Right Paraduodenal Hernia: A Rare Cause of Small Bowel Strangulation.

Internal hernias are a rare cause of intestinal obstruction. Among the internal hernias, left paraduodenal hernia is the most typical type followed by the right paraduodenal hernia. It is impossible to make a clinical diagnosis of internal hernia, as there are no specific symptoms or physical signs. A high degree of suspicion is required, and an accurate diagnosis can be made using cross-sectional imaging of the abdomen like a Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) scan. In this case report, we present our experience in managing a patient who had a right paraduodenal hernia with small bowel strangulation. We present this case report to highlight the importance of considering internal hernias like right paraduodenal hernia in the differential diagnosis of intestinal obstruction.

Desire for Information and Preference for Participation in Treatment Decisions in Patients With Cancer Presenting to the Department of General Surgery in a Tertiary Care Hospital in India.

PURPOSE: Providing appropriate information to patients about their illness helps them to cope with the diagnosis. Shared decision making is a key concept in managing patients with cancer. There are no data available about the desire for information and preference for participation in treatment decisions among Indian patients with cancer. The objective of this study was to estimate the proportion of patients who have information needs and to study the patient preference for participation in treatment decisions and the factors associated with them. METHODS: A cross-sectional survey was conducted among patients with cancer older than 18 years. They were interviewed with a questionnaire after signing an informed consent. The association of sex, educational level, residence, diagnosis (type of cancer), Eastern Cooperative Oncology Group performance status, and treatment status with information needs and decision-making preference was analyzed using χ2 test. RESULTS: Approximately 81% of patients said that they had an absolute need to know if the illness was cancer, and > 70% of patients either had an absolute need to know or would like to know about the prognosis, treatment options, and adverse effects. Regarding the decision-making preferences, 97% wanted their treating physicians to make the decision regarding their treatment, and 66% preferred to share decision making with their family. CONCLUSION: The majority of the patients with cancer expressed a need for knowing whether they had cancer. When it comes to treatment decisions, most of them preferred a passive role, and the majority wanted to involve their families in the decision-making process. We recommend that the treating physician should elicit the patient's preference in participating in treatment decisions and their preference about involving their family in making treatment decisions.

Portal Annular Pancreas: Case Report of a Rare Anomaly.

Portal annular pancreas is a rare congenital anomaly in which the portal vein and/or the splenoportal confluence are completely encircled by aberrant pancreatic parenchyma. It is an asymptomatic condition and is usually an incidental finding. It is, however, important to a surgeon because the postoperative pancreatic fistula (POPF) rates following pancreatic resection are higher in patients with this anomaly. A 47-year-old male presented with features of obstructive jaundice. He was diagnosed to have periampullary carcinoma, and pancreatoduodenectomy was planned. During surgery, uncinate process was seen extending posterior to the portal vein and was communicating with the body of pancreas to the left of the portal vein. After transection, there were two pancreatic stumps. The pancreatic duct was identified in the stump anterior to the portal vein. No duct was present in the posterior pancreatic stump. We closed the posterior pancreatic stump with interrupted polypropylene sutures and performed a duct to mucosa pancreaticojejunostomy in the anterior stump. On reviewing the preoperative computed tomography (CT) scan, we were able to identify the pancreatic tissue encasing the portal vein superior to the splenic vein. Circumportal pancreas is classified based on the orientation of pancreatic duct to the portal vein and the relationship of the aberrant pancreatic tissue with the splenoportal confluence. Following pancreatoduodenectomy, the surgeon has to manage two pancreatic stumps, one anterior and the other posterior to the portal vein. No standardised technique has been described for management of the pancreatic stumps. Every surgeon planning pancreatic surgery should be aware of this rare anomaly, and look for the same in the preoperative CT scan so that appropriate plan can be made regarding the type of pancreatic anastomosis.

Effectiveness of continuous wound infusion of local anesthetics after abdominal surgeries.

BACKGROUND: To assess the effectiveness of continuous preperitoneal wound infusion of local anesthetic drug bupivacaine in providing pain relief, reducing opioid consumption, and enhancing postoperative recovery. METHODS: Eligible patients were randomly allocated to two groups (study group: bupivacaine and control group: normal saline). There were 47 patients in each group. The patients received continuous infusion of either 0.25% bupivacaine or 0.9% normal saline at 6 mL/h, for 48 h, based on their group allocation, through a multiholed wound infiltration catheter placed preperitoneally. All patients also received intravenous morphine through patient-controlled analgesia pump. Pain scores at rest and on cough, morphine consumption, and peak expiratory flow rate were assessed at 12, 24, and 48 h postoperatively. The time to first perception of bowel sounds and first passage of flatus was noted. All patients were assessed for postoperative nausea and vomiting and any local or systemic complications. Chi-square test was used to compare categorical variables. The morphine consumption was compared using Student t-test, the visual analogue scale (VAS) scores were compared using repeated-measures analysis of variance. RESULTS: The mean total morphine consumption in the study group was significantly lower than the control group (18.8 ± 2.21 versus 30.8 ± 2.58 mg, P = 0.001). The median VAS scores were significantly lower in the study group than those in the control group both at rest (3 [1-4] versus 4 [2-5], P = 0.04) and during cough (4 [3-6] versus 6 [4-6] P = 0.03), except at 48 h, when the median VAS score at rest was similar (3 [1-4] versus 3 [2-4], P = 0.56). Bowel function returned earlier in study group (67.34 ± 2.61 versus 76.34 ± 5.29 h, P = 0.03). Postoperative nausea and vomiting was less in study group. Respiratory function, assessed by peak expiratory flow rate, was better in the study group (192.55 ± 12.93 versus 165.31 ± 9.32 mL, P = 0.03). The incidence of surgical site infection was similar in both the groups (3/47 versus 5/47, P = 0.06). There was no systemic toxicity of local anesthetic. CONCLUSION: Continuous preperitoneal wound infusion of local anesthetic provides effective analgesia, reduces morphine consumption and its associated side effects, and enhances the postoperative recovery by reducing the incidence of prolonged postoperative ileus.

Laparoscopic-assisted Tranversus Abdominis Plane (TAP) Block Versus Ultrasonography-guided Transversus Abdominis Plane Block in Postlaparoscopic Cholecystectomy Pain Relief: Randomized Controlled Trial.

OBJECTIVES: Transversus abdominis plane (TAP) block for postoperative analgesia in laparoscopic cholecystectomy is usually given under ultrasound guidance. Laparoscopic-assisted TAP block has been suggested as an alternative to ultrasonogram (USG)-guided block as it is less time consuming and does not need extra equipments. This study was done to compare the efficacy of both the techniques. PATIENTS AND METHODS: We conducted a randomized controlled trial between October 2012 and June 2014 involving adult patients with symptomatic gall stone disease. Patients were randomly assigned to laparoscopic or ultrasound-guided TAP block. Both groups were compared for amount of opioid consumption, postoperative pain scores, postoperative nausea and vomiting, bowel movements, peak expiratory flow rate, and time taken for administering the block. RESULTS: We included 60 adult patients in our study. The groups were comparable with respect to demographic characteristics, symptomatology, comorbidities, and intraoperative complications. Amount of opioid consumption and postoperative pain relief were comparable between the 2 groups. The time taken for laparoscopy-assisted block was shorter when compared with the time taken for USG-guided block (P≤0.05). Postoperative nausea and vomiting, bowel movements, and peak expiratory flow rate were comparable between the 2 groups. CONCLUSIONS: Laparoscopy-assisted TAP block is faster and equally efficacious when compared with USG-guided block and has a definite role in centers where ultrasound is not available in operating rooms.