EVALUATION OF MIDLINE INCISION VERSUS PARAMEDIAN INCISION FOR EMERGENCY LAPAROTOMIES

Prospective randomized controlled study was conducted between October,2015 and September,2017 evaluating midline incision and paramedian incision in case of emergency laparotomies. A total of 60 cases were randomized into two groups of 30 each. Time taken for midline incision opening and closing was less 9.86 min as compared to paramedian incision is 19.08 min. This is due to opening and closure of abdomen in layered manner in paramedian incision. Three cases of burst abdomen were reported in midline incision as compared to one case in paramedian incision. Cases having previous abdominal scar were excluded from the present study. 4 cases of incisional hernia were reported in case of midline incision as compared to one case in paramedian incision.

Ritka előfordulású, nagy méretű mellékvese-haemangioma sikeres sebészi kezelése

Összefoglaló. A mellékvese-haemangiomák ritkán előforduló, nehezen diagnosztizálható elváltozások, melyek sebészi eltávolítása gyakran nagy fokú technikai jártasságot igényel. Vizsgálatunkban egy 69 éves nőbeteg esetét ismertetjük, akinél fogyás és hypertonia miatt végzett kivizsgálás mellékvesecisztát feltételezett, valamint felvetette adrenocorticalis carcinoma jelenlétét. A preoperatív kivizsgálás során (CT és MRI) a felmerülő malignitás miatt sebészi eltávolítás vált szükségessé. A kezdeti laparoszkópos transperitonealis technikát követően a bonyolult elhelyezkedés, illetve vérzés miatt kis méretű, paramedián metszésből konvertáltunk, és bal oldali nyitott adrenalectomiát végeztünk, valamint a vese caudalis részéről egy folyadéktartalmú képletet távolítottunk el. A szövettani feldolgozás a vese középső harmadának magasságából reszekált cisztát, valamint a cranialis lokalizációról eltávolított, ritka előfordulású mellékvese-haemangiomát igazolt. A ritkán előforduló és többnyire bizonytalan preoperatív diagnózissal bíró mellékvese-haemangiomák sebészi eltávolítása nagy méretük, kompresszióra való hajlamuk, valamint malignitást utánzó megjelenésük miatt is indokolt. A laparoszkópos transperitonealis adrenalectomia extra nagy méretű (>10 cm ) és malignus tumorok, illetve nagy méretű haemangiomák eltávolítására is alkalmas eljárás. A mellékvese-haemangiomák sebészi reszekciója nagyfokú körültekintést igényel, megnövekedett vérzéshajlamuk, valamint a gyakori, nagyerekhez való közeli elhelyezkedés miatt a konverzió veszélye is jelentősen növekszik. Orv Heti. 2020; 161(47): 2006–2010. Summary. Adrenal hemangiomas are rare. Their preoperative diagnosis is usually vague, and often require advanced surgical skills for resection. We herein describe the case of a 69-year-old female patient initially presented with weight loss and hypertension. Preoperative Computed Tomography (CT) and magnetic resonance imaging (MRI) confirmed the presence of an adrenal cyst and possible adrenocortical carcinoma requiring surgical intervention. After initial laparoscopic transperitoneal approach, conversion to open surgery through a small paramedian incision was carried out due to the lesion’s problematic location and continuous intraoperative bleeding. Open adrenalectomy along with the removal of a fluid-bearing lesion from the caudal pole of the kidney was performed. Histology confirmed a cyst removed from the mid-third, and a rare occurring adrenal hemangioma from the cranial part of the kidney. Adrenal hemangiomas usually bear uncertain preoperative diagnosis. Surgical removal becomes necessary in case of increasing size, potential to compress neighbouring structures and possible malignancy. Laparoscopic transperitoneal adrenalectomy is a feasible approach for the removal of extra large (>10 cm) and even malignant lesions as well as for large hemangiomas. Surgery of adrenal hemangiomas require a high level of caution, moreover, their potential for bleeding and frequent vicinity to nearby vascular structures may increase the need for open surgery. Orv Hetil. 2020; 161(47): 2006–2010.

A COMPARATIVE STUDY OF THE FIGURE OF 8 SUTURING REINFORCED WITH FREE PARIETAL PERITONEAL PATCH VERSUS DIRECT SUTURING WITH OMENTAL PLUG/FALCIFORM PLUG IN PATIENTS WITH GASTRO-INTESTINAL PERFORATION.

Objectives: This present study was to compare the figure of 8 suturing reinforced with free parietal peritoneal patch versus direct suturing with omental plug/falciform plug in patients with gastro-intestinal perforation. Methods: A detail history, clinical examinations and relevant investigations were performed to all patients. All patients were anaesthetized: After painting and draping the operation site, right paramedian incision was made. Peritoneum was opened. Whole GIT and intra-abdominal organs were examined properly. Edges of perorated site were debrided. Then, the perforation firstly was stitched by a Figure of 8 stitch with vicryl 3-0 and then a free parietal peritoneal patch taken from lateral abdominal wall was applied and held in position with interrupted/continuous seromuscular sutures. Then, central tucking was also be done to keep the patch firmly fixed. Results: Data was analyzed by using SPSS version 26 software. One sample t test was applied. Mean and standard deviation were observed. P value was taken less than or equal to 0.05 for significant differences. Conclusions: Reinforcement of free parietal peritoneal patch over figure of 8 suturing is effective method for the closure of gastrointestinal tract perforations, with early evidence of gastrointestinal motility with oral intake allowed on an average 4th - 5th postoperative day was significant statistical difference with regards to complications like anastomotic leakage. Hence, the figure of 8 stitch reinforced with free parietal peritoneal patch is a simple and easy procedure with less hospital stay which does not require significant expertise and can even be performed in very short time by a trained general surgeon in a seriously ill patient in an emergency situation. Keywords: Gastrointestinal perforation, Figure of 8 stitch, parietal peritoneal patch, omental plug, direct suturing

Perforated appendicitis with peri-appendicular abscess within an incisional hernia: a report of an unusual case

Amyand’s hernia is a rare phenomenon referring to the presence of an appendix within an inguinal hernia. Hernial appendicitis occurs even more rarely in 0.07-0.13% of cases. Cases have been described in incisional hernias of laparoscopic port sites, nephrectomies and various other incisions. Author described an unusual case of an elderly lady who presented with nausea, fever and a tender abdominal mass over a previous paramedian incision. She was thought to have an incarcerated incisional hernia and was counselled for emergency surgical repair. Intra-operatively, she was found to have a perforated appendicitis with a large peri-appendicular abscess within an incisional hernia. The base of the appendix was unhealthy thus a limited right hemicolectomy was performed and the hernia was repaired primarily. Such cases present atypically and present a diagnostic challenge. Delays in recognition and timely intervention may lead to high morbidity and mortality. The authors hoped to raise awareness of this condition and contribute to the medical literature surrounding this unusual pathology.

A study of submental intubation for anaesthesia in patients with faciomaxillary injuries

<p class="abstract"><strong><span lang="EN-US">Background: </span></strong>Surgical repair of faciomaxillary trauma requires intraoperative occlusion of teeth that precludes orotracheal intubation. Airway management options in these patients are either nasotracheal intubation or tracheostomy. However nasal intubation is contraindicated in nasal bone fractures, skull base fractures. Tracheostomy, being a morbid procedure is not always a good option. Submental intubation allows a safe alternative in such patients.</p><p class="abstract"><strong><span lang="EN-US">Methods: </span></strong>25 Patients were studied with faciomaxillary trauma where submental intubation was indicated. After standard anesthesia induction patients were intubated with reinforced endotracheal tube (ETT), which is converted to submental route by a paramedian incision. At the end of the procedure, all patients had inter-maxillary wiring, were shifted to recovery room. Once they are recovered from the neuromuscular blockade ETT was removed through the submental tunnel.</p><p class="abstract"><strong><span lang="EN-US">Results: </span></strong>This was a prospective observational study in 25 adult patients undergoing faciomaxillary surgeries requiring submental intubation. The mean apnoea time was 1.28±0.38 minutes and induction to submental intubation time was 9.68±1.82 minutes. In one case there was damage to the pilot balloon while pulling the tube through the submental tunnel. Two patients had right endobronchial migration of the ETT. On postoperative follow up, one patient had infection at the submental incision site. </p><p class="abstract"><strong><span lang="EN-US">Conclusions: </span></strong><span lang="EN-US">Submental intubation is a safe, effective, alternative for short term tracheostomy in faciomaxillary sugeries. Careful handling of the ETT is must to avoid damage while passing through the submental tunnel. Avoid extra length of the tube introrally to prevent endobronchial migration of the ETT.</span></p>