buccal mucosa and vaginal graft gives the best results in women. The vaginal wall can be used safely in nonavailability of buccal mucosa. Labia minora grafts showed poor results.

Pancreatic trauma is often associated with high mortality and morbidity. Current management protocol advises conservative management when the duct is not involved but if there are higher-grade injuries with duct disruption it requires major pancreatic surgeries. These surgeries are technically challenging and carry a significant risk of morbidity and mortality. In this article, we propose open pancreatic duct stenting as the open counterpart of endoscopic retrograde cholangiopancreatography (ERCP) in open surgeries for pancreatic preservation. A 20-year-old male presented to emergency 3 days after blunt trauma abdomen with the chief complaint of upper abdominal pain and vomiting. Lab parameters were normal except S. amylase was − 1563 IU/L. Contrast-enhanced computerised tomography (CECT) abdomen shows almost complete transection at the level of the neck of the pancreas with complete disruption of the main pancreatic duct (MPD). Exploratory laparotomy with stenting of the pancreatic duct with pancreatic tissue repair with feeding jejunostomy was done instead of major pancreatic resection and anastomosis. The recovery period was uneventful, and the patient was discharged on the 8th postoperative day. In the literature, there are very few reports available where intraoperative pancreatic duct stenting was done without ductal repair in the trauma setting. Until now, ten cases have been reported in which a pancreatic duct could be approximated and was repaired over a stent. In recent years, there has been a paradigm shift in trauma management that advocates organ preservation. Existing pancreatic trauma guidelines still recommend morbid surgeries such as distal pancreatectomy or pancreaticoduodenectomy for severe-grade pancreatic trauma. However, there is an obvious need to consider organ preservation because pancreatic resection procedures have inherent complications as well as high morbidity and mortality.