Journal of Surgery

Introduction: Laparoscopic appendectomy is the gold standard method of treatment of acute appendicitis. Closure of appendicular stump is the most important step to prevent complications. There are various methods to occlude the appendix. There is an insufficient analysis of the various methods to close the appendicular stump. The aim of this study was to analysis provide a treatment ranking of different options for securing the appendicular stump among endoloop, endostaplers, titanium clip, suture knots, Hem-o-Lok.

Methods: Online electronic databases were searched to find observation studies, review articles, randomized controlled trials comparing various methods ligation of the appendix. The primary outcomes were cost, availability, biocompatible, safety, learning curve.

Conclusion: The application of Hem-o-Lok for occluding the appendix in laparoscopic appendectomy seems to be superior to other methods but the final decision on the method to be used will depend on the surgeon’s experience and training with various techniques, the availability of equipment within the hospital, cost-effectiveness and the extent of appendix inflammation.

Introduction: Trauma represents a major cause of death in patients presenting in emergency department. Abdomen represents a commonly injured region which may often by missed in cases of blunt trauma particularly when compounded with other obvious musculoskeletal injuries. The role of trauma team is to assess, resuscitate and manage all poly-trauma patients in a systematic manner to avoid missing intra-abdominal injuries and manage such patients aggressively.
Materials and methods: This retrospective study was conducted in Liaquat National Hospital, Karachi which is a level 2 trauma centre. All the data was obtained from the hospital’s registry for the period of 1 year from January 2014 to December 2014. Trauma victims who fulfilled trauma team activation criteria were included in study with criteria like patients with abdominal trauma with obvious penetrating injury either in the form of gunshot injury, stab wound or any object penetrating the abdomen with or without an exit wound; patients with blunt trauma with ultrasound Fast/CT scan showing free fluid, hemoperitoneum or visceral injury; adult patients more than 18 years of age; poly trauma patients with associated abdominal injury. Patients excluded from study were trauma patients less than 18 years of age; poly trauma patients who had no abdominal injury; patients who expired with 10 minutes of presentation within emergency department or brought dead.
Results: A total of 150 trauma calls were generated during the year 2014. Out of these 150 trauma calls, 25 (16.6%) patients met the inclusion criteria of having intra-abdominal injury. Male to female ratio was 24:1. Among the patients who sustained abdominal injuries, 9 (26%) patients had blunt trauma to abdomen while 16 (64%) patients had penetrating abdominal injuries. In penetrating injuries, 15 (60%) cases were due to gunshot injuries while 1 (4%) was due to an assault. Sixteen (64%) patients required immediate laparotomy. Fifteen of these patients had penetrating injuries and 1 had blunt trauma, 8 patients were managed conservatively and 1 patient underwent angio-embolization of splenic artery. Time required to shift patient from ER to OT was variable between 36 minutes to 69 minutes with a mean value of 50 minutes. Patients who were managed conservatively had an ED stay time varying from 40 minutes to 160 minutes with mean value of 130 minutes. Of 25 patients who had abdominal injuries, 21 (84%) patients survived and 4 (16%) patients expired. Among the patients who went immediate surgical intervention, 3 patients expired and 1 patient who underwent angio-embolization of splenic artery expired.
Conclusion: Because of the concealed nature of intra-abdominal hemorrhage, one is likely to miss abdomen as a potential source of bleeding until patient decompensates to unresuscitable state of shock. Thus, appropriate management of severe trauma patients can only be achieved by a systematic evaluation by Trauma team according to ATLS guidelines. Our study concluded that the time factor for activation of trauma team and shifting of patient was not the major factor among patients who expired. Although the shifting time was fairly long for patients who were managed conservatively, it was not identified as a cause of death.

Background: Pre-peritoneal mesh repair for inguinal hernia is a minimally invasive open technique that has become an alternative to laparoscopic groin hernia repair. It mimics the laparoscopic repair for tension-free, preperitoneal herniorrhaphy, but does not require specialized equipment, thereby decreasing cost. In our study, we evaluated the immediate and long-term outcomes of the preperitoneal mesh repair of inguinal hernia in Albany Regional Hospital Western Australia
Methods: All patients who had pre-peritoneal mesh repair for inguinal hernia by the local two surgeons between 2010 and 2015 were identified and included in the study. The data included patients’ demographics, length of hospital stay, complications; including hematoma, seroma, wound infection, recurrence; and chronic groin pain. All patients were reviewed 4-6 weeks post-operatively in the outpatient clinic. Patients with symptoms or an apparent groin swelling were reassessed by one of the two primary operators. Patients who developed complications were offered longer follow up appointments, otherwise discharged back to GP care. Patients who developed late complications were referred back by the GP.
Result: A total of 435 cases were operated, recorded, analyzed and included in the study. 93% were males, mean age 59 and mean operative time 35 minutes. Patients were seen in the clinic 4 weeks postoperatively, patients with late complications were referred by the GP. Complication were acute urinary retention 3.9%, hematoma 3%, seroma 2.7%, infection was 0.9%, recurrence 2.7%,chronic pain 0.2%.
Conclusion: The open pre-peritoneal inguinal hernia repair is a safe minimally invasive approach and is associated with a low rate of postoperative chronic pain or recurrence.

Background: Management of laryngeal carcinoma has been widely developed, either by surgery, radiotherapy, and/or chemotherapy. The treatment has a major impact on physical, social, and psychological health that can change the quality of life of patients.

Objective: The purpose of this study to determine the quality of life of laryngeal carcinoma patients after total laryngectomy at Hasan Sadikin General Hospital, Bandung.

Methods: We are using descriptive research methods. Research data is primary data taken through interviewed using Short Form 36 (SF-36) Study Questionnaire and the European Organization for Research and Treatment of Cancer Head and Neck Cancer Quality of Life Questionnaire (EORTC QLQ-H and N35) to patients post total laryngectomy that came to the Ear, Nose, Throat, Head and Neck Surgery Division at Hasan Sadikin General Hospital, Bandung.

Result: This study was taken form 23 subjects with a total of 19 men (82.61%) and 4 women (17,39%), patients are generally 56-65 year old as many as 15 subjects (65.22%) and the most recent high school education as many as 16 subjects (69, 57%). The average value of the quality of life of SF-36 physical components was 87.55 ± 2.35 and mental components were 85.35 ± 3.92. The highest average quality of life of EORTC QLQ-H and N35 on the speech problem scale was 51.69 ± 6.36 and the lowest on the feeding hose scale was 0.00 ± 0.00.

Conclusion: The quality of life of laryngeal carcinoma patients after total laryngectomy on the SF-36 questionnaire is generally good and EORTC QLQ-H and N35 has problems with speech.

Introduction: Abdominal Actinomycosis is a rare granulomatous inflammatory disease caused by a Gram-positive anaerobic bacterium Actinomyces israeli, manifesting as a pseudoinflamatory tumor, or abscess formation. Evolution is slow and steady in inflammatory contiguous extension without a limit organ that lends itself to confusion with abdominal malignancies.
Methods: We performed a retrospective study between 1980 to 2018, by analyzing all medical records on 13 patients with abdominal actinomycosis operated in First Surgical Clinic, "St. Spiridon" Emergency University Hospital Iasi.
Results: There were 4 men and 9 women with a mean age of 44.07 years who were hospitalized with abdominal tumors (7 cases) in men and pelvic inflammatory disease in women (6 cases). We identified as predisposing factors: IUD maintained over 10 years (6 cases), 2 foreign bodies (a toothpick probably perforated colon, gallstones lost in peritoneum), and diabetes (3 cases). As a location, most were abdomino-pelvic mass (7 cases) which have evolved as an adnexal tumor or pelvic inflammatory disease and abdominal tumors in the ileo-cecal region (3 cases) or in the proximity of the transverse colon (3 cases). Was rarely suspected preoperatively the diagnosis by imaging (CT is the gold standard). The diagnostic was specified by histopathology exam. All cases were operated by laparotomy (9 cases) or laparoscopic approach (4 cases). We performed the drainage of an abdominal abscess (3 cases), adnexectomy and peritoneal drainage (4 cases), colon resection (3 cases) and omentum tumor resection (2 cases). Also the IUD it was extracted. All patients were treated with penicillin for 15-42 days. We recorded three relapses requiring further surgery to have made the short-term treatment with penicillin. The authors report two cases of great omentum actinomycosis approached laparoscopically who underwent resection of tumour followed by specific treatment with penicillin, with a good postoperative course.
Conclusion: Laparoscopic approach in abdominal actinomycosis is feasible. Tumor or abscess of actinomycosis benefit from surgical treatment without major organ sacrifice, completed by antibiotic therapy (penicillin) for at least 6 weeks. Follow up is required, relapses are possible.

Background: Pancreatic ductal adenocarcinoma is one of the most aggressive neoplasms, with a poor prognostic and overall survival, most of the patients (over 80%) being diagnosed in advanced stages of the disease, either with distant metastasis or with the locally unresectable tumor. The Ki-67 antigen is a nuclear antigen expressed in all cellular phases (except for the G0 phase) and a high Ki-67 index can be correlated with a recurrence rate of tumor and survival.
Aim: The aim of our study was to demonstrate if the Ki-67 index can be used as a negative prognostic factor for survival.
Methods: We reviewed retrospectively all patients with pancreatic ductal adenocarcinoma (confirmed histologically) and were selected only those with resectable tumors (19.5%). For these patients, immunoreactivity for Ki-67 was evaluated according to the percentage of positive tumor nuclei. The survival was calculated from the data of surgery to a patient’s death.
Results: 19.5% of patients were diagnosed with surgically resectable tumors, with a mean tumor’s size of 3.3 cm. The overall survival rate at 2 years was 21.15%. The patients with a Ki-67 index over 80% had a significantly lower average survival than the other patients.
Conclusions: The immunohistochemistry staining for Ki-67 can be applied as a prognostic marker for survival in resectable ductal pancreatic adenocarcinoma.

This short paper presents the life and activity of Professor Gh. Ghidirim, one of the most important surgeons in Moldavian Republic. The paper presents different aspects from his life and his didatctic and surgical activity.

Background and Purpose: Surgeons may encounter rare cases of difficult intubation. It is known the Cormack and Lehane grading as the prediction method of the intubation difficulty. However, the shape of the epiglottis greatly affects the visible range of the vocal cords. We report a classification of the shape of the epiglottis and the relationship between the shape and the grading.
Target and Method: By observation at their laryngeal expansion at tracheal intubation for 181 adult thyroid patients undergoing surgery, it was estimated the shape of the epiglottis and the grading.
Result: The shapes of the epiglottis were classified into five types. The classification of the shape was possible to know the difficulty of intubation and the frequency based on the grading. If the risk of intubation was recognized the shape, it was possible to infer immediately without the larynx expansion.
Discussion: The three axes theory for the easy intubation has been explained. If the three axes are close to parallel, the success of the tracheal intubation is depending on the shape of the epiglottis. There has been no discussion about the shape of the epiglottis that makes it difficult to see the vocal cords until now.
Many have been reported the intubation of children to be difficult because of the shape of the epiglottis. This study for adults is consistent with the cases of children. Many new safe and easy tools for difficult intubation are easily not considered the influence of the shape of the epiglottis.
Conclusion: Syphilis seropositive cases were observed among married women who come from a rural area with the age group of 26-35 years. Therefore, health education on etiology, prevention, and control of syphilis has to be provided for the community.