A quilting sutures technique for flap closure in patients undergoing modified radical mastectomy for the prevention of seroma: A single-center, randomized controlled trial.

Seroma formation is a common adverse event following modified radical mastectomy, and it leads to delayed wound healing and increased post-operative pain and increases overall morbidity of patients. The quilting sutures as a newer technique for the skin flap closure is done to reduce incidence of seroma formation. Although it has controversy in the literature for the satisfactory outcome, the study has aimed to compare the Quilting suture technique with the conventional closure method to evaluate the efficacy of the quilting technique. The primary objective of the study was to access and compare the frequency of seroma formation following the quilting suture technique with standard flap closure in MRM. The secondary objectives were to compare drain output, post-operative complications, and the requirement of additional procedures for management of related complications. The 72 female participants in this randomized control trial had modified radical mastectomy after being diagnosed with breast cancer. The quilting suture technique was applied in the 36 patients and conventional technique applied in 36 patients for skin flap closure. The frequency of seroma formation and other complications were reported. Between the two groups, there was no statistically significant difference in the frequency of seroma production (P = 0.233). Total drainage volume (P = 0.213), drainage duration (P = 0.652), and post-operative complications (P = 0.641) did not substantially differ between the two groups. The study concludes that the quilting sutures technique does not decrease the incidence of seroma formation, total drain output, and total duration of drainage. There is no significant difference in complications and requirement of additional procedures compared to the standard technique.

An Analysis of the Impact of Intra-abdominal Pressure on Surgical Outcomes in Cases of Intestinal Obstruction: A Prospective Observational Study.

BACKGROUND: The decision and timing of surgical exploration of intestinal obstruction depend on the clinical findings and probable etiology of the symptoms. Patients with intestinal obstruction often have intra-abdominal hypertension (IAH), which is associated with a poor prognosis. PURPOSE OF THE STUDY: The purpose of the study is to evaluate the surgical outcomes in patients with intestinal obstruction in relation to intra-abdominal pressure (IAP). MATERIALS AND METHODS: The study was conducted on 50 patients with intestinal obstruction undergoing surgery. Preoperatively, IAP was measured in all the patients and was allocated into two groups based on the presence or absence of IAP. Patients were assessed for the postoperative length of hospital or ICU stay, surgical site infection, wound dehiscence, and recovery following surgery. RESULTS: The patients with preoperative IAH had significantly longer postoperative stays, with a median stay of eight days in these patients compared to four days in patients without IAH (p=0.009). A significantly higher number of patients (24%) had gangrenous changes on the bowel wall (p=0.042) and fascial dehiscence (p=0.018) in the group associated with raised IAP. A total of 75% of patients who required ventilator support belonged to the raised IAP group. The mean IAP in patients admitted to the ICU was significantly higher than in patients not admitted to the ICU (p=0.027). CONCLUSION: Preoperative IAH in intestinal obstruction is a significant factor in predicting the possibility of bowel ischemia with gangrene, perforation, intra-abdominal sepsis, surgical site infections, and prolonged hospital stay. Early surgical exploration and abdominal decompression must be considered in such cases.

Effects of transcutaneous electrical nerve stimulation on recovery of gastrointestinal motility after laparotomy: A randomized controlled trial.

INTRODUCTION: Postoperative Ileus (POI) negatively impacts patient outcomes and increases healthcare costs. Transcutaneous electrical nerve stimulation (TENS) has been found to improve gastrointestinal (GI) motility following abdominal surgery. However, its effectiveness in this context is not well-established. This study was designed to evaluate the role of TENS on the recovery of GI motility after exploratory laparotomy. METHODS: Patients undergoing exploratory laparotomy were randomized in a 1:1 ratio into control (standard treatment alone) and experimental (standard treatment + TENS) arms. TENS was terminated after 6 days or after the passage of stool or stoma movement. The primary outcome was time for the first passage of stool/functioning stoma. Non-passage of stool or nonfunctioning stoma beyond 6 days was labeled as prolonged POI. Patients were monitored until discharge. RESULTS: Median (interquartile range) time to first passage of stool/functioning stoma was 82.6 (49-115) hours in the standard treatment group and 50 (22-70.6) hours in the TENS group [p < 0.001]. Prolonged POI was noted in 11 patients in the standard treatment group (35.5%) and one in the TENS group (3.2%) [p = 0.003]. Postoperative hospital stay was similar in the two groups. CONCLUSION: TENS resulted in early recovery of GI motility by shortening the duration of POI without any improvement in postoperative hospital stay. TRIAL REGISTRATION NUMBER: CTRI/2021/10/037054.

Current Trends in the Management of Port-Site Infections: A Case Series and a Review of Published Work.

Introduction Laparoscopic techniques have become standard for many surgeries, offering benefits such as quicker recovery and less pain. However, port-site infections (PSIs) can occur and pose challenges. PSIs can be early (within seven days) or delayed (after three to four weeks), with delayed PSIs often caused by non-tuberculous mycobacteria (NTMs). NTMs are difficult to treat and do not respond well to antibiotics, leading to prolonged and recurrent infections. Guidelines for PSI management are limited. This summary highlights a case series of 10 patients with PSIs, discussing their treatment experience and presenting a treatment algorithm used at our institute. Methods This is a retrospective study (2015-2020) on chronic port-site infections (PSIs) in laparoscopic surgeries. Data were collected on patient demographics, surgery type, prior treatment, and management at the institute. Results The study analyzed 10 patients with chronic PSIs following laparoscopic surgery between 2015 and 2020. Laparoscopic cholecystectomy was the most frequent index surgery. Three patients had a history of treatment with varying durations of anti-tubercular therapy, one of whom had completed anti-tubercular treatment prior to presentation. Complete surgical excision with histopathological examination and fungal, bacterial and mycobacterial cultures were performed. Seven of the 10 patients were treated with oral ciprofloxacin and clarithromycin combination therapy for three months, two were treated with culture-based antibiotics and one was treated with anti-tubercular therapy. All patients improved on treatment. The mean follow-up period was 52 ± 9.65 months, with no relapses being reported.  Conclusion Port-site infections (PSIs) are troublesome complications of laparoscopic surgery that can erode the benefits of the procedure. Delayed PSIs caused by drug-resistant mycobacteria are difficult to treat. Improved sterilization methods and thorough microbiological work-up are crucial. Radical excision and prolonged oral antibiotics are effective treatments. Clinicians should avoid empirical antibiotic therapy to prevent antimicrobial resistance.

A newer method of seroma reduction by fenestration of pseudo-sac during laparoscopic repair of direct inguinal hernia: A randomised, controlled pilot study.

Background: Minimally invasive surgeries for inguinal hernia repair have been reduced post-operative morbidity. However, certain complications such as seroma formation are unavoidable. In this study, we introduce a newer technique of reducing seroma formation by fenestration of the pseudo-sac (thickened transversalis fascia) in patients undergoing laparoscopic hernia repair for uncomplicated direct inguinal hernia. Patients and Methods: A randomised, controlled pilot study was conducted from January 2019 to December 2020 for the patients undergoing laparoscopic hernia repair for uncomplicated direct inguinal hernia. Study participants were randomised into interventional group and control groups. Demographics, operative duration and complications including post-operative pain and seroma on days 1, 10 and 30 were analysed between both the groups. Results: A total of 20 cases with 30 hernias were included in the study. Demographic data were comparable between the two groups. The intervention group showed a statistically significant decrease in the incidence of seroma formation on the post-operative day 10 (13.3% vs. 46.6%, P = 0.046). The mean volume of seroma on day 10 was also less compared to the non-fenestration group (2.5 vs. 6.58 ml, P = 0.048). After the 30th day, no patient had a presence of seroma. There were no statistically significant differences in terms of mean operative duration, post-operative pain and other complications. Conclusion: Fenestration of pseudo-sac in laparoscopic hernia repair for uncomplicated direct inguinal hernia is a simple and effective technique. It has reduced the incidence and volume of seroma formation without any increased risk of infection, acute or chronic pain and recurrence.

Clinical Profile and Evaluation of Outcomes of Symptomatic Gallstone Disease in the Senior Citizen Population.

Background There is a heavy burden of gallstone disease on the world's population. The incidence and severity of symptomatic cholelithiasis increase with age. There is often a delay in presentation, leading to complicated disease, diagnostic delay, and increased morbidity. There is a paucity of studies on the presentation and management of cholelithiasis in elderly persons from the western part of India. This study aimed to observe the spectrum of presentation and management of symptomatic cholelithiasis in senior citizens. Objectives  The primary objective of this study was to describe the presentation, diagnosis and intraoperative findings of symptomatic gallstone disease (GSD) in patients aged over 60 years. The secondary objectives of this study were to find the association of GSD with age, sex, and comorbidities, including diabetes mellitus, hypertension, and thyroid disorders. Methods All patients above the age of 60 years presenting to the surgical outpatient and emergency departments from January 2020 to July 2021 with symptomatic GSD were included. Details of history, physical examination, blood investigations, and imaging of the abdomen (ultrasonography and Magnetic Resonance Cholangiopancreaticography, when indicated) were recorded. Patients were managed as per the advice of the treating consultant. Details of management and outcomes, including hospital stay, mortality, and morbidity, were noted. The descriptive data were organised into tables and percentages. The significance of various data and relationships between various variables was analysed using the Pearson chi-square test, Fischer exact test and scatter plots. Results A total of 76 patients were evaluated in this study, of which 73.7% were female. The mean age was 70.8 ± 1.7 years. The majority of patients (63.2%) were admitted through the outpatient department (OPD). The most common presenting complaint was abdominal pain (96.1%). Clinical jaundice was noted in 9.2%. Complicated Gall Stone Disease (GSD) was found more commonly in the female population (57.1%). Complicated GSD was more commonly found in patients with diabetes (p=0.075) and hypothyroidism (p=0.057). No association of age with intraoperative complications was noted (p = 0.446). Conclusion Senior citizens can present with both complicated and uncomplicated GSD. GSD, in the presence of hypothyroidism or diabetes mellitus, presents in a much more complicated form. Early surgical intervention in form of laparoscopic cholecystectomy can be beneficial to the patient if diagnosed with symptomatic gallstones. Patients of this age group need not be over investigated if a benign pathology is suspected.

Maternal and Perinatal Outcome in Pregnancy Complicated by Intrahepatic Cholestasis.

Introduction Intrahepatic cholestasis of pregnancy (IHCP) is characterized by pruritus of the hand and sole with abnormal liver function test and bile acid metabolism. IHCP occurs in the second and third trimesters of pregnancy and usually resolves after delivery. The overall prevalence is about 1.2 to 1.5%. This study was conducted to assess the fetomaternal outcome according to maternal serum bile acids levels and its correlation with liver function tests in patients with IHCP. Material and methods This ambispective observational study was conducted in the department of Obstetrics and Gynecology (OBG) for two years at AIIMS Jodhpur, Rajasthan. It included all the pregnant women attending the outpatient department of OBG with the complaint of pruritis in the palm and sole after 28 weeks of pregnancy and diagnosed with intrahepatic cholestasis of pregnancy after investigations. Results Only 152 patients were diagnosed with IHCP out of 4,148 deliveries, with a prevalence of 3.6%. Among these, 140 (92.11%) had mild IHCP, 10 (6.58%) had moderate IHCP and two (1.32%) had severe IHCP. There was a significant difference between the birth weight in mild, moderate and severe IHCP (P-value 0.004). About 12.5% (n=19) of patients had meconium-stained liquor during delivery. Two patients (1.32%) with moderate IHCP had intrauterine fetal death in the third trimester, and 6.58% (n=10) neonates were kept on continuous positive airway pressure. Conclusions IHCP is associated with adverse fetal outcomes like spontaneous or iatrogenic preterm delivery, low birth weight, increase in the rate of lower section cesarean section (LSCS) and intrauterine death of a fetus. A significant correlation found between raised bile acid levels and variables of liver function test, hence cost-effectiveness and feasibility of liver function test (LFT) should be considered for the management of IHCP.

Awareness and understanding of COVID-19 among pregnant woman in Northern India.

BACKGROUND: The severe acute respiratory syndrome coronavirus (SARS-CoV-2) has become a public health concern worldwide. It is important for pregnant women to know about the mode of transmission, symptoms, and preventive measures against COVID-19. The aim of this study was to evaluate the awareness and outlook of pregnant women and practical measures taken by them against COVID-19. MATERIALS AND METHODS: This cross-sectional questionnaire-based study was conducted for 1 month (June 10, 2020- July 10, 2020) in the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. A prevalidated questionnaire was given to 109 pregnant women to assess the knowledge, attitude, and practice acquired against COVID-19 infection. The Chi-square test or Fischer's exact test was used to compare categorical data. RESULTS: Among 109 participants, 103 (94.5%) had good knowledge, 4 (3.7%) had average knowledge and 2 (1.8%) had poor knowledge about COVID-19. Majority of them had a positive attitude for the protective measures taken for the prevention of disease. CONCLUSIONS: Since there is no valid treatment for COVID-19, prevention is the only key to curve this infection. In the present study, 94.5% pregnant women had overall good knowledge score about the mode of transmission, symptoms, and preventive measures against COVID-19.

Assessment of Quality of Life After Ventral Hernia Repair: A Prospective Observational Study at a Tertiary Care Centre.

Background Ventral hernias are usually repaired by an open or laparoscopic approach. Quality of life after ventral hernia repair is a very important but often underestimated parameter. This prospective observational study was conducted to assess the quality of life and other related parameters after all types of ventral hernia repair, mainly between open and laparoscopic repairs.  Objectives This study aimed to determine the quality of life after ventral hernia repairs. We also analysed and compared various parameters such as outcomes and satisfaction, postoperative pain, and complications between laparoscopic and open ventral hernia repair.  Methods This was a hospital-based prospective observational study conducted from January 2020 to December 2021, which included a total of 70 patients with ventral hernias. Thirty-nine patients underwent open repair and 31 patients underwent laparoscopic repair. Demographic data and other data such as postoperative hospital stay, return to activity, postoperative pain, complications, and quality of life were collected and analysed. Results The distribution of different types of hernias observed in our study included 34% incisional hernias, 33% umbilical and paraumbilical hernias, and 33% epigastric hernias. The incidence of complications was significantly less in laparoscopic repair compared to open repair. Also, satisfaction at 1 month was significantly more in the laparoscopic group compared to the open group. However, there is no significant difference in the postoperative pain, postoperative hospital stay, return to activity, satisfaction at discharge, and quality of life at 1 month in both the laparoscopic and open repairs.  Conclusion Laparoscopic ventral hernia repairs are associated with lesser complications and higher satisfaction. The use of tackers and trans-fascial sutures can significantly increase postoperative pain in laparoscopic repair and is the major factor affecting the short-term quality of life in laparoscopic repairs. As there is no difference in postoperative pain, hospital stay, and return to activity, laparoscopic repairs should be preferred wherever possible in view of fewer complications and higher satisfaction.

Feasibility of safe laparoscopic surgery performed by junior residents without exposure of open appendectomy: A retrospective study.

Context: Appendectomy is the most commonly performed surgery in the emergency department. It is very difficult to determine the minimal duration of the learning curve for junior residents to perform safe laparoscopic surgeries. Aim: This study aimed to determine the feasibility of a safe laparoscopic appendectomy performed by junior residents. Settings and Design: A retrospective study was conducted at a tertiary healthcare center from May 2018 to May 2020. Methods and Material: This study reviewed all the data of laparoscopic appendectomy performed by junior and senior residents. Both groups were compared for the patient outcome in terms of complications, conversion to open, intraoperative findings, operative time, postoperative progress, and hospital stay. Statistical Analysis: The data were formulated in an excel sheet and analyzed with SPSS. Mean, median, range, standard deviation, percentages, univariate analysis with χ test and t-test were used. Results: No significant difference was found in operative time (mean [SD], 84.87 [24.73] vs. 86.95 [24.93], P = 0.679), intraoperative complication (9.2% vs. 7.8%, P = 0.769), postoperative complications (34.2% vs. 34.4%, P = 0.984), conversion to open (6.6% vs. 4.7%, P = 0.633), length of postoperative hospital stay (Mean [SD], 2.3 [2] vs. 2.2 [1], P = 0.739), and readmission (4% vs. 3%, P = 0.794). No major intraoperative complications and mortality were found in both groups. Conclusions: Junior residents may be allowed for safe laparoscopic appendectomy under supervision without experience of open appendectomy. The patient's outcomes may be comparable with surgery performed by well-experienced surgeons. They can improve the basic healthcare system in the future with feasible basic laparoscopic surgery for common diseases.

Laparoscopic transhiatal oesophageal diverticulectomy: An experience of large epiphrenic oesophageal diverticulum and review literature.

Epiphrenic diverticulum is a rare abnormality of the distal oesophagus. Both thoracic and abdominal approaches are suitable for this diverticulum. A 46-year-old male presented with complaints of regurgitation and chest pain for 2 years. Contrast-enhanced computed tomography of the neck, thorax, abdomen and oesophageal endoscopy revealed 12 cm × 10 cm size large intrathoracic oesophageal diverticulum. He underwent an elective laparoscopic transabdominal oesophageal diverticulectomy. Gastrograffin study on the first post-operative day did not reveal any leak. In this case report, we are sharing our experience in the management of large epiphrenic oesophageal diverticulum through a laparoscopic approach. The benefits of the laparoscopic approach include decreased morbidity because we can avoid large thoracotomy or laparotomy incision.

Decreasing the Duration of Point of Decision to Getting Non-stress Test Done: A Quality Improvement Study.

Introduction: Non-stress test is an important non-invasive tool of antepartum surveillance. The hypoxia, acidemia in the fetus can easily be picked up by a non-stress test. It is important to get a non-stress test done on time to prevent the adverse neonatal outcome. Aim: This quality improvement project aims to evaluate the waiting period for a non-stress test (NST) from the point of decision in the antenatal outpatient department and to increase the percentage of pregnant women getting NST done in less than 4 h from the point of decision from a baseline of 41% to 80% in 4 weeks. Method: This observational study was conducted in the Department of Obstetrics & Gynecology at All India Institute of Medical Sciences Jodhpur for twelve weeks. This study has three phases-baseline assessment, implementation phase and continued implementation with the assessment phase. The tool used for the analysis of this problem was the Fishbone method. Results: The baseline assessment showed that only 41% of pregnant women got the non-stress test done in 4 h. We conducted a plan-do-study-act (PDSA) cycle 3 times, and the target was achieved in the second PDSA cycle. Conclusion: This quality improvement project has demonstrated that increasing awareness among all the team members who are dealing with pregnant women requiring NST can significantly increase the percentage of pregnant women getting NST done within 4 h from the point of decision. By detecting the fetal heart rate variation, we can prevent adverse fetal and neonatal outcomes.

An Unusual Presentation of Ludwig's Angina with Empyema Thoracis and External Carotid Artery Pseudoaneurysm.

Ludwig's angina is a rapidly spreading soft-tissue infection and commonly occurs following odontogenic infection. A 30-year-old male presented to the emergency department, 7 days after the extraction of molar teeth with a sudden onset of mandibular swelling. He was diagnosed with Ludwig's angina with empyema thoracis and external carotid artery (ECA) pseudoaneurysm. He was successfully managed with video-assisted thoracoscopic surgery-guided drainage and endovascular embolization of ECA pseudoaneurysm. We share our experience of challenges faced during the management of unusual presentation of complicated Ludwig's angina.

Left-Sided Strangulated Obturator Hernia: A Rare Case Report and Literature Review.

Obturator hernia is a rare type of pelvic hernia and considers more common in female patients. The obturator canal is a narrow space, leading to high chances of bowel strangulation. It is rarely diagnoses, especially on the left side. The mortality rate of obturator hernia is high due to delayed diagnosis. We are presenting a case of a 70-year-old woman, admitted with the clinical features of acute intestinal obstruction. On clinical examination, she had a nontender, distended abdomen, and all hernial orifices were normal. Per rectal and vaginal examination was also normal. She diagnosed a left-sided obturator hernia with the help of a computed tomography scan abdomen. We should consider a differential diagnosis of obturator hernia, especially in old, thin-built female patients with recurrent episodes of obstructive features. Early diagnosis and timely operative intervention may reduce the chances of complications and mortality.

Awareness and experience of health-care workers during coronavirus disease 2019 pandemic.

BACKGROUND: During the 2nd week of July 2020, the coronavirus disease 2019 (COVID 19) infection spreading in the community. Now more than 15 lakhs peoples have been infected in India, out of the 26816 patients were deceased. COVID 19 outbreaks become an additional hazard to the health-care workers (HCWs), leading to fatigue, anxiety, depression and fear of death. The objective of this questionnaire-based study is to know about the knowledge of HCWs about COVID 19, their experiences while dealing with the disease, and the protective measures taken to prevent the infection. MATERIALS AND METHODS: A cross-sectional, questionnaire-based study was conducted for 1 month starting from the 2nd week of June 2020 after getting institutional ethical clearance. This study included 240 HCWs posted in the medical and surgical Departments of All India Institute of Medical Sciences, Jodhpur, Rajasthan. This questionnaire was prepared in online Google forms and required 2 min to complete. Mean, median, range, and standard deviation were used to describe the continuous variables, and percentages were used to describe the categorical data. RESULTS: Among 240 HCWs, 79.16% (n = 190) participants have good knowledge and adapted good precautions (score 15-23) for COVID 19 infection. Rest 20% (n = 48) and 0.8% (n = 2) participants has average (score 8-14) or poor knowledge (score <8) with adaptation of average or poor precautionary measures against COVID 19, respectively. CONCLUSION: This study concluded that we have the requirement of more educational training programs for awareness of HCWs and precautionary measures against COVID 19. Thereby, HCWs can improve their knowledge and participate in this fight against COVID 19 with more efficiency and confidence.