New Indian Journal of Surgery

Written Consent forms are lengthy and they tend to obscure important clinical details, and are written in a way to serve the interests and safeguard institutions and sponsors. The main challenge of writing an informed consent is to include all the details of the procedure and put it in such a way that the patient understands it thoroughly. In this article, we describe the use of audio-visual recordings to overcome the above said disadvantages and the challenges faced during the recording and solutions to the same.

Keywords: Consent; Video-consent; Adequacy of consent.

Difficult cavity wounds have undermined and tunneling morphology of their edges or a location which is difficult to access. Collagen dressing is an interactive dressing designed for wound management. Collagen particles are designed for cavity wound management. Filling the difficult cavity wound with collagen particles has some practical problems. To overcome these problems we have used an innovative method of filling collagen particles in difficult cavity wound. Innovative method of filling collagen particles is simple and effective solution of the problems faced in managing difficult cavity wounds.

Keywords: Difficult cavity wounds; Collagen particles; Wound bed preparation.

Intramuscular myxomas are rare benign soft tissue tumors of mesenchymal origin. They show areas of increased cellularity and vascularity that can lead to a mistaken diagnosis of sarcoma, especially myxofibrosarcoma, low-grade fibromyxoid sarcoma, and myxoid liposarcoma. FNAC of such a tumor is inconclusive as it may show just myxoid stroma or hypercellularity depending on whether the hypercellular portion or myxoid portion is sampled which further impedes diagnosis. Hence, total surgical exision followed by histopathological examination of the tumor is the gold standard. Their recognition is important to avoid an erroneous diagnosis of sarcoma.2 Surgery is always curative and recurrence is rare. This is a case report of 55 years old male presenting with such a tumor.

Keywords: Intramuscular myxoma; Myxomas.

Cranioplasty is done commonly following decompressing craniotomy following neurological trauma and other indications. Although a relatively simple procedure, cranioplasty is associated with a very high rate of complications. Among the most common complications is postoperative seizures. Seizures in immediate preoperative period can lead to trauma to the surgical site and lead to hematoma and risk of reexploration. We have devised a simple protective scalp protecting cap to be worn by the patient in the immediate preoperative period to protect the head from trauma. The cap is easy to fabricate, light and comfortable for the patient. We would like to share the same.

Keywords: Scalp; Protective; Cap; Cranioplasty

Abdominal cocoon also known as “Encapsulating peritoneal sclerosis” (EPS) is a rare cause of intestinal obstruction presenting as a surgical emergency. It is described as thick, white, fibrous “cocoon-like” membrane, formed by chronic intra-abdominal fibro-inflammatory process that results in formation of fibrous tissue sheets, which formed a “second abdominal cavity” containing variable amounts of bowel segments that cover, fix and ultimately constrict the gut compromising its motility. We present a case of acute intestinal obstruction due to primary idiopathic Sclerosing Encapsulating Peritonitis (SEP). The diagnosis was established and early laparotomy was done with surgical release of the entrapped bowel and complete removal of the fibrotic membrane.

Keywords: Abdominal cocoon; Encapsulating peritoneal sclerosis; Sclerosing encapsulating peritonitis; Intestinal obstruction.

Background: Pediatric Non-traumatic Surgical Emergencies (PNTSE) are a major part of pediatric surgical emergencies associated with varied spectrum and high morbidity. Aims: The aim of this study is to understand the clinical spectrum and epidemiology of PNTSE. Methods: The children in the age group of 1 month to 14 years admitted in Pediatric Surgery Department in an emergency were studied retrospectively from Jan 2014 to Dec 2018. Children with h/o trauma were excluded. Results: Total of 740 patients with PNTSE was admitted. The males were 65%. The females were 35%. Most of the patients (90%) presented within 48 hours of the appearance of symptoms. The vomiting and pain in the abdomen were the most common symptoms followed by fever, abdominal distension, blood in stools and diarrhea. The ultrasonography was the most common radiological investigation (89.5%) used followed by X-rays (11.4%) and Computed tomography scan (7%). Appendicitis was the most common diagnosis (30.8%) and Intestinal obstruction was the second most common diagnosis (20.3%) followed by abscess/cellulitis (7.8%). The conservative management was done in 24.6% cases. Rest of the cases required surgical intervention. The complications developed in 9.7%. There was a significant difference (p ≤ 0.0001) in the occurrence of complications between patients getting admitted within 48 hours and after 48 hours of onset of symptoms as well as between the conservatively managed patients and the surgically managed cases. There were four mortalities. Average hospital stay was 5.19 days. Conclusions: The PNTSE have a varied spectrum of presentation. The early diagnosis and appropriate intervention within 48 hours can decrease the complications. The patients undergoing surgical management have higher complications compared to those with conservative management. The PNTSE have a better outcome with the team approach involving Pediatric surgeon, Pediatric Anesthetist, Pediatric Intensivist and Radiologist.

Keywords: Pediatric non-traumatic surgical emergencies; Pediatric surgical emergency management.

Introduction: Pancreatitis is inflammatory process in which the pancreatic enzymes digest the gland. The pancreas sometimes heals without any impairment of function or any morphologic changes. This process is known as acute pancreatitis. Dealing with the clinical course of Acute Pancreatitis (AP) and management of acute pancreatitis are complicated by limited understanding of pathogenesis and multi-causality of the disease, uncertainties to predict outcome and a few effective treatment modalities. Thus, this study was undertaken at Dept of Gen Surgery, at DY Patil Medical College and Research Centre, Pimpri, Pune to study the the various etiological factors of causing pancreatitis, mode of onset of disease and to study the clinical presentations of pancreatitis and its management. Methodology: Total 50 patients were included in this study since 2017 to 2019, who got admitted in Dept of Gen Surgery at Dypmch, Pimpri, Pune. Cases were studied according to clinical history and physical findings and investigations. Treatment was given according to the severity of pancreatitis with either conservative or surgical method or interventional radiological prodcedure. Patients were followed up for 6 months to look for any recurrence or complications. Results: Total 72% pts were males, 28% were females in the study group. Alcohol was most common etiological factor 31 (62%) for pancreatitis followed by history of obstructive jaundice in 8 (16%). Abdominal pain (100%) and vomiting (74%) were the most common modes of presentation. Ascitis (17) and acute pseudocysts (10) were common complications. As severity of pancreatitis increases blood sugar level increases due to reduced secretion of insulin from pancreas after inflammation and it was statistically highly significant (Spearman’s rho = 0.638 p = 0.00), similarly severity of pancreatitis shows positive correlation with enzyme lipase due to release of lipase enzyme form pancreas after inflammation (Spearman’s rho = 0.557 p = 0.00). 42 (84%) subjects were managed conservatively only with IV fluids, antibiotic, antisecretory drugs, (somatostatin analog) 3 (6%) with CT guided percutaneous drainage while remaining treated as per etiology of pancreatitis along with medical management. Conclusion: Acute pancreatitis was a common cause of acute abdomen and alcohol and gallstones were most common causes. Once the final diagnosis is made, along with clinical knowledge one should simultaneously concentrate on laboratory or imaging investigation to find out the underlying etiology and managing the condition by predicting its complications. The management of acute pancreatitis is mostly supportive. Early enteral nutrition in a course of disease modifies the inflammatory response and improves patient outcome by reducing infective complications of the disease. Antibiotics should be used cautiously as prophylactic antibiotics might not be benificial in preventing infective complications of acute pancreatitis.

Keywords: Pancreatitis; Enzymes; Acute Pancreatitis (AP).

Aims: Gynecomastia is a common breast condition in males occurring due to varied etiological factors. Evaluation of such patients includes detailed medical history, clinical examination, specific blood tests, imaging and tissue sampling. Endocrinological workup forms the main part of investigation, the role of which is lacking in current literature. The objective of this study is to assess the productivity of such evaluation in current practice. Methods: A five year retrospective study was conducted of patients presenting to department of Plastic Surgery at Tertiary care hospital were review with respect to Endocrinological results, treatment and cost. Results: The mean age at presentation being 21.48 years (Range 15–30 years) with mean history of complaints since 1.84 (SD 0.84) years at presentation. 46.15% (n = 24) patients were overweight and 36.53% (n = 19) patients being obese. Unilateral case were 14 % (n = 7) and bilateral being 86% (n = 42). The median body mass index is 28.47. Four patients had positive family history with 7 of those patients having unilateral presentation. 1 patient was diagnosed with secondary gynecomastia due to anabolic steroids. Conclusions: Gynecomastia in young is more commonly idiopathic in nature and Endocrinology evaluation should be judiciously used when indicated by proper history taking and thorough clinical examination.

Keywords: Gynecomastia; Endocrinology; Evaluation.

Breast abscess is one of the common general surgical condition often affecting lactating women, it is very widely treated by incision and drainage in the peripheral centres where USG guided aspiration is not available. The aim of this study was to establish if USG guided aspiration is better, cost-effective and more feasible treatment option for breast abscess compared to Incision and Drainage. In our study, total of 154 patients divided into Two Groups, one underwent Incision and drainage and other USG guided aspiration. Many variable like age, parity, clinical features, USG findings were compared in the results we found that USG guided aspiration is easy procedure, cost-effective, well-accepted by the patient, less recurrence rate, more healing rate and also less hospital stay.

Keywords: Incision and Drainage; USG guided aspiration; Breast abscess; Comparative study.

In the current age and day of expertise the widespread cross-section of clinicians, an encounter with choledocholithiasis is usually dealt with in the following 2-step process. The patient is subjected to an ERCP which includes a sphincteromy followed by one of many methods of extracting gall stones from the CBD. In this study, we have compared the timing of cholecystectomy following ERCP in many aspects Such as, duration of surgery, chances of conversion to open surgery, subtotal cholecystectomy, and duration of hospital stay, postoperative morbidity and mortality. Performing laparoscopic cholecystectomy within index admission is beneficial to the surgeon in terms of operation time, chances of encountering adhesions, and chances of conversion to open cholecystectomy.

Keywords: Endoscopic retrograde chalangio pancreatography; Early vs delayed laparoscopic cholecystectomy; Choledocholithiasis; Cholangitis.

Context: Fistula-in-ano is an abnormal communication, lined by granulation tissue between the anal canal and the skin, which causes chronic inflammatory response. Surgery for fistula-in-ano is considered essential for decompression of acute abscesses and to prevent spread of infection. Treating anal fistula is a complex task because of anatomical location of disease, recurrence rate, potential risk of septic complications and postoperative fecal incontinence. Main objective of surgery is to heal the fistula and minimize the morbidity of disease. Many surgical techniques, fistulotomy, fistulectomy, Seton, LIFT and others used for treatment of fistula. Eradication of sepsis and maintenance of continence are two great challenges for the success of surgery. Aims: To study the incidence, etiology, clinical presentations and different treatment modalities for fistula-in-ano. Settings and Study design: Prospective analytical study, Study subjects and setting: 75 patients presenting with fistula-in-ano in Dept. of surgery SVRRGGH Tirupati. Study period: October 2017 to October 2018. Materials and Methods: In this study, 75 cases who underwent Fistula Surgery were taken Age, Sex, Complaints, Type of fistula, Type of surgery, Duration of hospital stay, Complications, Histopathological examination were noted for analysis. Statistical analysis used: SPSS11 Results: 80% Fistula-in-ano occur in men and around 30–50 years. Simple fistula is 84%, complex fistula 16%. Most common type is simple, low-level, posterior fistulas. Commonest presenting symptom is Discharge & Pain. Fistulectomy is the commonly done. Pain is the most common postoperative complication. Mean Hospital stay is 4–6 days. 7% of patients had recurrence in 3 months. Common etiology is non-specific. Conclusions: Fistula-in-ano is mostly due to crypto glandular infection. Diagnosis is by history, clinical examination, per rectal examination with discharging sinus and pain, histopathological examination of fistula tract. Most fistulas associated are non-specific etiology. Fistulectomy is better than fistulotomy because of complete healing and no recurrence after surgery.

Keywords: Fistula-in-ano; Fistulectomy; Fistulotomy; Seton; LIFT.

Introduction: Electrical burns constitute the fourth leading cause of work related death. Tissue destruction is extensive often requiring amputation. Upper limb involvement is present in majority of the electrical burn injuries, these injuries can be avoided with proper education, safety regulations, and a safe effective electricity delivery network. Aims: To study various types of treatment strategies with patients and clinical outcome in terms of functionality. Materials and Methods: This is a prospective study conducted for a period of 2 years. All the patients with major upper limbs electrical burns were included in the study. 140 patients were admitted with electrical burns out of them 90 had upper limbs involvement. Out of those 140 patients 34 were Pediatric patients with age less than 10 years. Results: Males (83.3%) mostly presented with burns of upper limbs when compared with females. Farmers and electricians are the most commonest group effected, Most of them being sustaining Highvoltage burns. Most common site affected was fore arm followed by hand and arm. Rural to urban ratio was 2:1 and hospital stay of 50 patients (55.5%) was approximately between 0 and 15 days. Conclusion: Pedicled distant flaps are reliable, durable and easy to perform for the post electrical burn defects of the upper limbs, which gives predictable results.

Keywords: Electrical Burns; amputation; Plasticreconstructive procedures.

Context: Perforation of the duodenal ulcer is common emergency surgical with significant morbidity and mortality rates. Operative management either open or lap is the treatment. Several factors determine the morbidity and mortality which were studied in this study. Aims: To study clinical risk factors, sociodemographic factors, in relation to outcome of surgery for duodenal ulcer perforation and analyze the mortality and morbidity in patients with peritonitis due to duodenal ulcer perforation. Materials and Methods: Patients of duodenal ulcer perforation admitted in SVRRGGH between August 2016 to September 2017 were studied prospectively. History, clinical examination, investigations, intraoperative findings and postoperative status, relationship of clinical and socio-demographic factors on peritonitis were documented in proforma. Statistical analysis used: SPSS 11. Results: The most common age group is 60–70 years. Male to female ratio of 7:1. Highest incidence occured during the months of September and October. Common precipitating factors were smoking, alcohol, NSAIDS. Among 110 patients 12 presented in shock, with mortality of 66%. Delayed presentation > 24 hours, Size of perforation > 1 cm, peritoneal contamination > litre were associated with increased mortality. Common postop complications were wound infection, Pneumonia. Mortality is more in elderly age group that is in patients more than 60 years of age. Conclusions: Smoking, alcohol and NSAIDS usage are predisposing factors for duodenal ulcer perforation. Early presentation, prompt diagnosis, adequate resuscitation, emergency surgery and postoperative monitoring are useful for successful management and good outcome of perforated peptic ulcer.

Keywords: Duodenal perforation; Peritonitis; Cellen Jones technique.

Background: Acute pancreatitis is a disease where earlier initiation of treatment in case of complication gives a better prognosis to the patient. It has been firmly established that the BISAP scoring system is superior to the other clinical scoring system and the superiority of the CTSI scoring has been established for almost a decade. Yet, there are very few studies that directly compare these two scores directly. Hence, such a study is of utmost importance at this time as it can decrease the financial burden for the patient as well as provide a simple scoring system for the surgeon. This study compares CTSI and BISAP scoring in the assessment of severity and mortality of acute pancreatitis, and assess the validity, the specificity and the sensitivity of both the scoring systems. Methodology: In 35 patients diagnosed with acute pancreatitis, the BISAP score was calculated, and after 48 hours of onset of symptoms, CTSI scoring done. The data was then analyzed with STATA statistical software. Results: BISAP score showed a sensitivity of 100% and specificity of 36.8% in establishing the mortality of acute pancreatitis with cut-off value taken as > 1. If the cut-off value is taken as > 2, the sensitivity became 56.3% and specificity became 79%. CTSI score showed a sensitivity of 64% and specificity of 100% in establishing the onset of complications in cases of acute pancreatitis. Conclusion: Our study showed that BISAP score is comparable to CTSI in predicting the prognosis and mortality of cases of acute pancreatitis but does not compare with CTSI in establishing degree of necrosis. Hence, BISAP score is a simple, cost-effective scoring system that can be implemented in tertiary and even most primary healthcare centres.

Keywords: BISAP; CTSI; Acute pancreatitis; Predicting morbidity; Complications of acute pancreatitis; Pancreatic necrosis BISAP; CTSI; Acute pancreatitis; Predicting morbidity; Complications of acute pancreatitis; Pancreatic necrosis.