Scalpel versus diathermy of midline skin incisions: comparison of mean pain scores on second post-operative day.

OBJECTIVE: To determine the mean post-operative pain in scalpel versus diathermy opening of midline laparotomies. METHODS: The randomised controlled study was conducted at Civil Hospital and Dow University of Health Sciences, Karachi, from May to November 2010, and comprised patients undergoing midline laparotomy. Patients were equally divided into two groups; those who received incision with diathermy were placed in group A, and those who received incision with scalpel in group B. Mean post-operative pain scores were recorded using numerical analogue scale on second post-operative day. SPSS 16 was used for statistical analysis. RESULTS: Of the 58 patients, there were 29(50%) in each group. The overall mean age of the patients was 31.8±12.8 years. Besides, 40(68.9%) patients were male. The mean post-operative pain scores at 48 hours in diathermy group was 1.48±0.68 while in scalpel group it was 2.17±0.46 (p<0.05). CONCLUSIONS: The use of diathermy for midline laparotomy incision had significant advantage over scalpel in reducing pain on second post-operative day.

Difficulties in laparoscopic cholecystectomy: Conversion versus surgeon's failure.

BACKGROUND: Laparoscopic cholecystectomy is considered to be gold standard treatment for symptomatic gall stones. Despite several benefits there are still disadvantages of laparoscopic cholecystectomy in difficult cases where anatomy is disturbed even in experienced hand. Aim of this study is to identify advantages of early conversion to open cholecystectomy in difficult cases and how it should not be associated with surgeon's failure. METHODS: Observational study was conducted at tertiary care hospital of Karachi, Pakistan from January 2012 till June 2015. All patients who presented to general surgery department with symptomatic gall stones and planned for laparoscopic cholecystectomy was included in the study. Demographic data was collected. Preoperative workup includes baselines investigations with liver profile test and imaging study (ultrasound scan). All patient underwent laparoscopic cholecystectomy at first. Operative difficulties, incidence of conversion, reason for conversion and complication intra-operative or postoperative were recorded. Data was analyzed using SPSS 20. RESULTS: Out of 1026 patients, 78.26% (803) were female. Mean age of patients were 41.30±8.43 years (range 26-68 years). Common presenting symptoms were pain at upper abdomen and dyspepsia. Most of the patients had multiple gall stones (93.85%). Nine hundred and ninety-two patients (96.68%) of patients underwent successful laparoscopic cholecystectomy. This includes patients in whom dissections were difficult because of disturbed anatomy of calots triangle. Only 3.13% of patients were converted to open cholecystectomy. There was a significant difference (<0.05) in complications observed between completed and converted cholecystectomies. CONCLUSIONS: Conversion from laparoscopic to open procedure should be done in cases of technically difficult situations to avoid significant mortality and morbidity. Surgeons experience had a pivotal role in determining its need and justification.

Metastasis to ileostomy of mucinous adenocarcinoma of rectum.

Carcinoma of colon and rectum is one of the most common malignancies of gastrointestinal tract. Primary ileostomy cancer following excision of primary tumour is a rare complication although a number of cases have been reported in the last 30 years. This case also reports lymph node metastasis to the adjacent mesenteric lymph nodes. Appearance of ileostomy tumour as synchronous or metachronous lesion is highly debatable. Once diagnosis is confirmed by biopsy enblock excision with or without stomal relocation is the main stay of treatment. Patient education and regular surveillance of patients with long-standing ileostomy is recommended for early detection of this unusual cancer.

Trilateral retinoblastoma with unilateral eye involvement.

Trilateral retinoblastoma (TRb) is a rare combination of unilateral or bilateral retinoblastoma with an ectopic midline intracranial neuroblastic neoplasm (primitive neuroectodermal tumour) usually in the area of pineal gland or sellar region. TRb can occur with both familial and sporadic forms of retinoblastoma. An occurrence of this rare tumour in a 12-year-old boy who had unilateral retinoblastoma in association with ectopic suprasellar primitive neuroectodermal tumour (PNET) is reported here. To the best of our knowledge, this is the first case report in Pakistan on TRb with suprasellar mass.

Mucinous adenocarcinoma of the appendix.

Mucinous neoplasm is a rare malignancy of the gastrointestinal tract, the most common site being the appendix. There are different types of mucin producing tumours that can occur in the appendix, which can be benign as well as malignant. Mucin produced by these tumours results in ascites that makes it palpable as jelly belly.

Use of Abdominal Binders after a Major Abdominal Surgery: A Randomized Controlled Trial.

Objective To compare the effect of abdominal binder versus no binder after major abdominal surgery and cesarean section on various post-operative recovery parameters. Materials and methods This is a randomized controlled trial conducted at the Department of General Surgery and Obstetrics, Civil Hospital, Karachi, Pakistan. All those patients aged ≥18 years having abdominal surgery including elective and emergency abdominal surgery and cesarean sections with American Society of Anesthesiologists Class I-III were included in the study. Randomization was done using the sealed envelope method by the principal investigator. The intervention group wore an abdominal binder postoperatively while the control group did not use it. Mobilization and the pain status of both groups were evaluated on the first, fourth, and seventh days after surgery. Results Primary outcome variables were mobility, assessed via 6-minute walk test (6MWT) and postoperative pain, evaluated via visual analogue scale. There was no statistically significant difference in the 6MWT distance before (p = 0.278) and on postoperative day one of the surgery (p = 0.0762). However, the difference was significant on fourth (p < 0.001) and seventh day (p value < 0.001). With regards to the pain status, patients in the binder group reported significantly less postoperative pain on first, fourth, and seventh (p value < 0.001) day compared to the non-binder group. Conclusion The use of abdominal binder postoperatively significantly reduced pain and improved mobility in both obstetric and surgery patients.

Surgically Resected Gall Bladder: Is Histopathology Needed for All?

Background. Laparoscopic cholecystectomy is considered to be gold standard for symptomatic gall stones. As a routine every specimen is sent for histopathological examination postoperatively. Incidentally finding gall bladder cancers in those specimens is around 0.5-1.1%. The aim of this study is to identify those preoperative and intraoperative factors in patients with incidental gall bladder cancer to reduce unnecessary work load on pathologist and cost of investigation particularly in a developing world. Methods. Retrospective records were analyzed from January 2005 to February 2015 in a surgical unit. Demographic data, preoperative imaging, peroperative findings, macroscopic appearance, and histopathological findings were noted. Gall bladder wall was considered to be thickened if ≥3 mm on preoperative imaging or surgeons comment (on operative findings) and histopathology report. AJCC TNM system was used to stage gall bladder cancer. Results. 973 patients underwent cholecystectomy for symptomatic gallstone disease. Gallbladder carcinoma was incidentally found in 11 cases. Macroscopic abnormalities of the gallbladder were found in all those 11 patients. In patients with a macroscopically normal gallbladder, there were no cases of gallbladder carcinoma. Conclusion. Preoperative and operative findings play a pivotal role in determining incidental chances of gall bladder malignancy.

Trail without Catheter after Transurethral Resection of Prostate: Clamp It or Not?

Background. There has been argument between clinical practitioners about clamping catheter or not prior to its removal after transurethral resection of prostate (TURP). We conducted a clinical trial to assess whether clamping has any role in early bladder tone recovery particularly in patients who undergo TURP. Methods. Randomized clinical trial was conducted at a tertiary care hospital, Karachi from January 2014 to July 2015. Eighty-six study participants who underwent TURP were randomly allocated into two groups of 43 participants each. In Group I, patient's Foley catheter was not clamped prior to its removal and in Group II Foley catheter was clamped. Data of all subjects were analyzed using SPSS version 20. Results. There was no significant difference in age and weight of resected tissues between two groups. Among 4 patients in Group I who required recatheterization, 1 patient was discharged with catheter as compared to Group II in which 2 patients were discharged with catheter (P = 0.99). Only 1 patient (2.3%) in Group II had bleeding which required recatheterization. Length of stay was significantly affected by early and free removal of Foley catheter (P < 0.001). Conclusion. The results of current study identified that clamping whether done or not had no significant impact on urinary retention.