Obstructed inguinal hernia containing ovary with an ovarian cyst: a case report.

A 27-year-old married woman came to the emergency room (ER) with the chief complaint of severe pain in the abdomen for 3 days, which was more pronounced in the right iliac fossa, along with the complaint of multiple episodes of vomiting for the last 6 hours. She also gave a history of swelling in the right inguinal region for last 9 months with the complaint of mild on and off pain in the swelling. On physical examination, diagnosis of obstructed inguinal hernia was made. Ultrasonography (USG) of abdomen was of no use, as it only commented on hernial defect and not on the contents of the hernial sac. An emergency surgery was planned; marsupialisation of ovarian cyst, repositioning of fallopian tube along with ovary and herniorrhaphy was performed without any difficulty.

Effect Of Age, Gender And Type Of Varicosity On The Post-Operative Pain Score After Seven-Day Compression Dressing After Varicose Vein Surgery.

Great saphenous vein insufficiency is linked to 80% of all remarkable lower limb varicosities. A total of 30 patients were enrolled from OPD fulfilling the inclusion criteria after the approval of the hospital's ethical committee. Patients had compression dressing for seven days after surgery. The patients were divided into two groups-Group-A (Compression dressing for two days) and Group-B (Compression dressing for seven days). Stratification of pain score was done against age, gender, and grades of varicose veins, and after dividing into groups t- test was put into use. A p 20 value ≤0.05 was contemplated to be remarkable. Thirty patients with primary varicose vein were enrolled in this study. The mean age of patients was 35.4±9.9 years. Mean pain score in these patients was 2.9±0.8 years. Pain score after seven days of compression dressing after the surgery for varicose veins depend upon the gender, age, and grades of the varicosity of the veins. It is lesser in the females, younger age groups, and in those who had initially lesser severity of the varicose veins.

Spontaneous splenic rupture during dengue fever.

Dengue fever is one of the most frequent arboviral diseases in the world. Dengue is known to cause myocarditis, hepatitis, and neurological illustrations but one of the established presentations is leakage of plasma resulting in circulatory failure. Spontaneous rupture of the spleen is one of the most infrequent but known outcome of dengue fever which has been reported from time to time in literature. We present, here, the case of a 50-year-old patient who developed this condition during dengue fever and was managed in our department successfully. This complication must be kept in mind while treating any case of dengue fever so that it can be avoided or if not then treated timely.

Role of interventional radiology in surgical diseases of breast.

Since the publication of the first imaging-guided wire localisation technique, the art of breast treatments has made great strides. Radiologists like Hall, Frank, Kopans, DeLuca, and Homer were all the pioneers in innovative breast interventional radiology field. Their approaches and gadgets for enhancing surgical outcomes in cases with breast diseases aided progress in the discipline and have withstood the ravages of time. Many of their methods are still in use. We are all standing together at the beginning of a new chapter in medicine. Cost effectiveness, comparative effectiveness studies, and an older population are all causing clinicians to reconsider what they perform. Similarly, we are now united on a global scale. The studies described in the current narrative review relate to multiple nations around the world. Breast cancer is a worldwide health problem. With the expansion of technological advances, as well as the apparent ease of worldwide travel, we must all collaborate to improve the outcome in the battle against breast cancer.

Experience of surgical management of rare cases of choledochal cyst in last five years-tertiary care reflection.

Choledochal Cyst (CC), also known as the biliary cyst, is one of the rare inherited anomalies of intrahepatic and/or extrahepatic biliary system characterised by varying degrees of cystic dilatation of the biliary tract without acute obstruction. The prevalence ranges from 1 in 13,000 people to 1 in 2 million people with preponderance in Asia1, particularly in Japan. Moreover, the presentation also varies in children and adults, and is usually vaguer and non-specific in adults. The prevalence is even lower in males, with female to male ratio being 3:1-4:12. We present here three cases of adult choledochal cysts excised in our surgical unit in the last five years. We discuss the aetiopathogenesis, presentation, diagnosis, surgical treatment, and complications of choledochal cysts based on the available literature. It is crucial to establish a multidisciplinary group of professionals, that comprises paediatric surgeons, pathologists, paediatric gastroenterologists, physiotherapists, nutritionists, oncologists, and radiologists, to get acceptable outcomes in diagnosing and treating children with choledochal cysts.

Post pancreatic surgery complications; surgeon vs interventional interventional radiologists.

Even at high-volume centres, pancreatic resections are linked with a high rate of complications, as well as significant morbidity and mortality. In the management of these occurrences, a multidisciplinary approach is required, and interventional radiology plays an important role in the treatment of patients who develop post-surgical problems. The current review was planned to provide an overview of interventional radiological techniques that can be used to treat various types of problems following pancreatic resection. Percutaneous fluid collection drainage, percutaneous transhepatic biliary operations, artery embolisation, venous interventions, and fistula embolisation are feasible therapeutic alternatives with fewer problems than a re-look surgery. They also have a shorter hospital stay and faster recovery.

The study of frequency of malignancy and its types in surgical jaundice; a tertiary care experience.

OBJECTIVE: To determine the frequency of malignancy and its types in patients presenting with surgical jaundice in a tertiary care setting. METHODS: The cross-sectional study was conducted at the North Surgical Ward, Mayo Hospital, Lahore, Pakistan, from May 8 to November 8, 2020, and comprised patients of either gender with a diagnosis of surgical jaundice made on the basis of history, clinical examination, haematological and biochemical reports and radiological investigations. All patients were managed as per the guidelines for surgical jaundice with injection vitamin K intramuscular, hydration with intravenous fluids, avoidance of constipation by lactulose or neomycin, vitals and urine output monitoring and prophylactic antibiotics. Demographic data as well frequency of malignancy were noted using a predesigned proforma. Data was analysed using SPSS 21. RESULTS: Of the 95 patients, 51(53.7%) were male and 44(46.3%) were female. The overall mean age was 49.96±16.54 years (range: 18-80 years). A total of 19(20%) cases had body mass index <30. Malignancy was identified in 50(52.6%) cases; 14(28%) gallbladder, 4(8%) head of pancreas, 9(18%) peri-ampullary carcinoma, 7(14%) cholangiocarcinoma, 6(12%) Klastkin tumour, 5(10%) hepatocellular carcinoma, and 5(10%) metastatic tumour. CONCLUSIONS: More than half of the surgical jaundice cases had malignancy, gallbladder being the most affected site.

Is intravenous magnesium sulphate a suitable adjuvant in postoperative pain management? - A critical and systematic review of methodology in randomized controlled trials.

A growing worldwide focus on opioid-free anaesthesia entails multimodal analgesic strategies involving non-opioids such as magnesium sulphate (MgSO4). Several systematic reviews have concluded there is beneficial analgesic effect of MgSO4 administration but do not take considerable heterogeneity among the studies into consideration. Medical literature published until June 2021 was searched in PubMed/Medline, Embase, Central and Web of Science: The final search yielded a total of 5,672 articles. We included only randomised controlled trials assessing the effect of intravenous MgSO4 on opioid consumption and acute postoperative pain when compared to either placebo or standardized analgesic treatment. The primary aim was to compare the homogeneity of essential variables and confounders. A post-hoc meta-analysis demonstrated a reduction in both postoperative morphine consumption (-6.12 mg) and pain score (-12.32 VAS points) in favour of the MgSO4-groups. Data for meta-analysis was missing from 19 studies (45%) on morphine consumption and 29 studies (69%) for pain score, the majority of which reports no effect for either morphine consumption or pain score. The calculated heterogeneity among the included studies was considerable for both outcomes; I 2=91% for morphine consumption and I 2=96% for pain score. Although we found a per se reduction in opioid consumption and pain score, methodological heterogeneity and clinical shortcomings of pre-, intra-, and post anaesthetic data precludes conclusions on clinical importance of intraoperative intravenous MgSO4. In addition, the reduction is likely less than what can be gained from using standardized analgesic treatment.

An outcome of emergency vascular surgery performed by general surgeons; our experience in a university hospital of Pakistan and can they substitute vascular surgeons?

OBJECTIVE: To measure the outcome of emergency vascular surgery performed by general surgeons, and to identify preventable causes of mortality. METHODS: The retrospective study was conducted at the General Surgery Department of Mayo Hospital, King Edward Medical University, Lahore, Pakistan, and comprised data between January 2014 and May 2019 related to cases regardless of age and gender that required emergency vascular surgery after diagnosis by a consultant surgeon at the surgical emergency. The cases were analysed from admission till discharge. Data was analysed using SPSS 20. RESULTS: Of the 135 cases, 127(94%) were males. The overall mean age was 28.8±11.5 years (range: 14-63 years). Mean duration of hospital stay was 11±3.92 days (range: 4-22 days). Three major peripheral arteries injured were brachial 32(38.5%), popliteal 55(40.7%) and femoral 20(20.7%), with more than half with complete transection 75(55.6%). Vascular repairs done were primary anastomosis 45(33.3%), reverse saphenous vein graft 68(50.4%), embolectomy 4(3%) and amputation 18(13.3%). Limb salvage rate and mortality was 101(74.8%) and 6(4.4%), respectively. Complications occurred in 38(28.1%) cases, with 24(18%) wound infections and 9(6.7%) myonecrosis. Factors leading to poor outcome/complications were Glasgow Coma Scale score <12 (p=0.01), referred case (p=0.04), significant bleeding (p=0.004), haemoglobin <9 at presentation (p=0.001), bone fracture (p=0.01), involvement of lower limb (p=0.003) and late presentation (p=0.003). CONCLUSIONS: Late presentation in hospital was the major modifiable factor improvement of which could lead to better outcome, apart from the early and proper surgical intervention.

Intravenous fosphenytoin as treatment for acute exacerbation of trigeminal neuralgia: A prospective systematic study of 15 patients.

INTRODUCTION: Intravenous fosphenytoin is widely used for acute exacerbation of trigeminal neuralgia, however, few studies have investigated this treatment. We aimed to examine the efficacy and side effects of initial intravenous fosphenytoin plus oral tapering of phenytoin for exacerbation of trigeminal neuralgia. METHODS: Consecutive patients with primary trigeminal neuralgia were included in this prospective observational 90-days follow-up study. Data were collected using standardized interviews before, at 24 hours, day 7, 30 and 90 post loading dose. The primary outcome was the proportion of responders defined as a 50% reduction in pain intensity 24 hours post loading dose. RESULTS: We included 15 patients. Nine patients (60%) were responders. Pain intensity 24 hours post loading dose was reduced by 5.00 points on the numerical rating scale (p < 0.001), and at day 7 by 5.5 points (p < 0.001). The most common side effects were hypotension and dizziness. CONCLUSION: Intravenous fosphenytoin relieves trigeminal neuralgia pain in most patients and provides a window for titrating prophylactic trigeminal neuralgia medications or planning neurosurgery. The decision to administer intravenous fosphenytoin should be taken with support from trigeminal neuralgia experts and involves considerations of co-morbidities and other treatment options for acute exacerbation of trigeminal neuralgia.Clinical Trial: Preregistered (ClinicalTrials.gov Identifier: NCT03712254.

Comparison of outcome of compression dressing for two days Vs seven days after varicose surgery.

Incompetence of the great saphenous vein (GSV) is a global issue and the most prevalent cause of chronic venous disease of the leg. Clinical manifestations range from moderate to severe, including tiredness, heaviness, and irritation, as well as hyperpigmentation and leg ulcers. A study was conducted to address this controversy,1 i.e. to determine the outcome of compression dressing after varicose vein surgery in terms of postoperative pain, on the Surgical floor, of Mayo Hospital, Lahore, from October 1, 2020, to April 1, 2021. A total of 60 patients with Primary varicose veins were enrolled in this study, fulfilling the inclusion criteria after obtaining approval from the ethical committee of the hospital. The patients were divided in two groups. Group A wore compression dressing for two days after surgery and Group B wore compression dressing for seven days after surgery. All the patients received 1gm Paracetamol I/V eight hourly followed by tablet Paracetamol 500mg P/O eight hourly. Then the outcome of compression dressing was analysed in the form of mean postoperative pain. The mean pain score was assessed on one week. Data were entered in SSPS v23.0. Stratification of pain score was done against age, gender, and grades of varicose veins. A comparison of the two groups was done by applying a t-test. A p-value of ≤ 0.05 was considered significant. Prescribing compression stockings for longer than two days after Trendelenburg's procedure leads to reduced pain and improved physical function during the first week after treatment.

Effect of sevoflurane versus propofol on neutrophil-to-lymphocyte ratio in healthy individuals: a sub-study of a randomised crossover trial.

Background: Sevoflurane and propofol are commonly used drugs in general anaesthesia. However, their effects on perioperative immune function are incompletely understood. We hypothesised that sevoflurane and propofol differentially affect immune function in healthy individuals. Therefore, we investigated the effect of sevoflurane and propofol on neutrophil-to-lymphocyte ratio before, during, and after general anaesthesia. Methods: In this randomised crossover study, 19 healthy individuals underwent 2 h of general anaesthesia with either propofol or sevoflurane. After 4 weeks, anaesthesia was repeated using the other drug. Blood samples were obtained before, during, 1 h after, and 1 day after anaesthesia. The primary outcome was whole-blood neutrophil-to-lymphocyte ratio, and secondary outcomes were specific white blood cell differential counts. A linear mixed-effects model was used to estimate effect sizes. Results: The neutrophil-to-lymphocyte ratio was higher in the propofol compared with the sevoflurane group during anaesthesia, 2.8 (confidence interval [CI]: 2.3-3.3) vs 1.6 (CI: 1.1-2.1), and 1 day after anaesthesia, 2.6 (CI: 2.1-3.1) vs 1.9 (CI: 1.4-2.4). In all patients, we observed transient lymphopaenia during propofol anaesthesia, 1.1 × 109 cells × L-1 (CI: 0.9-1.4), compared with sevoflurane anaesthesia, 1.9 × 109 cells × L-1 (CI: 1.7-2.1). In addition, neutrophil counts were higher 1 day after propofol anaesthesia, 4.4 × 109 cells × L-1 (CI: 4.0-4.9), compared with sevoflurane anaesthesia, 3.5 × 109 cells × L-1 (CI: 3.1-4.0). We observed no differences in the remaining white blood cell subgroups. Conclusions: In healthy individuals undergoing general anaesthesia without surgery, the neutrophil-to-lymphocyte ratio was affected by the type of hypnotic used. Transient lymphopaenia was observed in all participants during propofol anaesthesia.

Inflammatory mediators as surrogates of malignancy.

Inflammation related to cancer occurs in the cellular vicinity of the tumour and is involved with predictions related to the course of disease and survival prognosis in varioua malignancies. These inflammatory markers affect different phases of tumourigenesis, i.e. carcinogenesis, tumour expansion, lymphovascular invasion, and distant metastasis, and, as a result, tumour cells can activate immune mediators and cells directly and/or chemokines as well as prostaglandins. Numbers of circulating different blood cells, i.e. lymphocytes, platelets, neutrophils and levels of plasma proteins, like C-reactive protein and interleukins that are components of inflammatory responses, are hallmarks of pathways leading to tumourigenesis. Thus, they can provide vital information in stratifying patients according to the risk and precisely targeted clinical care and outcome in malignancies. The current narrartive review was planned to discuss the role of platelet-to-lymphocyte ratio alongside the use of systemic immune inflammation index as the inflammatory mediators of malignancies along with overview of their role in different studies. It was also planned to recommend what the future studies should should aim at, including multiple risk factors, exposures and inflammatory profiles and as well as their combined interactions, for a better understanding of the role of the inflammatory mediators in malignancy.

Thyroid-like follicular carcinoma of kidney: Case presentation and literature review.

Thyroid follicular carcinoma like renal tumour (TFCLRT) is a rare variant of primary renal epithelial tumour and was first reported in 2006. Up till now, 40 cases have been identified worldwide and alarmingly, 17 cases have been identified from China only. The condition has been included in the WHO Renal Tumours Classification 2016. We present here the first case of thyroid follicular carcinoma like renal tumour from Pakistan that was managed in our surgical unit and a literature review. Left-sided radical nephrectomy was performed through a midline incision. The left kidney was removed along with intact Gerota fascia, left adrenal gland and lymph nodes alongwith aorta.

An Experience Of Percutaneous Peritoneal Drainage In High-Risk Perforated Peritonitis In General Surgical Ward Of Tertiary Care Hospital Lahore, Pakistan.

BACKGROUND: Although conservative treatment has shown a good reduction in mortality and morbidity the majority of patients still need definitive surgery to get rid of the disease completely. It is of note that immediate laparotomy in high-risk patients who have a prolonged history or have multiple comorbidities or in organ failure is not advisable as it is associated with higher morbidity and mortality, besides improved postoperative intensive care. METHODS: We categorized these high-risk patients based on their comorbidities and then performed percutaneous peritoneal lavage to reduce the septic load from the peritoneal cavity before performing the definite procedure. RESULTS: Out of the high-risk patients who survived after the PPD and underwent definitive surgery, 61% survived (n=8/13) while the rest of these, 38.5% expired (n=5). CONCLUSION: Percutaneous peritoneal drainage initially instituted in high-risk patients to optimize their pre-op condition significantly, improves the outcome and has better results than to operate on such patients straightaway.

A ruptured seventeen weeks' ectopic pregnancy: A case report.

Ectopic pregnancy is a common condition with a prevalence of 2% in all pregnancies. Implantation of the developing blastocyst outside the uterine cavity leads to ectopic pregnancy. About 95% of ectopic pregnancies occur in the different segments of the fallopian tubes. Usually, an ectopic pregnancy grows up to 1.5-3.5 cm and any size greater than this leads to rupture. We present a case of ruptured ectopic pregnancy in which the foetus had a crown-rump length(CRL) of 12 cm was retrieved. To our knowledge, this is the largest foetus recovered from a ruptured ectopic pregnancy at the ampulla of fallopian tube reported in the literature. Timely diagnosis and proper management is the key to reduce morbidity associated with it.

Past, present, and future of surgical simulation and perspective of a developing country: A narrative review.

Healthcare systems around the globe have been revolutionised in the last few decades, resulting in a greater need and demand for surgical education outside the operation theatres. Surgical education through simulations started around 2,500 years ago when they were first used in the planning of unique and innovative surgeries while ensuring the safety of the subjects. Currently, simulations include animal models, cadaveric models, benchtop models and complex robotic models. In a programme involving surgical simulators, four requirements are followed to optimise their effectiveness, including mandatory involvement, skill-based instruction, standardised training plan, and overtraining. We can make a reasonable estimation that the future is technology-based. The speed with which we anticipate the fusion of these virtual reality and robotics-based simulation technology with medical educations and practices largely depends on the affordability and economics of these tools. The current narrative review was planned to highlight the historical aspects of simulations, their role in surgical education, and their importance in the future as an essential adjunct to surgical education.

Comparison of the outcome of mesh hernioplasty under local anaesthesia in patients with age less than 60 years VS more than 60 years in terms of wound complications and urinary retention.

OBJECTIVE: To compare the outcome of mesh hernioplasty performed under local anaesthesia in relatively young and older patients regarding wound complications and urinary retention. METHODS: This comparative study was conducted at Mayo Hospital, Lahore, Pakistan, from 17th Feb 2017 to 17th feb 2018, and comprised patients who underwent mesh hernioplasty. Demographic profile was noted and the patients were divided into <60 and >60 age groups. Surgical method used was Lichtenstein mesh repair under local anaesthesia. Outcome was documented in terms of urinary retention at 8 hours post-operation, wound seroma and haematoma at 24 hours and wound infection after 5 days of surgery. Data was analysed using SPSS 20. RESULTS: Of the 102 patients, there were 51(50%) in each of the two age groups. Among patients <60 years, urinary retention developed in 4(7.8%) compared to 6(11.8%) in the other group. Frequency of the wound complications, including wound haematoma, seroma and wound infection, were seen in 3(5.9%), 2(3.92%) and none respectively in the younger group compared to 2(3.92%), 2(3.92%) and none respectively in patients aged >60 years. CONCLUSIONS: The results in patients aged <60 years and >60 years were comparable in terms of urinary retention and wound complications.

Surgical smoke; an occupational hazard.

Surgical smoke is part of the environment during operative and invasive procedures. Electric diathermy is a very important tool for a surgeon and is used in every surgical treatment nowadays. It assists the surgeon to dissect the tissue or enables securing haemostasis in lesser time and with larger delicacy. But at the same time, it has harmful effects on surgeon as well as patients. Although there is a substantial amount of evidence and guidelines from various authors and societies, yet there are no clear policies and preventive measures towards surgical smoke handling. This article presents potential harmful effects of surgical smoke and aims to build guidelines for the surgical personnel based on current evidence in literature.

Neuroplasticity induced by general anaesthesia: study protocol for a randomised cross-over clinical trial exploring the effects of sevoflurane and propofol on the brain - A 3-T magnetic resonance imaging study of healthy volunteers.

BACKGROUND: Although used extensively worldwide, the effects of general anaesthesia on the human brain remain largely elusive. Moreover, general anaesthesia may contribute to serious conditions or adverse events such as postoperative cognitive dysfunction and delirium. To understand the basic mechanisms of general anaesthesia, this project aims to study and compare possible de novo neuroplastic changes induced by two commonly used types of general anaesthesia, i.e. inhalation anaesthesia by sevoflurane and intravenously administered anaesthesia by propofol. In addition, we wish to to explore possible associations between neuroplastic changes, neuropsychological adverse effects and subjective changes in fatigue and well-being. METHODS: This is a randomised, participant- and assessor-blinded, cross-over clinical trial. Thirty healthy volunteers (male:female ratio 1:1) will be randomised to general anaesthesia by either sevoflurane or propofol. Multimodal magnetic resonance imaging (MRI) of the brain will be performed before and after general anaesthesia and repeated after 1 and 8 days. Each magnetic resonance imaging session will be accompanied by cognitive testing and questionnaires on fatigue and well-being. After a wash-out period of 4 weeks, the volunteers will receive the other type of anaesthetic (sevoflurane or propofol), followed by the same series of tests. Primary outcomes: changes in T1-weighted 3D anatomy and diffusion tensor imaging. SECONDARY OUTCOMES: changes in resting-state functional magnetic resonance imaging, fatigue, well-being, cognitive function, correlations between magnetic resonance imaging findings and the clinical outcomes (questionnaires and cognitive function). Exploratory outcomes: changes in cerebral perfusion and oxygen metabolism, lactate, and response to visual stimuli. DISCUSSION: To the best of our knowledge, this is the most extensive and advanced series of studies with head-to-head comparison of two widely used methods for general anaesthesia. Recruitment was initiated in September 2019. TRIAL REGISTRATION: Approved by the Research Ethics Committee in the Capital Region of Denmark, ref. H-18028925 (6 September 2018). EudraCT and Danish Medicines Agency: 2018-001252-35 (23 March 2018). www.clinicaltrials.gov , ID: NCT04125121 . Retrospectively registered on 10 October 2019.