Jaboulay's versus harmonic scalpel hydrocelectomy: prospective randomized controlled study.

OBJECTIVES: Surgical procedures for vaginal hydroceles have been varied with the aims of preventing recurrence, hematoma and edema formation and providing a better cosmetic outcome. The Jaboulay's procedure remains a preferred procedure owing to its simplicity and good long term outcome. However, sac eversion during the procedure leads to scrotal edema and mass sensation due to remnant sac in cases of large or secondary hydrocele sacs. Sac excision in these cases may provide better outcomes by removing the excess tissue. We aimed to compare the postoperative outcome after Jaboulay's procedure and harmonic scalpel excision of the sac in terms of scrotal edema, hematoma formation and the final cosmetic appearance. PATIENTS AND METHODS: 72 adult patients with vaginal hydrocele were randomized into two groups, who underwent harmonic scalpel sac excision and Jaboulay's procedure respectively, performed by a single surgeon. Preoperatively, patient demographics were noted. Postoperatively, data was recorded on the 1st day, 3rd day & 10th day about postoperative complications, and outcomes. Satisfaction on final cosmetic outcome was compared between the groups at the 3rd month. RESULTS: Post operative edema and sensation of mass in the scrotum were more (but not significant) in the Jaboulay's procedure group. Seroma and wound infection rates were similar in both groups. Patient satisfaction on cosmesis was better in the sac excision group. CONCLUSION: Hydrocelectomy with excision of the sac using a harmonic scalpel results in a lower incidence of postoperative oedema and better patient satisfaction in terms of cosmetic outcome compared to Jaboulay's procedure in the treatment of adult hydroceles.

The management of complex fistula in ano by transanal opening of the intersphincteric space (TROPIS): short-term results.

Purpose: Many methods have been used to treat complex fistulas, but no single technique has been considered standard. Damage to the sphincter may sometimes be unavoidable, and incontinence may be an important cause of morbidity. This study aimed to validate the results of transanal opening of the intersphincteric space (TROPIS), as a technique that avoids damaging the anal sphincter, in patients with complex fistula in ano. Methods: A prospective study was conducted among 35 consecutive patients with complex fistula in ano. After a preoperative magnetic resonance fistulogram, TROPIS was performed in all patients. The St. Mark's incontinence score was assessed preoperatively and postoperatively at 3 months. Results: The tracts were intersphincteric in 16 patients, transsphincteric in 10, extrasphincteric in 2, and horseshoe in 3. Four patients had recurrent tracts (3 transsphincteric and 1 intersphincteric). A defined follow-up schedule was used. Curettage was done if postoperative pus drainage from the wound was noted. The fistula healed in 29 patients (82.86%) following TROPIS. The remaining 6 patients received curettage, with healing in 3 (overall healing rate, 91.4%). Patients who received curettage were followed for 3 months, and the outcome was labeled as healed or failed. The mean preoperative incontinence score was 0. One patient developed incontinence to gas postoperatively in week 2, but there was no significant change in the scores at 3 months postoperatively. The mean postoperative incontinence score was 0.02. Conclusion: TROPIS is an effective method for the treatment of complex fistula in ano, with minimal risk for incontinence.

Prophylactic mesh placement in emergency midline laparotomy for intestinal perforation peritonitis: An appeal for caution.

Prophylactic mesh placement (PMP) is increasingly being used to reduce the incidence of incisional hernia after routine and emergency midline laparotomy (EML). However, such studies are not available for EMLs done solely for intestinal perforation. Patients who underwent non-absorbable PMP during EML for intestinal perforation (Group A, 15 patients) were compared with those who had a conventional abdominal wall closure (Group B, 20 patients). The incidence of wound dehiscence was significantly higher in Group A, while surgical site infection (SSI), and incisional hernia were similar in both groups. Mesh explantation was needed in half the cases. A prophylactically placed non-absorbable mesh in patients undergoing EML for intestinal perforation is associated with significantly higher rates of wound dehiscence and of mesh explantation and therefore, routine use of such a mesh appears not to be justified.

Prospective randomised trial of bolus vs. continuous regime of jejunostomy feed.

Enteral alimentation can be administered continuously, cyclically, intermittently, or by a bolus technique. Current literature does not suggest superiority of any one regime. Most studies have used nasogastric feeds, little is known about the outcome of jejunal feeding.This study compares the efficiency and safety of bolus and continuous jejunostomy feeding. 46 adults undergoing a feeding jejunostomy for nutritional support or as an adjunct to a major upper GI surgery, were randomised to bolus feeding (BF group, n = 24) and continuous feeding (CF group, n = 22). Demographic, anthropometric, and laboratory parameters were measured preoperatively and on post-operative days (POD) 3, 7, 15, and 30. These parameters; as well as nutritional and functional outcomes, and complications at POD 30; were comparable in both groups. Both groups tolerated jejunal feeds well. Bolus feeding is simple, inexpensive, and permits daily physical activities. Hence it may be preferred over continuous jejunostomy feeding for enteral alimentation.

Feasibility and efficacy of ghost ileostomy in typhoid ileal perforations: A prospective observational study.

Loop ileostomy is commonly performed for typhoid ileal perforations as temporary faecal diversion. This is associated with several stoma-related complications and also requires further surgery for its closure. Thus, we were prompted to conduct a prospective observational study on the safety, feasibility and efficacy of ghost ileostomy in typhoid ileal perforations. After dealing with the perforation, a ghost ileostomy was performed in 10 selected patients with favourable circumstances; otherwise, a conventional loop ileostomy was performed in 19 patients. The two groups were comparable (p > 0.05) for morbidity and mortality except for stoma-related complications, seen only in the loop ileostomy group. Body weight was better preserved in the ghost ileostomy group. One patient in the ghost ileostomy group required conversion to loop ileostomy owing to signs of intra-peritoneal suture leak, without any detriment to outcome. Our study shows safety, feasibility and efficacy of ghost ileostomy in selected patients with typhoid ileal perforations, thus avoiding loop ileostomy in one-third of patients.

Whether Superficial Abdominal Reflex is Affected by Subcostal Transverse Abdominal Incisions? A Prospective, Observational Early Experience.

INTRODUCTION: Superficial abdominal reflex (SAR) is an important part of the neurologic assessment. It is normally present and may be present or absent in various physiological as well as pathological conditions. The presence of an abdominal incision creates a dilemma in the mind of the clinician for it affecting this reflex. As there is no literature on this, we decided to study the effect of abdominal incisions on SAR. MATERIALS AND METHODS: It was a prospective, observational study. We evaluated the patients requiring transverse subcostal incision (range 3-12 cm) both preoperatively and postoperatively, for their abdominal reflexes. Patients with preoperative normal and symmetrical abdominal reflexes were included in the study. Postoperatively, we compared the change of SAR with the preoperative status and analyzed the data. RESULTS: A total of 94 patients underwent surgeries, out of which 54 patients came under inclusion criteria, comprising 36 males and 18 females. Subcostal transverse abdominal incisions were made for surgeries including both gastrointestinal and ventriculoperitoneal shunts. SAR was found unaffected by the incisions in all patients. CONCLUSIONS: Although the study was small, subcostal transverse abdominal incisions were not found to affect SAR.

Thoracoscopic dorsal sympathectomy for upper limb Buerger's disease.

BACKGROUND AND OBJECTIVES: Thromboangiitis obliterans is a common peripheral vascular disease in India. This study was conducted to assess the efficacy of thoracoscopic dorsal sympathectomy as a treatment for Buerger disease of the upper extremities. METHODS: Thirty thoracoscopic dorsal sympathectomies (17 left- and 13 right-sided) were performed in a tertiary medical center in 5 women and 20 men (mean age, 41 years) between July 2010 and February 2013. RESULTS: The mean operative time was 30 minutes, and the mean hospital stay was 52 hours. There were no complications. All patients had improvement in pain and were relapse-free after a mean follow-up period of 11.63 months. DISCUSSION: Thoracoscopic dorsal sympathectomy reduces pain significantly by reducing peripheral resistance and promoting collateral development. The increased magnification of the thoracoscopic approach permits better visualization, ensuring complete excision and therefore good results. Thoracoscopic dorsal sympathectomy for Buerger disease of the upper limb is a safe and effective treatment.

A simple and safe extracorporeal knotting technique.

INTRODUCTION: Extracorporeal knotting in laparoscopic surgery can be used in certain situations or as a bridge to mastering more technically demanding intracorporeal suturing. We describe a simple, easy, and safe extracorporeal knotting technique. TECHNIQUE DESCRIPTION: A simple knotting technique, borrowed from the art of tatting, is used. DISCUSSION: This very simple and safe technique has been successfully followed in more than 50 cases for tying an extracorporeal knot. Its advantage is that any number of additional knots can be tied and easily slid down in a single maneuver.

Anatomic study of distribution, numbers, and size of lymph nodes in mesorectum in Indians: a autopsy study.

This study was conducted to find the number, size, and distribution of the lymph nodes in the mesorectum in fresh cadavers without rectal cancer in Indians and to compare fat clearance method versus manual dissection of lymph nodes in terms of efficacy of lymph node yield. Thirty fresh cadavers underwent total mesorectal excision (TME) by midline incision. TME specimen was divided transversely (upper, middle, and lower thirds), and then further divided radially into 4 equal areas and the right lateral, left lateral, and posterior areas were taken for lymph node harvesting. In the first 15 cases (group A), lymph nodes were dissected manually from each of 9 areas. Number and diameters of harvested nodes were noted, and specimens were histopathologically examined. In the next 15 cases (group B), fat clearing technique was used, and the procedure was repeated. Mean number of lymph nodes recovered per cadaver was 6.2 (SD = 1.3; range, 5 to 9, group A = 5.86 ± 1.24, group B = 6.60 ± 1.29, P = .126) and mean size of the lymph node was 2.1 mm (SD = 0.38; range, 2 to 8 mm). Size and numbers of nodes in all the areas were similar between the 2 groups except in lower third, where smaller nodes were identified in greater numbers in group B. Manual dissection is an effective technique for node harvesting after TME, except for very small nodes found in the lower third of mesorectum. Accurate pathological examination of TME specimen is mandatory to avoid understaging of disease.

A simple prognostic scoring system for typhoid ileal perforation peritonitis.

The increasing awareness of the worse than expected outcome after typhoid ileal perforation (TIP) prompted us to prospectively prognosticate patients with the help of the Jabalpur prognostic score (JPS), a simplified scoring system for peptic perforation peritonitis (PPP). Eighty-two consecutive patients with TIP were studied from May 2005 to August 2008 in the Department of Surgery, NSCB Government Medical College, Jabalpur (MP), India. Six parameters used in the JPS were recorded: age, heart rate, mean blood pressure, serum creatinine, any co-morbid illness and perforation-operation interval. JPS correlated with morbidity and mortality in TIP patients and, as the score increased, so did the morbidity and mortality. Survivors had a significantly lower mean score (3.86 ± 2.23) than non-survivors (7.94 ± 3.6; P < 0.001). Expectedly, TIP patients had worse outcome, stage by stage, than PPP patients. JPS can be easily modified for TIP (JPS-TIP) and can be easily used for its prognostication.

Functional outcome and quality of life following restorative proctocolectomy for ulcerative colitis in Indians.

BACKGROUND: The functional outcome and quality of life after sphincter-saving operations for ulcerative colitis have not been previously assessed in Indian patients whose dietary habits and socio-cultural practices differ considerably from those in western countries. PATIENTS AND METHODS: Between 1996 and 2002, we performed 46 J-pouch ileoanal anastomoses (IPAA), for patients with ulcerative colitis. Thirty-eight of these patients had had their ileostomy closure more than 4 years previously of whom 31 could be assessed by interviews and a telephonic questionnaire. Their quality of life was objectively assessed using the Cleveland Global Quality of Life (CGQL) index, a validated index for IPAA, the score being 1 in normal people. There were 20 males and 11 females with a mean age of 38 years. In the same period, six of the nine patients who did not opt to have an IPAA (permanent stoma) were assessed. These included four males and two females, mean age 45 years (36-52). RESULTS: One patient died in the postoperative period and another died 3 months after surgery from multiple small bowel perforations. Other complications included intestinal obstruction in seven, pouchitis in four and incisional hernia in two. One pouch had to be converted to a permanent ileostomy following development of a fistula because of Crohn's disease. The mean daily postoperative stool frequency was seven (range 2-20). Eighty-one percent had perfect daytime continence and 81% used dietary restrictions. Eighty-four percent rated their pouch function to be excellent or good. All patients preferred IPAA to an ileostomy citing mainly social and cultural reasons and were willing to choose it again. The mean preoperative CGQL score (0.27) increased significantly after colectomy (0.50) and after closure of ileostomy (0.77; p < 0.001). The mean CGQL in the "permanent stoma" group did not improve significantly after surgery (0.62 vs. 0.50) and four of these expressed a wish to have an IPAA. CONCLUSIONS: Restorative proctocolectomy provides a good functional outcome and improves the quality of life in Indians with ulcerative colitis and may be the most appropriate procedure for such patients in developing countries.

Mesopancreas: myth or reality?

CONTEXT: A recently published study hypothesized the concept of 'mesopancreas', defining it as a firm, well-vascularized structure extending from the posterior surface of the pancreatic head to behind the mesenteric vessels. OBJECTIVE: To verify and define mesopancreas from resection specimens obtained from fresh cadavers. DESIGN: Postmortem anatomical-pathological study. SETTING: Department of Surgery in conjunction with the Departments of Forensic Medicine and Pathology, Government Medical College and Hospital, Jabalpur, MP, India. PARTICIPANTS: Twenty fresh adult cadavers without any intra-abdominal injury or gross intra-abdominal pathology. INTERVENTIONS: Specimens containing the entire duodenum, pancreatic head and neck, gallbladder, cystic duct, common bile duct, superior mesenteric vessels, inferior vena cava and aorta were removed en-bloc. Gross and histopathological examinations of the specimens were carried out. MAIN OUTCOME MEASURES: To look for a fibrous sheath or fascia around the retropancreatic structure purported to be a mesopancreas. RESULTS: Loose areolar tissue, adipose tissue, peripheral nerve, nerve plexus, lymphatic and capillaries were found in the retropancreatic tissue, extending from the head, neck and uncinate process of pancreas to the aorto-caval groove but no fibrous sheath or fascia was found around these structures. CONCLUSIONS: The concept of 'mesopancreas' is anatomically unfounded.

Effect of Candida infection on outcome in patients with perforation peritonitis.

Perforation peritonitis is treated with surgery and antibiotics. This study was conducted to identify bacterial and fungal microorganisms responsible for peritonitis in patients with hollow viscus perforation and to examine the influence of these microorganisms on the outcome. A prospective study was conducted from May 2005 to September 2006 involving 84 consecutive patients with spontaneous gastrointestinal perforation peritonitis, who were referred for surgery. Peritoneal fluid was analyzed by microbial culture and biochemical tests for bacteria and fungi. The Jabalpur Prognostic Score was calculated. Forty-two of the 84 patients had positive peritoneal fluid cultures. Escherichia coli was the most common bacterium (n=26) and Candida (n=13) the most common fungus isolated. Bacterial isolates were largely sensitive to amikacin while all the Candida isolates were sensitive to fluconazole. Mortality was significantly higher in patients with positive peritoneal cultures (15/42) compared with those with negative peritoneal cultures (0/42, p<0.001), and in patients with mixed bacterial and fungal-positive cultures (10/13) compared with those with isolated bacterial cultures (5/29, p<0.001). Using the Jabalpur Prognostic Score, positive fungal cultures were found to be associated with a significantly higher than expected mortality. Patients with gastrointestinal perforations and positive peritoneal cultures have a poor prognosis, which is significantly worsened by the association of positive fungal cultures. Early recognition and treatment of fungal infection is advisable.