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INTRODUCTION: The portal vein (PV) originates behind the neck of the pancreas, where it is formed classically by the union of the superior mesenteric vein (SMV) and the splenic vein (SV) [1]. It courses upwards towards the liver in the free margin of the lesser omentum, the hepatoduodenal ligament, along with other structures of the portal triad, i.e. proper hepatic artery (PHA) and common bile duct (CBD) anterior to it [1]. The PV is found posterior to the PHA and CBD. The abdominal aorta perfuses abdominal viscera via three ventral branches celiac trunk (CA), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The celiac trunk supplies the derivates of the foregut and is divided into the left gastric artery (LGA), splenic artery (SA), and common hepatic artery (CHA). The CHA, after its origin, is divided into the gastroduodenal artery (GDA) and PHA. After giving off the right gastric artery (RGA), the PHA bifurcates into the right and left hepatic arteries (RHA, LHA) [2]. IMPORTANCE: This case report aims to share the rare variations in the anatomy of hepatoduodenal ligament structures to increase awareness and understanding among fellow surgeons which may reduce complications. CASE PRESENTATION: We are reporting 2 cases in which during pancreaticoduodenectomy Portal vein was present anteriorly in the portal triad and the common hepatic artery was absent; instead, both the right and left hepatic arteries originated directly from the CA posterior to PV. This retro-portal origin of hepatic arteries directly from CA is not reported in Michel's classification of hepatic artery variations [3]. CLINICAL DISCUSSION: The confluence of SMV and SV posterior to the neck of the pancreas forms the PV. The portal vein runs upwards in the free edge of the lesser omentum. Anteriorly it is related to the CBD laterally and CHA anteromedially. Posteriorly it is related to the inferior vena cava (IVC), and PV is separated from IVC by epiploic foramen [4]. The overall reported incidence in the variation of the portal vein anatomy is 25%. Among all the variations seen, the anterior PV with posteriorly bifurcating hepatic artery is present in only 10 % of the cases [5]. There is an increased risk of hepatic artery anatomical variation in the presence of portal vein variants. Michel's classification [6] classified variations in the hepatic artery anatomy. In our cases, the hepatic artery anatomy was standard and was classified as Type 1. The bile duct was normal anatomic (lateral to the PV). Hence our cases are unique in describing isolated variant locations and courses. Detailed information about the anatomy of the portal triad and all possible variants can help reduce the incidence of iatrogenic complications during surgeries like liver transplants and pancreatoduodenectomies. Before the advancement of modern imaging techniques, the variations in the anatomy of the portal triad were clinically irrelevant and considered less significant. However, recent literature supports that variant anatomy of the hepatic portal triad can prolong the time of surgery and increase the risk of iatrogenic complications. The clinical relevance of variable hepatic artery anatomy has immense importance in hepatobiliary surgeries, including liver transplants where the viability of the graft depends on adequate arterial perfusion. In addition to that, in pancreatoduodenectomies, aberrant arterial anatomy with a reteroportal course is associated with an increased number of reconstructions [7] and bilio-enteric anastomosis disruptions since the CBD derives its blood supply from the hepatic arteries. Therefore, the imaging must be carefully interpreted with radiologists' help before surgical planning. As surgeons preoperative imaging is usually seen for the abnormal origin of hepatic arteries and vascular involvement in case of malignancies. "Eyes don't see what mind doesn't know", the anterior portal vein is a rare entity and should be considered while reviewing preoperative imaging for operative planning. In our cases, EUS and CT scans, both were done but we determined resectability on scans and abnormal origin (replaced or accessory arteries) only. Above mentioned findings were noted during surgery but now in every preoperative scan, we try to determine the presence of all possible variations including the reported ones. CONCLUSION: Detailed knowledge about the anatomy of the portal triad and all possible variants can help reduce the incidence of iatrogenic complications during surgeries like liver transplants and pancreatoduodenectomies. It also reduces the time of surgery. A careful review of all possible variations in preoperative scans with appropriate knowledge all anatomical variations helps avoid unpleasant events and hence, reduce morbidity and mortality.
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Background Anal fistula, or fistula-in-ano, is a chronic abnormal communication between the epithelialized surface of the anal canal and the perianal skin. Video-assisted anal fistula treatment (VAAFT) is a novel, minimally invasive, and sphincter-saving alternative to traditional seton use. This study aimed to determine the short-term and long-term outcomes of VAAFT compared with seton treatment. Material and methods This randomized control trial was conducted at the Department of Surgery, Services Hospital, Lahore, from August 2014 to July 2020. Patients were randomly assigned to either the VAAFT group or the seton group, and postoperative outcomes were assessed for up to three years. Results The study included 80 patients (64 men and 16 women) with a mean age of 39.1 ± 11.2 years. The most common type of fistula was a transsphincteric fistula (n=36, 45%). The mean duration of surgery was significantly longer in the VAAFT group (78.6 minutes) compared with the seton group (36.97 minutes; p=0.000). The mean pain score was significantly higher in the VAAFT group (4.22) compared to the seton group (2.82, p=0.000). The mean time to return to work was shorter in the VAAFT group (7.4 days) than in the seton group (9.2 days, p=0.000). The mean healing time was significantly shorter for patients treated with VAAFT (5.75 weeks) than for those treated with a seton (9.7 weeks; p=0.000). Fistula recurrence after one, two, or three years was not significantly different between groups, and neither group had incidences of anal incontinence. Conclusions VAAFT is associated with earlier healing time and earlier return to work than the traditional seton technique, with no significant difference in fistula recurrence. VAAFT is minimally invasive and, when used in patients where indicated, allows for a prompter return to routine life for the patients, which is an optimal outcome for both patients and physicians.
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Background Nonspecific abdominal pain (NSAP) is a pain for which no immediate cause is evident on acute admission and does not necessitate emergency surgical intervention. NSAP is a frequent reason for presentation in the emergency department (ED). Laparoscopy is a well-established technique that allows a surgeon to visualize the abdominal cavity after insufflation through a few small incision ports. Despite the increasing availability of laparoscopic investigation, the availability of a laparoscope in the ED settings in Pakistan is low due to the expense and maintenance needs of the system. Objective This study aimed to evaluate the role of laparoscopy in diagnosing the cause of acute NSAP and its role in treating the pathology of disease in patients presenting to the emergency department (ED) of Services Hospital, which is a government sector hospital in Lahore, Pakistan. Materials and methods This study was conducted in Services Hospital Lahore, Pakistan, from January 1, 2016 to December 31, 2019. The study included patients aged 12 to 70 years of either sex who presented to the ED with abdominal pain for whom no diagnosis could be achieved on clinical assessment, laboratory findings, and radiological findings (x-ray abdomen, ultrasonography, and computed tomography scan). All study participants underwent diagnostic laparoscopy under general anesthesia. Patients were monitored weekly via follow-up postoperatively for the first month and then monthly for 12 months. All study data were recorded on a predesigned proforma. The data were analyzed using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Results A total of 122 patients diagnosed with acute NSAP were enrolled in our study (mean age, 46.4 ± 20.3 years). The study population consisted of 52 male patients (42.6%) and 70 female patients (57.4%). Our study participants had a mean body mass index of 24.2 ± 3.3 kg/m2. The most common ED presentation was lower abdominal pain. One hundred sixteen patients (95.1%) had positive findings on laparoscopy, while six patients (4.9%) had no identified pathology on laparoscopy. The most frequent pathology was appendicular in origin, followed by pelvic inflammatory disease. Surgical management of patients through laparoscopy was performed in 97 patients (79.5%). Conversion to laparotomy was done in 12 patients (9.8%). Definite diagnosis was established in 118 patients (96.7%). Port site infection occurred in four patients (3.3%), chest infection in five patients (4.1%), deep venous thrombosis in one patient (0.8%), and anastomotic leakage in one (0.8%) patient. Four patients (3.3%) developed recurrence of symptoms. Conclusions This study explored the role of laparoscopy in diagnosing and treating patients presenting to the ED with acute NSAP. According to our results, laparoscopy is a safe and effective method for diagnosing and treating acute NSAP with low postoperative morbidity and potentially decreased risk of postoperative complications. Physicians should consider laparoscopy as a first-line invasive investigation for patients presenting with undiagnosed acute abdominal pain.
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OBJECTIVE: To evaluate the effect of COVID-19 on the working of a tertiary care hospital. STUDY DESIGN: Audit study. PLACE AND DURATION OF STUDY: Services Hospital, Lahore from 1st March to 30th June 2020. METHODOLOGY: We calculated and compared various parameters of hospital working. Two time periods were selected. The study period was defined as the time after first confirmed case of COVID-19 in Pakistan. The control period was defined as one year prior to the first case being reported, taken from 1st March 2019 to 29th February, 2020. The parameters we studied included were number of number of hospital admissions, emergency patients, OPD patients, major surgeries, total surgeries, radiological investigations done, laboratory investigations done, births and mortalities. All parameters were calculated by taking monthly average during each time period and then compared. RESULTS: A decrease in almost all parameters was seen when the cases of the two time periods were compared. There was a decrease in the average hospital admission by 51%, while the patients seen in OPD fell by almost 60%. A slight decrease of 25% was seen in the cases presenting to the emergency. The most marked decrease was in the elective surgeries, which was 66% closely followed by average monthly mortality which decreased by 64%. Average monthly minor surgeries and births were decreased by 33% and 35%, respectively. CONCLUSION: There had been a decrease in the number of patients presenting to the hospital across the board with the most marked increase being in elective surgeries. Key Words: COVID-19, Hospital working, Patient load, Elective surgery.
