Y Singh

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.

Secondary abdominal pregnancy

Col Yoginder Singh , Col S.K. Singh , Maj Gen Manomoy Ganguly, VSM, Somya Singh , Brig Praveen Kumar, (Retd) a Professor & Head (Obstetrics & Gynaecology), Command Hospital (Central Command), Lucknow, India b Classified Specialist (Obstetrics & Gynaecology), Command Hospital (Central Command), Lucknow, India c Commandant, Officers Training College, Lucknow, India d Resident (Obstetrics & Gynaecology), Command Hospital (Central Command), Lucknow, India e Ex-Brig Adm, Command Hospital (Central Command), Lucknow, India

Training and Credentialing in Laparoscopic Surgery - The Need of the Day

Laparoscopic surgery has come to stay, ‘warts and all’. The year 1901 was an important one in the history of laparoscopy. George Kelling, a surgeon from Dresden used a ‘coelioskope’ to examine the abdominal cavity of dogs. He created pneumoperitoneum by using filtered air through sterile cotton. Over the next 90 years or so various surgeons used their skills and innovations towards advancements and perfection of laparoscopic procedures. With the advent of solid state camera in 1982, it was just a matter of time before the land mark, first laparoscopic cholecystectomy was performed by Dr Philippe Mouret of Lyons, France in 1987 [1]. It has caught the fancy of surgeons all over the world. However, this new and exciting branch of surgery has had its share of controversies. The proponents of laparoscopic surgery highlight the reduced post operative pain, shortened hospital stay and cosmetic acceptance. Those concerned with the drawbacks of laparoscopic surgery mainly refer to the iatrogenic injuries, particularly so, during the so called learning curve [2]. Notwithstanding the controversies, today, patients are flooding the hospitals with request for laparoscopic surgery, not only for gall bladder disease but also for other surgeries. The situation obviously calls for introspection. First, the ethical aspect of this issue. Are we entitled to subject patients to a higher risk of complication during the early phase of learning to do laparoscopic procedures? This aspect assumes increasing importance as more and more complex surgical procedures are being carried out laparoscopically. Colectomy, splenectomy and fundoplication are some such procedures being reported from many centres [3, 4]. It is not possible to justify the performance of such operations by those attending short term courses of training in laparoscopic surgery over weekends. At present there is no check on the previous surgical expertise of surgeons aspiring to be laparoscopic surgeons. New surgical procedures have been introduced at regular intervals in the evolution of modern surgery. Then why laporoscopic surgery be scrutinized so closely! Laparoscopy is the result of a quantum leap in technological advancement as opposed to the gradual progress that the surgeons have been used to. A laparoscopic surgeon needs to learn to operate with a two dimensional view of three dimensional situation. In addition these surgeons have to do without the all important tactile sensation, depriving him of all important depth perception. Laparoscopic manipulations require precise eye hand co-ordination, with awkwardly long and narrow instruments. Retraction is quite unlike that which surgeons customarily take for granted. Even simple knotting which most surgeons do, more or less subconsciously, have to learnt anew. All these factors predispose to an increased probability of complications such as bleeding and cautery injuries. Thus the criticism of the conservatives is not entirely a cry of sour grapes. It is imperative, therefore that the reigns be held tight on this new and exciting surgical horse, lest it runs away to ignominy and oblivion. The surgical community owes it to the public and to itself. The relatively high incidence of biliary tract injuries reported in the first three years of laparoscopic cholecystectomy [5, 6], led to a fall in the demand for the procedure. Such incidents have a negative effect on the entire surgical fraternity. Thus conscientious surgeons started to address the need for credentialing and granting of privileges to surgeons desirous of entering the laparoscopic arena [7, 8]. If laparoscopic surgery is indeed to flourish in the coming years, it is mandatory that established surgeons alike get adequate training in the field. In addition the young surgical post graduates must be trained in the craft and skills of laparoscopic surgery in their formative years. Essentially training in laparoscopic surgery involves three levels as outlined by Rau [9]. Atlases of laparoscopic anatomy and technique, lectures on various procedures from practising specialists in the field and watching of video recordings and/or attending workshops form the first level. The second stage of training is done on simulators. These devices help the budding laparoscopic surgeon to master eye-hand co-ordination, two dimensional dissection, mobilization etc. The third level of training is recommended to be done on animals or by assisting laparoscopic surgeons. The subject of credentialing surgeons and residents in laparoscopic surgery has been dealt with comprehensively by the Society of American Gastrointestinal and Endoscopic Surgeons. Essentially the directives include the following: a. The individual must have an MS or equivalent degree. b. He must be competent in performance of the procedure by the open method. c. He should have experience in performing diagnostic laparoscopies. d. Surgeons and residents would require to undergo the three levels of training described earlier and participate as first assistant to a qualified laparoscopic surgeon. e. He must perform these procedures under direct supervision of an already privileged laparoscopic surgeon. As we march ahead in the 21st century we must realize that laparoscopic surgery will occupy a prominent and dominant role. Structured training of surgeons and specialists alike will become mandatory. This can best be done by setting up credentialing committees for supervising the training process [9, 10]. With robotic laparoscopic surgery [11] knocking at our doors, the surgical community will do itself a lot of good by getting its house in order as far as training in laparoscopic surgery for the future generation of surgeons is concerned.

Early prenatal diagnosis in a case of conjoined twin with Craniopagus and Thoraco-omphalopagus.

Conjoined twins are the most extreme form of twinning, occurring in about 1% of monozygotic twins with incidence of about 1 in 50,000 to 1 in 100,000 births. However 60% are still born or die shortly after, the true incidence is around 1 in 200,000 live births.1 The antenatal diagnosis is difficult clinically but extremely important. The prenatal diagnosis of conjoined twins is usually suggested at prenatal sonography, which has the advantage of offering a safe, accurate, and reliable method of detecting anomalies of foetal growth and structure.2,3 However, because of the intrinsic limitation of sonography with regard to tissue contrast, MRI has been explored as a safe alternative. We present a case of conjoined twin (Craniopagus and Thoraco-omphalopagus) diagnosed by ultrasound and MRI at 15 weeks of gestation.

Outcome of external cephalic version in breech presentation.

Breech presentation is the most common abnormal foetal presentation with an incidence of 3–4% at term. It is associated with increased perinatal mortality and morbidity irrespective of the route of delivery. There is higher incidence of premature rupture of membranes, premature labour, prolapsed cord, traumatic deliveries, perinatal mortality and morbidity including various birth injuries, which makes breech an unfavourable presentation. Not only is the foetal asphyxia more commonly seen in breech, the incidence of traumatic morbidity like intracranial haemorrhage, visceral injuries, fractures, dislocations, and peripheral nerve injuries are encountered more frequently.1 With the passage of time, the art of assisted breech delivery has suffered significant setback. Most of the cases of unfavourable presentation like breech are subjected to caesarean section in the current obstetric practice. The elective caesarean section does not guarantee the improved outcome of the baby and may also increase the risk for the mother, compared to vaginal delivery.2 This situation is further compounded by current small family norms and fear of litigation. In view of this, converting an unfavourable presentation like breech into cephalic presentation by carrying out an external cephalic version (ECV) is a viable option. With ECV the expected 3–4% incidence of breech presentation at delivery may be reduced to 1%. Besides, ECV may also protect against premature labour, its complications, and permit a higher percentage of term deliveries as 20–30% of obstetric patients with breech presentation deliver prematurely.3 External cephalic version is also a potentially hazardous procedure. There is increased risk of ante partum haemorrhage, foeto-maternal haemorrhage, and foetal distress, rupture of membranes, placental abruption, and cord complications. External cephalic version is a strong stimulant of foeto-placental unit as evident by increased middle cerebral arterial blood flow and increased cell free foetal deoxyribonucleic acid in maternal circulation. In the hands of an experienced surgeon and with aid of tocolytics, ultrasonography, and cardiotocography the overall success rate of the procedure is 77% with very small risk of complications.4 Moreover, low cost, ease of procedure, and patient preparation are the added advantages. The delay to attempt ECV at or after 37 weeks of gestation has obvious advantages like management of complications by emergency caesarean section, giving time for spontaneous version to take place with the requirement of fewer procedures.5,6 Thus, there are some uncertainties related to the role and outcome of ECV in breech presentation. The present study aims to determine the outcome of ECV in breech presentation.

Pentalogy of Cantrell: case report

Pentalogy of Cantrell (thoracoabdominal ectopia cordis) is a rare congenital syndrome of abdominal wall defect, lower sternal defect, diaphragmatic pericardial defect, anterior diaphragmatic defect, and intracardiac abnormalities. First described by Cantrell in 1958, the syndrome occurs sporadically with variable degrees of expression.1 Less than 90 cases have been reported in the literature. The defect is characterized by the association of five anomalies, viz. omphalocoele, cardiac ectopia, absence of the distal portion of the sternum, absence of the anterior diaphragm, and absence of the parietal pericardium. It has a rare frequency of about 1/100,000 births.2 The proposed pathogenesis involves a defect in embryogenesis between 14 and 18 days after conception, when the splanchnic and somatic mesoderm is dividing. Chromosomal abnormalities have also been associated with the syndrome prenatal diagnosis by ultrasonography is possible, depending on the size and extent of the defects. We report a case of pentalogy of Cantrell diagnosed in early second trimester.

Blood Transfusion Practices in Military Medicine

BACKGROUND This observational study was conducted in a small, 45 bed border static hospital, located in a field area, where no blood bank facilities were available. The present study was conducted to elucidate the blood transfusion practices of this hospital. METHODS A retrospective analysis of all blood transfusions performed in this hospital between Dec 2004 and Dec 2006 was carried out. The data collection included blood group patterns, common indications, haemoglobin levels and complications of blood transfusion. Inferences were based on available data and relevant statistical analysis. RESULT A total of 246 blood transfusions were administered to 79 recipients during the study period. Only one patient had an Rh negative blood group. The most frequently transfused blood group was A Rh positive. Majority of transfusions were administered to surgical cases and the commonest indication was gunshot wounds with haemorrhagic shock. The mean haemoglobin at admission was 8.93 g/dl. The mean number of blood transfusions per patient was 3.13. No haemolytic or other transfusion reactions occurred in any of the transfusions. CONCLUSION This study demonstrates that blood transfusions can be safely administered in field conditions despite constraints of not having a blood bank.

Adnexal Torsion in Second Trimester of Pregnancy

Isolated adnexal torsion is a rare event and accounts for 2.7% of all gynaecological emergencies. The incidence of first trimester adnexal torsion in pregnancy is 1:5000 [1]. This condition is rare during late second trimester. The findings are non specific and the entity is difficult to diagnose pre-operatively [2]. We report a case of mid trimester adnexal torsion diagnosed during laparotomy done for suspected acute appendicitis.

Recent Trends in Dealing with Inguinal Hernial Sac

High ligation of the hernial sac is a hallowed and time-honoured concept in inguinal hernia repair and it is considered essential for preventing recurrence. However, this concept has been contested in recent reports. We conducted a prospective study of 186 cases of inguinal hernia repair. In 92 cases the sac was ligated at the neck and excised, in 94 cases the sac was not ligated at all but either simply inverted or excised without ligation. The type of repair was Bassinis repair, Shouldice repair or Lichtensteins repair. Degree of post-operative pain was significantly less in those cases where sac was not ligated. There were no cases of recurrence in either group at 3 years follow up. Ligation of sac in inguinal hernia surgery is not only unnecessary and time consuming but also leads to increased post-operation pain. Recurrence is unaffected by not ligating the sac.

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.