Comparison of Absorbable versus Non Absorbable Tackers for Fixation of Mesh in Laparoscopic Midline Anterior Abdominal Wall Hernia Repair: A Randomised Clinical Study

Introduction: Tackers are divided in two broad categories namely, absorbable and non absorbable. Absorbable tackers are believed to achieve sufficient tensile strength compared to conventional non absorbable tackers. It is a matter of debate that which type of tacker has an upper hand over the other especially in terms of postoperative pain and recurrences even after few years of clinical experience with these tackers and available clinical studies. Aim: To compare various aspects of absorbable versus non absorbable tackers for fixation of mesh in Laparoscopic Midline Anterior Abdominal Wall Hernia Repair for short period of follow-up. Materials and Methods: In this prospective randomised clinical study from November 2016 till March 2018 at ABVIMS and Dr. RML Hospital, India. Eighty patients of age ≥18 years with midline anterior abdominal wall hernia were included and randomised into two groups (40 patients each). Group 1: Absorbable Tackers; and Group 2: Non Absorbable Tackers. Outcomes evaluated were postoperative pain, seroma formation, paralytic ileus, early recurrence (3 months follow-up) and duration of hospital stay.The data acquired was analysed using Statistical Package for Social Sciences (SPSS) version 22.0. Comparison of ordinal paired data was done using Wilcoxon signed rank sum test. The nominal categorical data was compared using chi-squared or Fisher’sexact test as appropriate. A p-value of <0.05 was considered statistically significant. Results: Out of 80 patients included in this study with a range of 21 to 60 years, the median age was 30 years. There was no statistically significant association noted in terms of postoperative pain (p-value >0.05), seroma formation (p-value=1), paralytic ileus (p-value >0.05), length of hospital stay (p-value=0.801) and early recurrence (3 months). Conclusion: This study has shown that both non absorbable and absorbable tackers are associated with minimal postoperative complications and have similar postoperative morbidity. Both absorbable and non absorbable tackers are comparable for fixation of mesh in laparoscopic midline anterior abdominal wall hernia with respect to the above mentioned outcomes.

A Prospective Randomised Controlled Study Comparing Ultrasonic Dissector with Electrocautery for Axillary Dissection in Patients of Carcinoma Breast

Background

Axillary dissection is one of the important components of modified radical mastectomy (MRM). The present study was conducted to compare surgical outcomes by using monopolar electrocautery and ultrasonic dissector for axillary dissection in MRM.

Methods

A parallel randomised controlled single blinded study was conducted with a sample size of 70 patients who were randomised into two groups. One group underwent MRM using ultrasonic dissector (Group A) and the other one using electrocautery (Group B). Intra- and post-operative outcomes were compared.

Results

Group A had an average operating time of 30.86 min, which was statistically less than that of Group B. The mean mop count and the daily drain output in Group A were less as compared to Group B and the differences were statistically significant. Drain was removed early in Group A as compared to Group B. However, post-operative pain scores and seroma formation were not statistically significant among the two groups.

Conclusion

Ultrasonic dissector group had significantly lesser intra-operative bleeding, operating time and post-operative drain output when compared to electrocautery group. However, the two groups had no significant difference in post-operative pain scores and seroma formation.

Giant Malignant Phyllodes Tumour of Breast- A Clinical Dilemma and Surgical Challenge

Phyllodes tumour is an uncommon tumour of the breast. It is fibroepithelial in origin and mostly benign. Giant phyllodes tumours are described as tumours with size more than 10 cm and are extremely rare. Differentiating malignant and benign tumours pathologically is difficult and needs clinical judgement and high index of suspicion. A 50-year-old female presented with complaint of swelling in the left breast. On further evaluation, it was diagnosed as phyllodes tumour on biopsy. She underwent left mastectomy and excision of pectoralis major muscle due to clinical and radiological suspicion of malignancy. Postoperative histopathology report revealed malignant phyllodes tumour. Cases of giant phyllodes tumour should undergo adequate imaging and image guided biopsy with high index for suspicion for malignancy. They should be operated as per the principles of oncosurgery as there is a high probability of such huge tumours harboring malignancy.

Evaluation of Risk Factors for Septic Complications after Laparotomy for Abdominal Trauma: A Longitudinal Cohort Study

Introduction: Septic complications are the most common cause of death in trauma patients who survive beyond 48 hours. Early diagnosis and treatment of infectious complications is essential to prevent life-threatening complications like Systemic Inflammatory Response Syndrome (SIRS) and Multi-Organ Dysfunction Syndrome (MODS). Aim: To study the various risk factors for septic abdominal complications following laparotomy for trauma. Materials and Methods: A prospective longitudinal cohort single-center study was conducted from November 2016 to March 2018. Sixty patients above the age of 12 years, who underwent laparotomy for abdominal trauma in the Surgical Department of our hospital, were included in the study. Various patient variables were compared with postoperative septic abdominal complications like wound infection, wound dehiscence, anastomotic leak and intra-abdominal abscess. Data was analysed using Statistical Package for Social Sciences (SPSS) version 21.0. Results: In the total 60 patients (35.60±16.54), significant association was seen between wound infection and dehiscence with the time interval between trauma and surgery (p<0.001), lesser Revised Trauma Score (RTS) (p<0.001) and greater Injur Severity Score (ISS) (p<0.001). A significant association of all septic complications was seen with the need for Intensive Care Unit (ICU) stay (p<0.001) and the presence of associated injuries (p<0.001). Variables such as age, gender, co morbidities, Body Mass Index (BMI), pre-hospital care received, intraoperative findings and duration of ICU stay had no association with outcomes (p>0.05). Conclusion: In trauma patients, factors like low RTS score, high ISS score, need for ICU stay and the presence of associated injuries may help the surgeons to decide in which patients to go for techniques like delayed closure of the wound, stoma instead of bowel anastomosis, etc., which may help to reduce postoperative septic complications.

Surgical Triage of Breast Disorders During the COVID-19 Pandemic: An Indian Perspective

Breast complaints are a very common cause of healthcare visits in the female population. They range in severity from benign to malignant, and treatment options vary from simple observation to mastectomy. As healthcare facilities are overburdened with coronavirus disease 2019 (COVID-19) patients, properly triaging patients diagnosed with breast disorders is necessary for the optimal use of limited resources in developing countries. We are proposing a concise triage system for timely intervention among patients with breast disorders during the havoc of the COVID-19 pandemic.

Comparative study between P- POSSUM and Apache II scores in predicting outcomes of perforation peritonitis: Prospective observational cohort study

BACKGROUND

Scoring systems are needed to prognosticate, compare and audit surgical procedures. Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and morbidity (P-POSSUM) and Acute Physiological and Chronic Health Evaluation II (APACHE II) are well known and validated scores to predict surgical outcomes. The objective of this study was to compare P-POSSUM and APACHE II scores in predicting morbidity and mortality of patients who underwent emergency surgery for perforation peritonitis.

MATERIALS AND METHODS

A prospective single-center cohort study was conducted with a sample size of 56 patients of perforation peritonitis from November 2018 to March 2020. All patients were followed up prospectively for a period of 30 days to monitor the primary outcome variable mortality and secondary outcome variables such as wound infection, wound dehiscence, anastomotic leak, respiratory complications, Intensive Care Unit (ICU) stay and hospital stay.

RESULTS

Mean age of patients was 37.1 years and 67.86% were males. Ileum was the most common site of perforation followed by the stomach. The most common post-operative complication was wound infection (71.43%) followed by respiratory complications (64.29%) and wound dehiscence (35.71%). ICU stay was required for a majority of patients (74.42%). The mean hospital stay was 8.93 days and the mortality rate was 23.21% in this study. P-POSSUM and APACHE II scores had a good association with mortality, post-operative wound dehiscence, respiratory complications, ICU stay and hospital stay. However, there was no statistical difference between the two scores in predicting the above outcomes. Post-operative wound infection and anastomotic leak had no association with P-POSSUM or APACHE II scores.

CONCLUSION

As the APACHE II score is based only on preoperative parameters and is easier to calculate we recommend its use for patients of perforation peritonitis over the P-POSSUM score as both have similar predictability.

Isolated Epitrochlear Filarial Lymphadenopathy: Cytomorphological Diagnosis of an Unusual Presentation

Filariasis is a major public health problem in tropical countries like India. Despite the large number of people at risk, detection of eggs with or without larva (microfilaria) on fine-needle aspiration cytology is very unusual, especially in an uncommon site or incidentally detected in clinically unsuspected cases of filariasis with the absence of microfilariae in the peripheral blood. A 19-year-old male presented with swelling over medial aspect of left arm (just above the elbow), with no other specific signs and symptoms. Fine needle aspiration cytology revealed an adult gravid female filarial worm in a background of reactive lymphoid cells and lymphohistiocytic clusters. We report a case with elaborate fine needle aspiration cytology findings of filarial worm infestation with unusual presentation of isolated epitrochlear lymph node involvement in a clinically unsuspected case and recommend clinicians and pathologists to consider a high index of suspicion for such infections at uncommon sites especially in endemic territories, as early diagnosis and treatment prevent the more severe manifestations of disease.

Primary cutaneous non-Hodgkin's lymphoma, clinically mimicking a soft tissue sarcoma

Primary cutaneous B-cell lymphomas (PCBCL) are a heterogeneous group of neoplasms with distinct biology and clinical course when compared to their nodal counterparts. They usually present as violaceous, erythematous plaques, and nonulcerated nodules, which are confined to skin at the time of presentation. We present an unusual case of primary cutaneous diffuse large B-cell lymphoma, clinically mimicking a sarcoma. This case highlights the uncommon aggressive behavior and ulcerated type of nodular lesions seen in PCBCL and also revisits the cytomorphological findings of the same.

Transmural Migration of Gossypiboma: a Rare Cause of Acute Abdomen

Gossypiboma is the retained foreign body which is generally a cotton sponge/gauze after surgery. Incidence of gossypiboma is around one in 3000 to 5000 surgeries. This low incidence is mainly attributed to a low case reporting due to an associated medicolegal aspect. We are reporting a case of a 38 years old male, who presented with signs and symptoms of peritonitis. The patient had a history of open cholecystectomy 2 years back. A working diagnosis of perforation peritonitis was made, and the patient underwent exploratory laparotomy. Intraoperatively, a surgical sponge was present inside the ileal lumen causing intestinal obstruction with dense adhesion of bowel loops proximal to the site of obstruction with multiple ileal perforations. Even though the incidence of gossypiboma is very low, it should always be kept in mind as a cause of chronic abdominal pain and abdominal discomfort in a patient with previous abdominal surgery.