Minilaparotomy Cholecystectomy: A Forgotten Art in Laparoscopic Cholecystectomy Era (Our Experience from a Peripheral Hospital in North India)

Background: This study aimed to report the experience of performing minilaparotomy cholecystectomy in a peripheral hospital by a single surgeon. Methods: Data collected from 50 consecutive patients undergoing minilaparotomy cholecystectomy by a single surgeon over 18 months at a peripheral hospital were reviewed and studied. The recorded data encompassed demographics, operating time, incision size, conversion rate to open cholecystectomy, perioperative complications, and hospital stay duration. Results: Fifty consecutive patients, who underwent minilaparotomy cholecystectomy for symptomatic cholelithiasis, were studied, among whom 48 patients were females. The participants’ mean age was 45 years. The length of the surgical incision was 4.5 - 6 cm, and only three patients required conversion to open cholecystectomy. The average operating time was 60 minutes; and the average postoperative hospital stay was 2.14 days. Conclusions: Minilaparotomy cholecystectomy is comparable with laparoscopic cholecystectomy in terms of postoperative morbidity, and it is ideal for peripheral hospitals lacking laparoscopic facilities.

Arnold-Chiari Malformation Type II and CYP1B1 Congenital Glaucoma: A Possible Association

Background. We describe a case of an infant with Arnold-Chiari Malformation Type II (ACM-II) who was born with lumbosacral myelomeningocele, hydrocephalus, and primary congenital glaucoma (PCG) together with dysmorphic features (scaphocephaly, frontal bossing, hypotelorism, entropion, and flat nasal bridge), which according to our knowledge, is a combination that has yet to be described in literature. Primary diagnosis. A 2-year-old female who is known to have ACM-II was referred due to abnormal eye examination done in a peripheral hospital that suggested infantile glaucoma in both eyes. Findings. During her last physical exam (postop), she was vitally stable, conscious with good feeding. Ophthalmic assessment revealed buphthalmia, superior paracentral scar, deep anterior chambers (AC), and round pupils with positive red reflex, clear lens, and an IOP of 16, 14 mm Hg, respectively. Neurological exam showed paraparesis and moving upper extremities and has axial hypotonia. Genetic testing showed CYP1B1 gene mutation. Conclusion. The aim of reporting this case is to share the findings in this infant as it may be a new association. The main learning message here is that ACM-II patients may present with certain ocular symptoms, including glaucoma-related ones that may mimic neurological disorders. This report brings information that could alert general practitioners, neurologists, and neurosurgeons. A deeper understanding of this rare disorder may aid the diagnosis of cases with similar characteristic physical findings by referring them to an ophthalmology clinic for further evaluation. Case presentation. A 2-year-old female who is known to have Arnold Chiari Malformation Type II (ACM- II) was referred due to abnormal eye examination done in a peripheral hospital that suggested infantile glaucoma in both eyes. MRI at 3 months of age showed lumbosacral myelomeningocele and hydrocephalus. Genetic testing confirmed a CYP1B1 mutation. These combinations of symptoms were never described in the literature before.

A Case of Congenital Urethrovaginal Fistula in a Female Child with Suspected Imperforate Hymen: A Case Report

Urethrovaginal fistula is an abnormal communication between the urethra and vagina. Urethrovaginal fistula results in urinary incontinence with urine continually leaking from the vagina. In children congenital anomaly may also be the cause. Congenital Urethrovaginal fistula is an extremely rare genitourinary anomaly. The reported five cases in the literature are all associated with urogenital abnormalities like vaginal septum, vaginal agenesis and imperforate hymen. We present a case of a 7-year-old female that was referred from a peripheral hospital for micturating cystourethrography (MCUG) on account of urinary incontinence and passage of urine from vaginal orifice. Following MCUG the urethra, proximal fistula between the urethra and vagina, distended urinary bladder, contrast opacified uterus and a fallopian tube were all demonstrated. We report this case because of its rarity in the literature.

A retrospective study to analyse the rate of caesarean section according to Robson's 10 group classification in a peripheral hospital in a metropolitan city

Background: In the past several decades, a pattern of rapid increases in Caesarean section (CS) delivery rates has been observed worldwide, as also in India. It is important to identify the reason behind the rising rates of CS since they can pose unnecessary risks to the mother and the neonate. The aim of the study was to analyse the CS rate in the ten groups as per Robson’s ten group classification, in a peripheral hospital in a metropolitan city. By this study we have tried to identify specific groups of women to be targeted to reduce CS rates.Methods: This is a retrospective study carried out at a peripheral hospital in Mumbai, India. It included all women who had delivered in the hospital from January, 2019 to December, 2019. The sample size was 2603.Results: Under this study, we found out that the rate of CS delivery is higher than what is recommended by WHO in Robson’s group 2, 5 and 6.Conclusions: This study will help us carry out targeted interventions so as to reduce the CS rates in these groups.

​Diagnostic Indicators and Therapeutic Evaluation of Pregnancy Toxaemia in Goats

Background: Periparturient mortality in goats have a great economic impact on the livelihood of marginal farmers. Pregnancy toxaemia, a metabolic disease in small ruminants occurs as a result of negative energy balance consequent to enhanced requirement for glucose by the developing fetuses in the last trimester (last 6 to 4 weeks) of gestation. The present study was aimed to identify diagnostic and prognostic indicators of pregnancy toxaemia. Methods: During the period October 2016 to September 2018, a total of 516 adult non descriptive does were brought to Veterinary University Peripheral Hospital, Madhavaram Milk Colony, Chennai - 51, of which 264 (51.16%) were treated for medical conditions. Among the does treated for various medical conditions, 72 does were in their last six weeks of gestation carrying twins/triplets and presented with the history of off feed. They were subjected to determination of blood β-hydroxybutyric acid (BHBA) level by means of a portable blood ketone and glucose monitoring system and qualitative urinalysis using urine dip stick. Does with BHBA level greater than 0.8 mmol/L and less than 1.6 mmol/L were classified as sub-clinical pregnancy toxaemic group (n=12) and BHBA level greater than 1.6 mmol/L were classified as clinical pregnancy toxaemic group (n=12) and subjected to therapy while the remaining 48 does had BHBA levels less than 0.8 mmol/L. The control animals were selected from adult Tellicherry does in the age group of 2 to 4 years maintained at Livestock Farm Complex (LFC), Madhavaram Milk Colony, Chennai - 600 051. Result: All the twelve does of sub-clinical pregnancy toxaemic group recovered completely with a cure rate of 100%, while in the clinical pregnancy toxaemic group the cure rate was only 33%. Reliable diagnostic indicators of pregnancy toxaemia include blood â-hyroxybutyric acid concentration (³ 0.8 mmol/L) and presence of ketone body, glucose and protein in urine, while hypergly­caemia in advanced pregnancy toxaemic does indicate fetal death.

Outcome of Surgical Site Infection in General Surgical Practice in a District Hospital

Background: Surgical site infection (SSI) can affect the surgical procedures in the peripheral hospital adversely and adequate data can help in the management of this unwanted complication. Aim & Objective: The study was conducted with the aim to identify the outcome of surgical site infection (SSI) in a secondary level district hospital. Materials & Methods: A total of 192 patients, underwent general surgical procedures in the 100-bedded district hospital, Shariatpur, Bangladesh from January to December, 2016. All were observed for development of SSI for a period of 30 days after their surgical procedure. SSI cases were identified according to National Healthcare Safety Network (CDC/NHSN) guideline and Southampton wound scoring system. Univariate and multivariate analysis was done to identify significant risk factors for development of SSI. Results: Overall incidence of SSI was 20.31%. Significant risk factors for development of SSI were age, BMI, ASA grade, wound classification, diabetes, type of surgery, duration of surgery and perioperative transfusion (p<0.05). Among them, BMI (OR=1.434), diabetes (OR=8.126), type of surgery (routine/emergency) (OR=6.097), duration of surgery (OR=1.023) and perioperative transfusion (OR=2.130) were determined as independent risk factors on logistic regression. Conclusion: SSI has a relatively high incidence in rural surgical practice. Identification and control of predictable risk factors would help to reduce the incidence of SSI. J Bangladesh Coll Phys Surg 2021; 39(3): 171-177

Multi-institutional and multi-disciplinary care: A successfully managed aortic dissection in the third trimester of pregnancy

Multi-disciplinary collaborative care for pregnant women with complex and emergent conditions is essential. Logistical planning, clear communication and human factor awareness are all non-clinical skills which need to be utilised in order to maximise outcomes. We describe the case of a proximal aortic dissection in the late third trimester of pregnancy diagnosed in a peripheral hospital that was transferred to a cardiothoracic centre for successful operative management 160 km away. This required the time-sensitive mobilisation and liaison of a receiving cardiothoracic, anaesthesiology and perfusionist team in conjunction with obstetric and midwifery support from an affiliated maternity hospital, as well as the national neonatal transport team. We emphasise the importance of multidisciplinary team management in complex cases and how imperative good inter-disciplinary communication is to ensure safe inter-hospital transfer.

Acute Generalized Peritonitis in a Peripheral Hospital Centre in Benin: Can It Be Managed by a Local General Practitioner?

Background. Acute generalized peritonitis in resource-poor countries is still a health challenge due to late diagnosis, surgical delay, and specialists’ unavailability. These are the foremost determinants of surgical morbidity and mortality. We report the experience of a peripheral hospital in Benin not equipped with specialized surgeons. Methods. This is an observational, retrospective, and descriptive study including patients operated for acute generalized peritonitis at the Atacora Departmental Hospital Centre, Benin, where unfortunately CT scan and intensive care unit are still not available. Most of surgical activities were performed by a general practitioner with previous surgical training (but no surgical specialization). Age, gender, cause of peritonitis, surgical procedures, and postoperative outcome were evaluated. Results. Sixty-three patients were included. The mean age was 23.2 years and sex ratio M/F 1.5. The mean surgical delay was 26 hours (range: 6–92 hours). An ileal typhoid perforation was found in 40 patients (63.5%), and 35 of them (87.5%) underwent a primary perforation repair without bowel resection. 73% of surgical procedures were performed by the general practitioner. Morbidity was 34.9% and mortality was 14.3%. The average postoperative hospital stay was 12 days (range: 11–82 days). These results were comparable to those observed in the subgroup of patients (17 cases) operated by the general surgeons (morbidity 32.6%, mortality 13.0%, and average postoperative hospital stay 11 days, range: 1–58 days). Conclusion. Acute generalized peritonitis requires urgent management, and it can be effectively carried out, in a context of limited resources, by a general practitioner with surgical skills.