Puerperal complications in elective versus emergency caesarean deliveries

Background: The aim of current study was to compare puerperal complications in elective vs emergency caesarean section. Though similar complications occur in elective and emergency caesarean sections, this study aims to find out which complications are more common in either of them.Methods: A prospective case comparative study was conducted at GCS Medical College and Hospital, Department of Obstetrics and Gynecology, Ahmedabad from 01 December 2020 to 01 June 2021.Results: The emergency caesarean section (CS) rates (36) were more common in the age group of 21-25 years than the elective CS (32). Emergency CS was most common in primipara women (69). The most common risk factor is previous known history of hypothyroidism and most common indication is known history of previous lower segment caesarean section (LSCS). 10 patients in elective CS and 8 patients in emergency CS had previous LSCS. Body mass index (BMI) of 26 patients in elective CS was ranging between 24.9-29.9 kg/m2 when compared to 28 patients with similar BMI in emergency CS. Overweight patients underwent more emergency CS when compared to elective CS. Most common intra-operative complication was adhesions between rectus sheath and muscle and second most common was dense adhesion. Most common post op complication was breast engorgement and mastitis.Conclusions: There is a significant difference between the number of patients in elective and emergency CS group when common indications are seen (p<0.05). Similarly, statistically significant is observed between the 2 groups when post-operative complications are observed (p<0.05).

Small Bowel Obstruction Caused by Tubo-Ovarian Abscess Following Chronic Pelvic Inflammatory Disease: A Case Report

BackgroundAlthough there are reports of small bowel obstruction (SBO) secondary to tubo-ovarian abscess (TOA), there have been no documented cases of unexpected SBO, multiple intestinal ruptures and adhesions in a patient with chronic PID followed by successful surgical treatment of TOA who was successfully treated by surgery after failure by conservative treatment.Case presentationA 40-year-old female was admitted with main complaint of abdominal pain and fever for six days. A pelvic mass measuring 6.37x7.85x9.04 cm and ascites at rectovaginal pouch were found despite local treatment with metronidazole and cefazolin. Laboratory tests revealed leukocytosis of 8.9x10^9/L with hyper-neutrocytophilia of 82.8%, C-reactive protein increase at 223 mg/L and Procalcitonin 0.14ng/L. The patient was diagnosed with an acute attack of chronic PID. Tests and body temperature improved after 4 days of IV antibiotics. However, two days later, the patient presented abdominal distension, poor appetite, and difficulty in defecation. Abdominal CT suggested possibility of bowel obstruction. Accordingly, an explorative laparoscopy was performed, revealing 500ml pale yellow ascites within the abdominal cavity. The intestinal tube was clearly dilated with poor peristalsis. Multiple intestinal ruptures and adhesions were found. Dense adhesion existed between the intestinal loop and posterior uterus wall, closing the rectouterine pouch. Pale yellow thick pus could be seen from the end of fallopian tube, and part of the right ovary showed serious pyosis. All the adhesions were split, ruptures were repaired and normal anatomy was restored. Postoperative pathology indicated acute and chronic inflammation of both fallopian tubes with focal abscess formation. The patient was discharged 15 days after operation and followed up at one month without any symptoms.ConclusionIn such cases, close attention should be paid to changes in the patient’s condition and lesion changes. Early laparoscopy is advised when there are significant clinical or CT scan signs of bowel obstruction in TOA patients. Precise predictors or a predictive model for the need of invasive intervention to TOA will require further investigation.

Shunt coronarography in patients with recurrent stenocardia in long term after aorto-coronary bypass

Проблема профилактики и диагностики стеноза - окклюзирования шунтов после аорто - коронарного шунтирования в отдаленном периоде остается нерешенной. Наиболее часто закрываются шунты в течение первого года, возникновение окклюзии венозных шунтов в течение первого года после операции наблюдаются у 25-30% больных, в дальнейшем в течении 5-7 лет частота окклюзии составляет около 2% в год, после этого срока 5% в год. Артериальные шунты остаются проходимы до 98%, и в основном причиной их дисфункции является прогрессирование атеросклеротического процесса и технические погрешности. Основными причинами которые могут привести к нарушению функции шунта в отдаленном периоде считают [1, 2, 4, 6, 8] следующие: 1-техническое (повреждение эндотелиального слоя и стенки аутовенозного трансплантата при его взятии (ретроспективный анализ), чрезмерная длина и перегиб шунта (на шунтографии), натяжение шунта из-за недостаточной его длины, неправильный выбор места наложения дистального анастомоза) [11,12,13]. 2- анатомические факторы[3, 5, 7] . 3 - общие факторы (низкая объемная скорость кровотока по шунту, нестабильность общей гемодинамики, массивные сращения в полости перикарда, гиперкоагуляция, гнойный медиастинит, длительное лихорадочное состояние и неадекватный прием антикоагулянтов. 4 - прогрессирование атеросклероза [9]. 5- использование венозных трансплантантов как одна из важных причин стеноза - окклюзии шунта [10]. The Problem of stenosis prevention and diagnostics - occlusion of shunts after aorto-coronary bypass in long term remains unaddressed. Typically, shunts are closed within the first year, emergence of phleboid shunts occlusion within the first year after surgical intervention is observed in 25-30% of patients, and further frequency of occlusion within 5-7 years is about 2% per year, 5% per year after this term. Arterial shunts is passable up to 98%, and mainly the reason for their dysfunction is the atherosclerotic process progression and technical faults. The main reasons which can results in shunt dysfunction in long term are the following [1, 2, 4, 6, 8]: 1-technical (damage of endothelial layer and paries of autovenous transplant during its drawing (retrospective analysis), excess length and shunt bend (at the shuntography), shunt tension because of its insufficient length, improper location of distal anastomosis application) [11,12,13]. 2- anatomical factors [3, 5, 7] . 3 - general factors (low volumetric blood flow along the shunt, instability of general hemodynamics, dense adhesion in pericardial cavity, hypercoagulability, purulent mediastinitis, prolonged febrile state and inadequate intake of anticoagulants. 4 - atherosclerosis prgression [9]. 5- using venous transplants as one of the important reasons of stenosis - shunt occlusion [10].

Features of surgery for proliferative diabetic retinopathy in young patients

Purpose. To investigate the technical features and difficulties of performing vitreoretinal surgery in proliferative diabetic retinopathy (DR) in young patients. Material and methods. 12 patients (12 eyes) aged 19 to 30 years, averaging 26±2 years. There were 4 men and 8 women. All patients had diabetes mellitus (DM) in childhood. The duration of type 1 diabetes ranged from 12 to 18 years. Results. Initially, 8 eyes showed combined retinal and peripapillary neovascularization with gliza on the vascular arcades. In 4 eyes, there was both diffuse hemophthalmos and preretinal clots of varying length and volume. In 8 eyes, dense adhesion of the altered posterior hyaloid membrane and the inner border membrane was revealed. In 4 eyes, vasoproliferative membranes were determined, which contributed to the development of traction effects on the retina. The most dangerous was the traction component on the macular retina. Conclusion. Surgical treatment of proliferative DR in young patients has a number of technical difficulties associated with the anatomical features of the macular interface and the features of the proliferative response to surgery. Noteworthy is the minimum time for the transition of DR to the proliferative stage. Key words: proliferative diabetic retinopathy, endovitreal surgery, type 1 diabetes mellitus.

Rare Presentation of Retroperitoneal Leiomyosarcoma Mimicking a Myoma in a 46-year-old Woman: A Case Report

Background: Retroperitoneal sarcoma (RPS) are relatively uncommon, constituting only 10 to 15 percent of all soft tissue sarcomas. Case presentation: We share our experience in encountering RPL with vascular and urethral adhesion in the operation room in a 46-year-old woman, whom was scheduled for surgery as a case of leiomyoma.Huge solid retroperitoneal mass (16*12*11 cm) was detected in right broad ligament which was attached to the pelvic floor and seemed to be separated from uterus. Because of a dense adhesion of the tumor to the ureter and vessels tearing of internal iliac vein and ureteral injury occurred during dissection that was repaired. Pathologic examination revealed grade II / III leiomyosarcoma with mitotic rate 12 / 10 HPF, including atypical forms. she candidates for radiation. Conclusion: This case report describes the clinical, imaging, surgical and histopathological findings of retroperitoneal leiomyosarcoma. Due to the rarity of these tumors and the complexity of treatment, evaluation and management should ideally be carried out in a center with multidisciplinary expertise in the treatment of sarcomas.

DURATION OF SURGERY OF LAPAROSCOPIC NEPHRECTOMY -AN INITIAL EXPERIENCE IN IGMC, SHIMLA

Background: Laparoscopic nephrectomy has been established as the standard of care for the management of benign non-functioning kidneys and has gained worldwide popularity over the past decade. Methods- This study was conducted in the Department of General surgery, Indira Gandhi medical college, Shimla on 20 selected patients of benign non functional kidney admitted for elective Laparoscopic Nephrectomy between July 2018 to June 2019 Results: In this study, the mean operating time in success full laparoscopic nephrectomies was 103.7 + 20.6 min in lap converted to open it was 165 .7 +26.99 min and in hand-assisted tame taken was 150 min which is statically not significant with p value =0.1317. Conclusion: The mean time taken for completion of laparoscopic nephrectomy in first 4 cases was 105 min and in next 4 cases was 108 min and in last 4 cases it was 97 min there was definitive learning curve as in last 4 cases operating time was less as compared to initial cases but operating time also depends on other factors like in hydronephrotic kidney due to well maintained plane dissection take less time ,but in pyonephrotic kidney ,tubercular kidney,previously intervension like PCN, there were dense adhesion resulting in more time for disection. Keywords: Laparoscopy, Nephrectomy, Duration of surgery

BLOOD LOSS IN LAPAROSCOPIC NEPHRECTOMY -AN INITIAL EXPERIENCE IN IGMC, SHIMLA

Background: Laparoscopic nephrectomy has been established as the standard of care for the management of benign non-functioning kidneys and has gained worldwide popularity over the past decade. Methods: This study was conducted in the Department of General surgery, Indira Gandhi medical college, Shimla on 20 selected patients of benign non functional kidney admitted for elective Laparoscopic Nephrectomy between July 2018 to June 2019 Results: Less than 100 ml of blood was lost in 3(15%) of the patient. 100 to 200 ml was lost in 9(45%) and in 3(15%) patients 200 to 300 ml blood was lost and 5 (25%) had blood loss more than 300 ml. The mean blood loss in successful laparoscopic nephrectomy was 129 +123 ml and in lap converted to open was 435.7 + 174.9 ml. which is significantly less in successful lap nephrectomy which is statistically significant with a p-value of o.oo3 Conclusion: Mean blood loss in laparoscopic nephrectomy was 145 +144 ml and in converted cases, it was 350+200 ml. mean blood loss in hydronephrotic kidney was 145+ 144.2 ml in pyonephrotic kidney 325+ 318 in end stage nephrolithiasis 350+ 200 ml .There was more blood loss in ESRD and pyonephrotic kidney due to dense adhesion whereas blood loss is less in hydronephrotic kidney due to well maintained plane for dissection . Keywords: Laparoscopy, Nephrectomy, Blood loss

RETROSPECTIVE STUDY OF CLINICAL, RADIOLOGICAL AND SURGICAL FINDINGS OF XANTHOGRANULOMATOUS CHOLECYSTITIS AN EXPERIENCE AT TERTIARY LEVEL INSTITUTION

Background: Xanthogranulomatous cholecystitis is a benign disease of gallbladder which presents almost classically similar with the chronic calculus cholecystitis, but it mimics GB carcinoma intraoperatively. Materials and methods:In our study, 54 cases were found in a study period of 2 yr in which histopathological reports was xanthogranulomatous cholecystitis whether the pt underwent lap/radical/open or lap converted open cholecystectomy for cholelithiasis and chr. cholecystitis and suspicious carcinoma GB. They were retrospectively analysed for getting an idea preoperatively to differentiate them on clinicoradiological ground and while during surgery. Datas were Results and Observation: retrospectively analysed and observed that clinical and biochemical features are non specic. Imaging in the form of USG and CT does help but not to that much extent to accurately diagnose them. intraoperatively presence of dense adhesion and loss of fat plane to surrounding structures creates a big dilemma for the operating surgeon and multiple frozen section biopsy can be of immense help here in guiding further treatment course .Frozen section analysis was not present at our institution so we did not avail its use. Our study is an attempt to derive any correlation Conclusion: between clilnicoradiological and intraoperative aspects preoperatively for the diagnosis of xanthogranulomatous cholecystitis. Although its incidence is greater here than other countries due to rising gallbladder diseases but till this time it is concluded that neither clinical nor radiologically xanthogranulomatous cholecystitis can be ruled out preoperatively. Only histopathological diagnosis is absolutely correct, and in our study we concluded that histopatholigal diagnosis is still the gold standard.

Laparoscopic Resection of a Left Upper Quadrant Mass Leading to a Surprise Diagnosis

Background. Resplenectomy is most commonly done for the treatment of recurrent idiopathic thrombocytopenic purpura (ITP) refractory to medical management due to the regrowth of a missed accessory spleen. Case Report. A 66-year-old male had undergone open splenectomy for traumatic rupture 40 years ago. He presented with a leiomyosarcoma of his leg, which was surgically removed. When he developed metastatic disease, chemotherapy was started. He developed left upper quadrant pain, and on CT scan, a 5 cm mass compatible with a sarcoma was found between the tail of the pancreas and the left adrenal gland. During laparoscopy, dense adhesion of the omentum to the abdominal wall and the stomach from his previous splenectomy was divided. The lesser sac was opened through the gastrocolic ligament, and the splenic flexure was taken down. Superior and dorsal to the tail of the pancreas next to the left adrenal gland, the mass was identified and carefully dissected out. The vascular pedicle, which originated from a side branch of the splenic vessels at the tail of the pancreas, was stapled. The gastric fundus showed multiple nodules, and therefore, a modified sleeve gastrectomy was done; also, a 2 cm nodule in segment 5 of the liver and an omental nodule were removed. The tumors and gastrectomy specimen were placed in an endobag and removed through a periumbilical mini-incision. The patient recovered without any complications from the procedure and his LUQ pain resolved. Pathology revealed no sarcoma metastases but accessory spleens in all specimens. Discussion. Splenosis with multiple implants within the abdomen after splenectomy for trauma is a rare condition. In our patient, this seems to have been triggered by chemotherapy for his sarcoma resulting in extramedullary hemopoiesis. Laparoscopic removal of accessory spleens can be safely done.

Mitral Valve Surgery via a Right Infra-axillary Thoracotomy in High-Risk Reoperative Patients

Background: A right infra-axillary thoracotomy can offer excellent exposure of the mitral valve. This study evaluated this incision for high-risk patients undergoing redo mitral valve procedures. Methods: Of a series of 189 patients who had redo mitral valve surgery, 32 were reoperated via vertical infra-axillary thoracotomy based on previous aortic valve replacement, dense adhesion, location of patent bypass grafts, and peripheral vascular disease. Results: Sternotomy was avoided in all cases. The mitral valve was replaced in 22 patients and repaired in 10 patients; left atrial folding was performed in 6 patients. All patients had uneventful outcomes and normal valve function during follow-up. Conclusions: Reoperative mitral valve surgeries can be performed safely using right infra-axillary thoracotomy in certain patients. The procedure offers excellent exposure of the mitral valve and minimizes the need for cardiac dissection, thus reducing injury risk. Avoiding a high risk of resternotomy increases patient comfort and safety.