Arshad M. Malik

Pattern of acute intestinal obstruction: is there a change in the underlying etiology?

Background/Aim: To study the changing pattern of acute intestinal obstruction at a teaching institute. Patients and Methods: It is a prospective descriptive study conducted at a teaching hospital during the period from June 2004 to June 2009. All patients with clinical or radiological evidence of acute intestinal obstruction were included in this study regardless of the gender of the patient. Patients below the age of 10 years were excluded from the study. The treatment strategy was planned ranging from conservative treatment to emergency laparotomy after resuscitation and rehydration of the patient. Details of individual patients were recorded on a pro forma sheet and data analyzed statistically on SPSS version 14. Results: A total of 229 patients with acute intestinal obstruction were admitted and treated. The mean age of the study population was 43.08 ± 13.07 years. Postoperative adhesions accounted for 41% (n= 95) of the total cases, followed by abdominal tuberculosis (25%, n= 58), obstructed/ strangulated hernias of different types (18%, n= 42). There was an obvious change in the pattern of etiology of acute intestinal obstruction as the common causes were postoperative adhesions and abdominal tuberculosis instead of obstructed inguinal hernias. Conclusion: An increase in the adhesive obstruction and a concomitant decrease in the incidence of obstructed hernias indicate a changing trend towards early operation before it gets complicated. Abdominal tuberculosis is emerging as another common cause of acute bowel obstruction.

Video-assisted laparoscopic extracorporeal appendectomy versus open appendectomy.

OBJECTIVES Laparoscopic appendectomy (LA) is categorized into intracorporeal appendectomy (ICA) and video-assisted extracorporeal appendectomy (VAECA). This study is conducted to compare feasibility and effectiveness of video-assisted extracorporeal appendectomy (VAECA) with open appendectomy (OA). PATIENTS AND METHODS This was a comparative descriptive study conducted at the Department of Surgery of Liaquat University of Medical and Health Sciences (Jamshoro, Pakistan) from June 2003 to November 2007. Two hundred and eighty-three patients of acute appendicitis were included and categorized into two groups: A and B. Group A included 150 (53%) patients operated on by the OA technique, while group B included 133 (47%) patients in whom VAECA was performed. VAECA was accomplished through three ports in the majority of patients (89%), while a few cases (11%) were completed by two ports only. Patients below 10 years of age and with suspected appendicular mass were excluded from the study. Both operative techniques and their merits and demerits were explained to all the patients and, depending upon their choice or by a simple flip of a coin, they were operated on by either of the techniques. A well-informed written consent was also taken from every patient. The results of both the groups were collected on a proforma and were compared in terms of cosmesis, total operative time, operative and postoperative complications, and total duration of hospital stay. RESULTS The mean operating time was much shorter in group B (p < 0.001), compared to group A patients. The incidence of postoperative infection was comparatively higher in OA, compared to VAECA. The rate of operative complications (p < 0.001), postoperative complications (p < 0.01), and duration of hospital stay (p < 0.001) were all significantly lower in the VAECA group. Cosmetic results were excellent in VAECA, compared to OA, as assessed by length of incision and the postoperative scar formation. CONCLUSION VAECA can be a good alternate option in simple cases without much adhesions or mass formation.

Iatrogenic biliary injuries during laparoscopic cholecystectomy. A continuing threat

BACKGROUND Despite improvement in the technique and increasing experience, complications of different nature and severity continue to occur during laparoscopic cholecystectomy all around the world. We present bile duct injuries in this series with regards to the incidence, severity and management of this problem. STUDY DESIGN Descriptive. PLACE AND DURATION Department of surgery, Liaquat University of medical and Health Sciences, Jamshoro and other private hospitals at Hyderabad city during April 2003 to December 2007. MATERIALS AND METHODS A total of 1132 patients with symptomatic gallstone disease were included in the study regardless of their age and gender. Laparoscopic cholecystectomy by classical four-port technique performed in all cases with few amendments as per situation. Patients with growth in gallbladder and with severe associated medical or cardiac problems were excluded from the study. Details of every patient collected on a proforma and data finally analyzed on SPSS version 10. RESULTS Of total 1132 patients, 1088 (96%) were females and 44 (4%) were males with a mean age of 47.64 years. Elective laparoscopic cholecystectomy was performed in 1118 (98.7%) patients whereas emergency laparoscopic cholecystectomy was done in 14 (1.23%) patients. Various types of common bile duct injuries as well as post -operative bile leaks and their management is discussed with a view to improve upon the technique and out come. CONCLUSION Iatrogenic biliary injuries continue to occur despite tremendous overall improvement in technique and expertise.

Laparoscopic cholecystectomy in empyema of gall bladder: An experience at Liaquat University Hospital, Jamshoro, Pakistan

Objective: To find out the safety profile of laparoscopic cholecystectomy in empyema of gallbladder. Background: Empyema of gall bladder is a severe form of acute cholecystitis with superadded suppuration. It has been considered a contraindication for the laparoscopic cholecystectomy (LC) because of fear of life-threatening complications. This study aimed to determine the safety and feasibility of LC in empyema of gallbladder. Materials and Methods: LC was attempted in 67 patients of empyema of gallbladder within 24h. However in few cases there was a delay because of reluctance for surgery or delay in giving consent etc. The procedure was performed by standard four-port technique with few changes made to facilitate dissection according to situation. Results: Between April 2003 to June 2006, 970 LC performed for gallstone disease at surgical unit-1 of LUMHS by the same surgical team. Among these, 67 (6.90%) patients were diagnosed to have empyema gall bladder. LC successfully completed in 54 (80.59%) patients. In 13 (19.40%) patients the procedure was converted to open cholecystectomy (OC) due to various operative difficulties of which the most serious injuries included bleeding from cystic artery (four cases), common bile duct injury (two cases) and duodenal injury in one case. Maximum operating time was up to 160 minutes (one case). Postoperative complications occurred in 10 (18.51%) successfully operated patients. Maximum patients (n=45, 83.33%) were discharged in 48-96 hours while three patients were discharged after two weeks. Conclusion: Laparoscopic cholecystectomy can be performed in empyema of gallbladder keeping in mind a slightly increased risk of complications even in the best hands. However, the experience of the surgeon plays a key role in the overall outcome.

Extra-biliary complications during laparoscopic cholecystectomy: How serious is the problem?

Objective: To deteremine the incidence, nature and management of extra-biliary complications of laparoscopic cholecystectomy. Materials and Methods: This study presents a retrospective analysis of extra-biliary complications occuring during 1046 laparoscopic cholecystectomies performed from August 2003 to December 2006. The study population included all the patients with symptomatic gallstone disease in whom laparoscopic cholecystectomy was performed. The extra-biliary complications were divided into two distinct categories: (i) Procedure related and (ii) Access related. Results: The incidence of access-related complications was 3.77% and that of procedure-related complications was 6.02%. Port-site bleeding was troublesome at times and demanded a re-do laparoscopy or conversion. Small bowel laceration occurred in two patients where access was achieved by closed technique. Five cases of duodenal and two of colonic perforations were the major complications encountered during dissection in the area of Calots triangle. In 21 (2%) patients the procedure was converted to open surgery due to different complications. Biliary complications occurred in 2.6% patients in the current series. Conclusion: Major extra-biliary complications are as frequent as the biliary complications and can be life-threatening. An early diagnosis is critical to their management.

Yield of Diagnostic Laparoscopy in Abdominal Tuberculosis: Is it Worth Attempting?

Background Abdominal tuberculosis is extremely common in developing countries such as Pakistan and India. The presentation is varied and nonspecific, making the diagnosis extremely difficult at times. This study was performed to find out the efficacy of diagnostic laparoscopy in establishing the histopathological diagnosis of abdominal tuberculosis. Methods An analytical descriptive study of 109 patients with abdominal tuberculosis diagnosed by laparoscopy was conducted over a period of 5 years (between January 2004 and December 2009) in a teaching hospital and in various private hospitals. All patients with vague abdominal symptoms and suspicion of abdominal tuberculosis were admitted and examined thoroughly. Data were collected and statistically analyzed using SPSS version 16. Results A total of 133 patients with vague abdominal symptoms and an unsettled diagnosis were included in this series, of which 109 (82%) patients were diagnosed with abdominal tuberculosis on laparoscopy. The common symptoms were pain in abdomen, changing bowel habits, loss of weight, and generalized weakness. Clinical examination was not significant, except for anemia in the majority and generalized abdominal tenderness in a few patients. Various tuberculous lesions were detected on laparoscopy. Biopsy of the specimens proved abdominal tuberculosis in 109 patients. Patients were saved from unnecessary laparotomies and were managed on antituberculosis drug therapy. Conclusions Diagnostic laparoscopy is an efficient and reliable diagnostic tool for patients suspected with abdominal tuberculosis.

A Walk along the Learning Curve of Totally Extra-Peritoneal (TEP) Repair of Inguinal Hernia

Objectives/Background: Laparoscopic repair of inguinal hernia is a recent advancement gaining global popularity. It supposedly has a very steep learning curve due to various reasons. This study highlights an initial experience with totally extra-peritoneal repair of inguinal hernias with respect to difficulties, the learning curve, and outcome of this experience. Methods: It’s a prospective descriptive analysis of first 78 consecutive TEP repairs of inguinal hernias performed in 67 patients in a teaching hospital as well as private hospitals during one and a half year. Patients less than 15 years, morbidly obese, old unfit patients and patients with previous history of lower abdominal surgery, recurrent hernias, complicated and complete scrotal hernias were excluded. All the patients were explained the new technique and were informed of the likely complications and all the known benefits. Those who gave consent were registered as study subjects. Variables studied included demographics, difficulties/complications during surgery, early post-operative complications, chronic pain and recurrence of hernia. A detailed pro forma was duly filled in by one of the authors and attached with history chart of every patient. The patients were reviewed after 15 days and then every three months for a period of one year. The data collected was then statistically analyzed on SPSS version 16. Results: This study took one and a half years to complete from Jan 2009 to Jun 2010 during which we operated 67 patients with 78 primary inguinal hernias with a mean age of 40.27, Std 9.724 and a range of 38(20-58) years. All the patients were males with 56 (83.58%) unilateral and 11 (16.41%) bilateral inguinal hernia. The mean operative time of the initial 30 cases was reduced by 50% in the last cases. A number of early post-operative complications occurred during the same hospitalization. Results of three years of follow up are quite promising and encouraging. Conclusion: TEP is a safe and reliable method of inguinal hernia repair. Initial problems and fear due to a totally different anatomy soon overcome by repeated attempts at repair by this technique and sticking to the rules laid down by experts in this field.