Bm Nagpal

A Prospective Randomized Controlled Study of Lichtenstein's Tension Free versus Modified Bassini Repair in the Management of Groin Hernias

BACKGROUND Bassinis repair and the Lichtensteins tension free mesh hernioplasty are commonly used hernia repair techniques. A prospective randomized controlled study of Lichtensteins tension free versus modified Bassini repair in the management of groin hernias was undertaken to compare the technique and postoperative course in the two procedures. METHODS A prospective study was conducted on patients reporting to Command Hospital (SC) Pune with inguinal hernia. One hundred and ninety six patients were included in the study, operated upon by either of technique and followed up. RESULTS Study involved 196 patients with 216 primary inguinal hernias, studied over a period of 24 months. A total of 118 Bassini repair and 98 Lichtensteins repair were done. Of the 196 patients, four were females. Bassini Repair took more time than Lichtensteins repair, though the difference was not statistically significant (p>0.05). Direct hernias took lesser time to operate than the indirect hernias. Pain on the operative day, in the evening, was similar in both the groups. The commonest complication in both the groups was scar tenderness followed by erythema, scrotal swelling, neuralgia, superficial wound infection, funiculitis and seroma formation in the order of frequency. The average hospital stay was 5.74 days for Bassinis repair as compared to 4.97 days for Lichtensteins repair. Patients undergoing Bassinis repair took longer (mean 28.4 days) to return to work as compared to those who underwent Lichtensteins repair (mean 21.4 days) and the difference was statistically significant (p < 0.05). The recurrence rate was similar in Bassinis (6.78%) and Lichtensteins repair (5.10%). CONCLUSION The Lichtensteins tension free mesh hernioplasty was comparatively better than modified Bassinis repair due to its simplicity, less dissection and early ambulation in the postoperative period. Surgeons in training found the technique easier to master than the Bassinis repair.

Cold Injuries : The Chill Within.

Cold injuries have had profound effects upon the fighting force and military operations throughout history[1] including our own military experiences from the highest battlefield in the world, Siachen. Cold injuries are as preventable as heat injuries and require the medical services to work closely with the tactical commanders to implement effective prevention strategies[2]. The initial treatment offered by the Regimental Medical Officer (RMO) is crucial to the final outcome. This article attempts to review the various types of cold injuries and identify prevention and treatment strategies. Cold injuries are divided into freezing and nonfreezing injuries (occur with ambient temperature above freezing). They include hypothermia, frostnip, chilblains, immersion foot and frostbite. Exposure to cold can induce Raynauds disease, Raynauds phenomenon and allergic reactions to cold. Other conditions encountered during cold weather operations are acute mountain sickness, psychiatric and psychosocial disorders, snow blindness, and constipation (due to decreased fluid intake).

Fecal Incontinence after Posterior Sagittal Anorectoplasty – Follow up of 2 years

After an anorectal malformation (ARM) is repaired, the goal is fecal continence of the patient. Toilet training is not complete in children below 4 years of age. Manometric and radiological studies need cooperation of the child, and are therefore of little value during the critical preschool years. In this present study, we used only clinical criteria to assess the child for constipation and incontinence after definitive operation. We included all patients of ARM wef 01 April 1998 to 31 March 2000. Only 2 children had crossed 4 years of age at the time of this assessment and therefore it was not possible to assess total continence postoperatively. We found that the incidence of incontinence was less in low anomalies and more in high or intermediate anomalies, while the incidence of constipation was higher in low anomalies and less in high and intermediate anomalies. 31% of all patients born with anorectal malformations and subjected to posterior sagittal anorectoplasty (PSARP) approach were totally continent, 38% suffered with soiling of faeces while 31% had problems of constipation. The higher incidence of constipation as well as incontinence in our study is because of a short follow-up and secondly, these problems are known to improve with passage of time. The purpose of this article is to highlight the problems of bowel control even after the definitive operation and still much more is required to improve the quality of life of these unfortunate children.

War Wounds — Changing Concepts

The accepted standard treatment of war wounds through the last century has been debridement and delayed primary closure. However, recently, there has been a renewed Interest In primary closure of these wounds. 1481 war wounds were managed by the authors and out of 789 soft tissue injuries, 389 (47%) were closed primarily (group 1) after meticulous debridement and 220 (28%) underwent delayed primary closure (group 2). The infection rate in group 1 was 4.87% compared to 6.36% in group 2. The average hospital stay in group 1 was 15 days, significantly shorter by 10 days than in group 2. In the war zone both time and resources are at a premium and primary closure of selected wounds offers a better alternative to delayed primary closure.

Wound Healing - A Surgical Fundamental Revisited.

The treatment of wounds is an age-old problem. A small Sumerian clay tablet lists three gestures for wound treatment namely: washing, making plasters and bandaging. Ancient surgeons had devised many methods appropriate to their time as reported in the Edwin Smith papyrus, Sushrut Samhita and so on, Greek and Roman physicians cleansed wounds, applied animal fat, ash, oils and herbs. Following the failure of aggressive methods like boiling oils, Ambrose Pare used gentler methods like rose oil and ligation of bleeders. In the latter half of twentieth century, both topical and systemic antibiotics were in vogue in addition to local wound care. The recent trend is early wound closure with skin or skin substitutes and emphasis on nutritional support and anabolic steroids. The future appears to be towards cellular and molecular biological manipulative techniques of wounds. Acute wounds may be clean as an incised wound or potentially contaminated as a war wound. Chronic wounds, by commonly accepted definition, are those that fail to improve at four weeks or close within eight weeks (like a traumatic wound) or often complicated by circulatory disturbances, metabolic disorders like diabetes and so on. Healing of wounds is a complex interplay of multiple physiochemical reactions in which epithelial and collagen tissue are laid down, fibroblasts and macrophages playing a dominant role. In acute wounds, re-epithelialisation in as little as three to five days and a peak collagen synthesis between two to four weeks is noticed. Chronic wounds respond differently [1] and the repair process being staged I to IV - particularly unique are wounds around the ischium, sacrum and heel [2]. Wound healing, for ease of comprehension, may be explained in three phases, namely; inflammatory, proliferative and maturation. The initiation and transition of these phases are ill defined and are a continuation of events. Inflammatory phase involves transient vasoconstriction of local arterioles and capillaries followed by increased blood flow and oxygen with an influx of inflammatory cells to mediate the process. Several growth factors like platelet derived growth factor, basic fibroblast growth factor, vascular endothelial growth factor are involved. The proliferative phase is characterized by angiogenesis and rapid fibroblastic activity. The final maturational phase involving collagen synthesis and breakdown may last up to two years, though the resultant scar only regains up to eighty percent of its original tensile strength [3]. Any shift between collagen synthesis and degradation disrupts healing. Failure of wound healing is multifactorial. Local factors impeding wound healing include, inadequate nutrients, tissue hypoxia, tissue desiccation, wound exudate and infection. Systemic factors include inadequate blood, oxygen, systemic infection, stress and loss of body proteins. Acute wounds heal by primary or first intention after immediate closure. War wounds heal after debridement and delayed primary suturing. Recently, primary wound closure is being tried after thorough wound debridement, in some selected cases of war wounds. Chronic wounds heal by spontaneous intention or secondary closure. Effective use of dressings is essential for optimal wound management. Dressings once served only a protective function, but many of them are now used for interactive functions. The ideal dressing maintains a moist environment, is not cytotoxic, minimizes discomfort, protects the wound, absorbs exudation, allows gas exchange, is impermeable to micro-organisms, is cheap and is acceptable to the patient. Such dressings include alginates, foams, hydrocolloids, hydro gels, povidone iodine dressings and transparent films. A variety of procedures are used to close chronic wounds, the most common involve skin grafts of varying thickness and flaps. The role of nutrition in wound management cannot be overemphasized [2]. Caloric intake should increase to about 50% beyond daily needs and proteins up to 1.5gm per kg per day. Micro-nutrients like vitamins and inorganic compounds like trace elements along with water intake of about 25 to 50ml per kg body weight is essential. Tube feeding or hyper alimentation whenever necessary is resorted to. Accelerated wound healing is an area of active research. Sub atmospheric pressure dressings have been used in recent years for closure of large wounds. The vaccuum assisted closure system uses a polyvinyl foam sponge applied directly over the wound. It is then tightly sealed in a polyurethane drape. A tube embedded in the foam exits to a vaccuum pump suction machine, providing a sub atmospheric pressure environment on the wound bed. These forces are believed to enhance local blood flow, assist debridement, reduce oedema and bacterial count to co-apt the wound edges [4]. Living skin equivalent is a biological skin substitute commercially produced from neo-natal fibroblasts and keratinocytes using tissue engineering technology. These are available for epidermal, dermal and composite wounds. The disadvantage is a biopsy, and a two to three week delay for cultivation. Dermal grafts consist of neonatal dermal fibroblasts cultured in vitro on a bio-absorbable polyglactin mesh. Composite grafts are bi-layered which look and feel like human skin. It does not contain blood vessels, hair follicles or sweat glands. It acts like human skin, produces all cytokines and growth factors. It is non-invasive, does not require anaesthesia, avoids donor site complications and has a shelf life of five days. It is an effective but expensive technology. The pharmacological manipulation with growth hormone, insulin-like growth factors and anabolic agents are topics for future review and discussion. Recombinant DNA technology has provided widespread research in growth factors. Platelet derived growth factor is already in use as it is commercially available [6]. Transforming growth factor B and granulocyte macrophage colony stimulating factors are not yet approved for clinical studies. Additional technologies and modalities like transfection of IGF-1 gene into dermal cells of small animals is a new approach to wound healing. The issue of angiogenesis is another possible research tool. Aloe Vera, a herbal product, is increasingly being used for wound healing. Chronic topical and systemic hyperbaric oxygen, hydrotherapy, low intensity laser, ultra sound, ultra violet light and intermittent pneumatic compression have all been reported of value [7]. In conclusion, focussed assessment, an interdisciplinary team approach using clinical pathways incorporating new technological advances will help in improving problematic wounds.

Actinomycetoma of hand and foot.

Mycetoma refers to the chronic suppurative pathological process in which exogenous etiological agents generate pus and sulphur like granules. These agents belong to two groups: true fungi and the actinomycetes. Eumycetoma (caused by fungi) and actinomycetoma (caused by actinomycetes) must be distinguished as their treatment is different. These causative agents are introduced into the skin by minor trauma. Most cases of mycetoma occur in tropical regions such as Asia, Africa and Central and South America but this disease is endemic in India. Nocardia brasiliensis is the most common isolate found in India [1]. The pathologic process is characterized by tumefaction, subcutaneous nodules and in most cases discharging sinuses that drain exudate containing granules. It gradually invades the tissues and bones causing a functional disability. Bone involvement depends on the duration of the disease and the causative agent. Here we present two cases of actinomycetoma, one affecting the hand and the other the foot. The pathogenesis, radiological features and the therapeutic management of this entity are reviewed. Case Report A 32-year old individual, tailor by profession reported with a gradually increasing painless swelling of the left hand associated with progressive development of multiple discharging sinuses, of 8 years duration. He did not give any positive history of direct prick or any injury. Local examination revealed a diffuse swelling of the left hand involving mainly the palm and the dorsum, sparing the fingers and thumb. The feel of the swelling was woody and there were multiple discharging sinuses present all over the dorsum and palmar aspect of the hand (Fig 1). The granules contained in the discharge were yellowish in colour. 1–2 mm in size, multiple and discharging intermittently. The surrounding skin was thickened, unhealthy and hyperpigmented. Systemic examination was normal. There was no evidence of any distant spread. Gram stain of the granules showed gram positive branching bacillary filaments (1μ in diameter) having a distinct sunray appearance, diagnostic of actinomycetoma. Repeated culture both under aerobic and anaerobic conditons did not grow any organism.(the patient gave history of prior antibiotic treatmment). X-ray of the left hand showed a patchy resoiption of all the metacarpal bones with lucent filling defects and thickened cortex with partial destruction of the carpal bones (Fig 2). There was no involvement of the small joints. He was managed with high dosage of penicillin along with dapsone (DDS) and rifampicin to which he responded well. The chemotherapy was then switched over to dapsone (DDS) and trimethoprim-sulfamethoxazole combination at the time of discharge, for the patients convenience. He is under close follow up. Open in a separate window Fig. 1 Palmar view of the left hand showing massive soft tissue swelling, subcutaneous nodules and multiple discharging sinuses.

Gruber-Frantz Tumour

Gruber-Frantz tumour is a rare cystic neoplasm of the pancreas that is most frequently seen in young females. Cystic pancreatic neoplasms are commonly misdiagnosed as pancreatic pseudocysts that are, by far, the most common cystic lesions of the pancreas. The presence of cystic pancreatic mass in the absence of a history of pancreatitis must be regarded with great suspicion and investigated thoroughly. These tumours are important because even benign tumours have a malignant potential and correct treatment by total surgical resection is curative. Prognosis is very good unlike in ductal adenocarcinomas of the pancreas.

Clinical Features and Management of Blast Injuries

Today we have inherited a world in which spiralling violence has brought people from all walks of life closer to the dangers of blast injuries. On an average, 68-75% [1] of all injuries in war are blast injuries. A cursory look at any headline of a national daily reminds us that the civilian populace is no less immune, and considering this, it becomes imperative for all medical personnel to be aware of the manifestations and the correct line of management of these injuries. All this involves a good understanding of the biomechanics of the event of a blast.

CONGENITAL ANOMALY PRESENTING AS LUMP ABDOMEN IN ADOLESCENT GIRL

The close embryological proximity of the mullerian, wolffian and metanephric systems increases the potential for a common ipsilateral embryological error around the fourth week of gestation. Genital anomalies are four times as common in females as in males with unilateral renal agenesis. Uterine anomalies associated with congenital renal agenesis and skeletal abnormalities represent an uncommon pathology that often presents important diagnostic and therapeutic problem [1]. The Mayer-Rokitansky-Kuster-Hauser syndrome is an eponym often applied to individuals with mullerian duct anomalies in association with a solitary kidney. We present a rare variant where left sided renal agenesis was associated with a large ipsilateral ovarian cyst and a bicornuate uterus. The left sided cornua was not communicating with the cervix hence there was ipsilateral hemihematometra. We could not find a report of this particular triad inspite of an extensive search of literature.

CRANIOSYNOSTOSIS : MANAGEMENT IN INFANCY.

Craniosynostosis is defined as premature fusion of one or more cranial sutures, which may occur in isolation or in association with a syndromic constellation, resulting in cranial deformity. Functionally, craniosynostosis may be defined as the premature conversion of dynamic region of growth and resorption between two adjacent bones of the cranium into a static region of bony union. In the treatment of such cases, each case must be judged individually and a multidisciplinary approach is recommended. We present a case of microcephaly with bilateral coronal craniosynotosis treated with early wide linear craniectomy followed by relative normalization of skull and facial appearance.