A randomised controlled trial of excision versus invagination in the management of indirect inguinal hernial sac.

INTRODUCTION: Lichtenstein tension-free mesh hernioplasty of primary inguinal hernia is currently considered as the preferred method for the plastic reconstruction of inguinal hernia by the majority of surgeons. Several studies have examined the best way to manage the hernial sac in this surgery, but no consensus has been reached. This study was designed to compare the effects of excision of sac and invagination of sac on post-operative outcomes. METHODS AND METHODS: This prospective randomised study included a total of 70 patients with primary unilateral uncomplicated indirect inguinal hernia. Group A (35 patients) underwent high dissection and invagination of the hernial sac and group B (35 patients) underwent high ligation and excision of the hernial sac. The repair of the posterior wall of the inguinal canal was done according to Lichtenstein tension-free technique. The primary outcome of this study was postoperative pain and secondary outcomes were wound infection, chronic sepsis, sinus formation, persistent pain, testicular atrophy and recurrence during the one-year follow-up period. RESULTS: There was a significant difference (P < 0.01) in pain experienced by the patients in the immediate post-operative period between the two groups; group A experienced less postoperative pain than group B. There was no significant difference in incidence of infection between the groups. CONCLUSIONS: Invagination of the sac results in less postoperative pain compared with excision, with no significant difference in other postoperative outcomes.

Anterior Roux-en-Y Pancreatico-jejunostomy for Pancreatic Trauma.

Isolated pancreatic laceration is a rare injury. The typical mechanism by which it occurs is overstretching of the pancreas across the vertebral column during blunt abdominal trauma. The management depends on the location and extent of the injury. Disruption of the pancreatic duct usually requires operative treatment. Operative options for pancreatic laceration at the neck include distal pancreatectomy or suturing of the cephalic remnant and Roux-en-Y pancreatico-jejunostomy on the left remnant. We are reporting two cases of isolated pancreatic injury with disruption of the pancreatic duct but preserved posterior surface of the pancreas. These patients were managed by performing anterior Roux-en-Y pancreatico-jejunostomy at the lacerated area. Both the patients had successful outcome with removal of drains by 6(th) postoperative day. Anterior Roux-en-Y pancreatico-jejunostomy in this particular scenario is easy, less time consuming, and has the advantage of preserving the pancreas and the spleen.

Bile duct injuries during open and laparoscopic cholecystectomy: management and outcome.

BACKGROUND: The widespread application of laparoscopic cholecystectomy has led to a rise in the numbers of major bile duct injuries (BDI). Perioperative management of these injuries is complex and challenging. There are few published reports locally regarding the perioperative management of BDI. Purpose of this review was to analyze our experience in diagnosis, management and prevention of BDI. METHODS: This study was conducted in department of surgery at B. P. Koirala Institute of Health Sciences. From January 2001 to September 2010, a observational study of all patients with a BDI following cholecystectomy was maintained. Patients' charts were retrospectively reviewed to analyze incidence, type of injury, presentation, and perioperative management of BDI. RESULTS: A total of 92 patients had BDI which occurred during cholecystectomy, were analysed retrospectively. There were 60/92 (65.5%) patients with BDI resulting from the wrong identification of the anatomy of the Calot's triangle during cholecystectomy. Abdominal ultrasonography was diagnostic for BDI in 71/90 (78.8%). Magnetic resonance cholangiography could reveal the site of injury, the length of injured bile duct and variation of bile duct tree with a diagnostic rate 22/23 (95.6%). The most common injury was Strasberg's E2 in 65/92 (70.7%). A transection or stricture of the bile duct was repaired by hepaticojejunostomy (83 cases in this series). Seventy-five (81.5%) patients were followed up. The mean follow-up time was 2.6 years (range 0.16-6). Good results were achieved in 62/75 (82.6%) of the patients. CONCLUSIONS: The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

Primary renal fibrosarcoma: a rare case report and review of literature.

Primary renal fibrosarcoma is a rare tumor. We describe a case of primary renal fibrosarcoma in a 54-year-old male who presented with abdominal lump and intermittent hematuria.

Giant cavernous haemangioma of the spleen presenting as massive splenomegaly and treated by partial splenectomy.

Cavernous haemangioma is a rare disorder of the spleen with fewer than 100 cases reported. Only rarely do they attain large sizes. A 36-year-old woman presented with a six-month history of pain in the left hypochondrium and a massive splenomegaly. Ultrasonography, Doppler studies, and computed tomography could not distinguish between a haemangioma and a secondary deposit. Magnetic resonance imaging showed characteristic features of splenic haemangioma with central fibrosis, thrombosis and haemorrhage. Partial splenectomy was done. Intraoperative imprint cytology was negative for malignant cells. Histopathology showed cavernous haemangioma with areas of infarction necrosis. It is extremely rare to have such a massive solitary splenic haemangioma presenting as a giant splenomegaly. Preoperative investigations are often inconclusive and may not distinguish between haemangioma and metastases. Magnetic resonance imaging is the most reliable imaging method. Haemangiomas are treated only when they are symptomatic or very large with an increased risk of haemorrhage. Partial splenectomy is the treatment of choice.

Clinicopathological profile of an unusual case of chondroid syringoma: a case report.

Chondroid syringoma or mixed tumor of the skin is an uncommon tumor that typically presents as small, solitary, slow growing, firm, subcutaneous or intracutaneous nodule. It presents commonly in the head and neck region. This is a case report of 45-year-old female who presented with multiple masses in the flank, chest wall, arm, -thigh and neck measuring 10, 6, 3.5, 2 and 1 cm in maximum dimension. FNAC and excision biopsy revealed benign chondroid syringoma. This is a rare case of chondroid syringoma exhibiting large size, multiplicity and unusual locations in flank, chest wall and thigh.

Preoperative ultrasound-guided fine-needle aspiration cytology for axillary staging in breast carcinoma.

Axillary lymph node (ALN) status is considered to be the single most important prognostic indicator in patients with breast cancer. It can be assessed by various radiological, pathological and surgical techniques, the most accurate being histological examination of lymph nodes after axillary lymph node dissection (ALND). This prospective study was conducted to assess the feasibility and diagnostic accuracy of preoperative ultrasound (US) and ultrasound-guided fine-needle aspiration cytology (USG-FNAC) of ALN in patients with breast cancer. Thirty patients with FNAC-proven breast cancer, planned for definitive surgery with axillary clearance, were included in this study. Ultrasonographic evaluation of the axillae of these patients was conducted for alterations in size, shape, contour and cortical morphology of lymph nodes that could reflect presence of underlying metastases. Ultrasound-guided fine-needle aspiration cytology of the ALN was done in 24 of these patients. These findings were evaluated, with the ALN status determined by histological examination after ALND. Out of the 30 patients, eight had T(1), 16 had T(2), five had T(3), and one had T(4) lesions. Ultrasound evaluation of the ALN had a sensitivity of 86.3%, a specificity of 41.6%, a positive predictive value of 79%, a negative predictive value of 50% and a diagnostic accuracy of 73.3%. Sensitivity of USG-FNAC was 78.95%, specificity was 100%, positive predictive value was 100%, negative predictive value was 55.56% and diagnostic accuracy was 83.33%. Our study concludes that preoperative USG-FNAC of ALN is a simple, minimally invasive, easily available and reliable technique for the initial determination of ALN status in patients with breast cancer. Those who are USG-FNAC positive can be directed towards ALND straight away, and only those who are USG-FNAC negative should be considered for sentinel lymph node biopsy. This will save considerable operating time, especially where facilities for sentinel lymph node biopsy (costly dye, gamma camera, nuclear medicine facilities) are restricted or not available.

Cytological diagnosis of cholangiocarcinoma with rib metastasis in a young female--a case report.

Intrahepatic cholangiocarcinomas are second most common primary tumors of the liver. They are usually seen in 6th to 7th decades of life and at an advanced stage leading to poor prognosis. Their occurrence in the young age group is rare. Histopathological features of this tumor are well documented but literature regarding cytomorphological features on FNA is limited. We describe the cytological features of this tumor in a young woman presenting primarily with a rib metastasis. FNA smears from hard lump in the right chest wall and liver mass showed small round tumor cells arranged in the form of sheets, clusters and occasional tubules. The cells showed mild pleomorphism and bland nuclear morphology. Intimately admixed with tumor cells were spindle shaped fibroblastic cells. Serum alpha-fetoprotein level was within normal limit. Special stain for bile and immunocytochemical staining for NSE, chromogranin and CALLA were all negative. Cholangiocarcinoma was diagnosed based on cytological findings and special stains and this diagnosis was histologically confirmed on biopsy.

Metaplastic carcinomas of the breast (light microscopic and immunohistochemical features).

Metaplastic carcinomas of the breast are uncommon tumors that contain other cellular components besides the glandular component. These carcinomas have a poor prognosis as compared to breast carcinomas without metaplasia. It is, therefore, important to recognise the metaplastic components. The study was conducted over a three year period. All breast carcinomas received during this period in the department of pathology were analysed for areas of metaplastic carcinomas. The light microscopic features, special stains as well as the immunohistochemical markers of metaplastic carcinomas are highlighted in this paper.

Leiomyosarcoma arising from tunica vaginalis testis: a case report.

Benign and malignant soft tissue tumors of the paratesticular region i.e. those arising from the testicular tunics, epididymis and spermatic cord are uncommon. Of these, leiomyosarcoma arising from the tunica vaginalis is extremely rare. On extensive computerised search, a single case has been reported till date in the literature. We hereby report one such case because of its rarity.

Polycystic disease: a rare indication for combined liver and kidney transplantation.

We report on a 52-year-old woman who presented with polycystic disease. Both of her kidneys had been removed and she had undergone one failed kidney transplantation. She had severe symptoms from the polycystic liver. The diseased liver and kidney were both treated successfully by performing a combined liver and kidney transplantation.

Efficacy of hepatobiliary scintigraphy in demonstrating cholangio-colic fistulae. Is formation of internal biliary fistula related to external leak closure?

The authors present four cases of internal biliary fistulae (IBF) identified on hepatobiliary scintigraphy. All of the cases share common history of external biliary leak closure. Scintigraphy in all four cases showed a similar pattern of direct visualization of transverse colon without any significant small bowel activity. This suggests an increased frequency of IBF formation in cases with external fistulous tract closure. Retrospectively, it appears that spontaneous closure of external leak may be pathological consequence of formation of IBF involving hepatic flexure.

The Indian experience with hypertrophic pyloric stenosis.

A study of 58 consecutive Indian infants operated for congenital hypertrophic pyloric stenosis revealed an accentuated male predominance in the incidence of the disease and far less preoperative hemetemesis as compared to that in their Western counterparts. 'Pyloric tumor' was palpable in 89% of cases. Only 34.5% of these infants were first born. Postoperative vomiting occurred in 13.8% of patients and wound sepsis was not encountered. Air contrast radiography confirmed the diagnosis in clinically doubtful cases.

Acute intussusception: referral in relation to presentation and aetiology.

A study of 42 consecutive children with acute intussusception was undertaken. The emphasis was on the time taken for surgical referral in relation to the presenting symptom. Operative findings and outcome revealed late referral (greater than 72 h) in cases presenting with diarrhoea and bleeding per rectum. A higher incidence of gangrenous gut and irreducibility of intussusception was found in the ileoileal variety of intussusception. Some interesting facts about the aetiology have also been noted. Rupture of intussuscipiens was also encountered.