No abstract

No abstract

, an interesting and a unique surgical technique described in the past, but seems to have resurfaced now amidst commendation and condemnation. The technique involves the incorporation of a subcutaneous access stoma in the long limb of Roux-en-Y loop of jejunum used for the anastomosis. This stoma provides permanent access to the bilioenteric anastomosis and thus to the hepatobiliary tree for non-operative management of chronic and recurrent biliary tract problems. The most commonly encountered problem is a strictured hepaticojejunostomy, which can be radiologically or endoscopically approached and subjected to calibrated hydrostatic dilatation.The access-loop HJ is a controversial burning issue in the realms of GI surgeons of the world. Some say it is a useless surgical exercise and strongly believe that no interventional radiologist can enter the access loop by whatever means available. While others strongly vouch and advocate, the 'establishment of access loop' in all cases of difficult HJ. In our opinion the access loop acts as a "Parachute" to a patient with "restrictured HJ". In return it exacts a small penalty, in form of mildly extended operating time, an unsightly abdominal scar and in a few, an associated un-complicated incisional hernia.In the hands of a competent interventional radiologist or an endoscopist, an access loop certainly obviates a messy and a hazardous re-operation and in a few, a taxing, albeit lifesaving, liver transplantation. ABSTRACTBackground: Access-loop Roux-en-Y hepaticojejunostomy (HJ), an interesting and an unique surgical technique described in the past seems to have resurfaced amidst commendation and condemnation. Methods:The technique involves the incorporation of a cutaneous access stoma in the Roux-en-Y loop of jejunum used for the anastomosis. This stoma provides permanent access to the bilio-enteric anastomosis and thus to the hepatobiliary tree for non-operative management of chronic and recurrent biliary tract problems. Here we are presenting our experience in 22 cases managed by us with "access-loop Roux-en-Y hepaticojejunostomy (HJ)" over a period of 15 years (2001 to 2016). Results: 22 cases were managed successfully. The maximum follow-up was for 05 years with no recurrence or stricture only 01 patient had a small Incisional hernia. Conclusions:The objective of this work is to, describe an optional technique (although less known and practiced) during the accomplishment of a "roux-en-Y" hepaticojejunostomy that, allows future endoscopic and interventional radiology access to the bilio-enteric anastomosis.

Background: Two most demoralizing things in life are physical pain and bad body odour. A counted few body pains are as terrible, as oppressive and as tormenting, almost on daily basis as the pain of fresh acute fissure in ano. It pins your whole being, your awareness of life and focus of living on to your painful anus. Anal fissures are commonly encountered in routine colorectal practice. Fissure has traditionally been treated surgically. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment.Methods: 40 patients with acute fissure in ano were divided into 02% diltiazem gel and unilateral subcutaneous internal anal sphincterotomy (USIAS) groups. Patients in the two groups were followed up subsequently.Results: Anal fissures were found completely healed in 14 (70%) out of 20 patients treated with 02% diltiazem gel between 4-8 weeks. Healing was 100% with “USIAS” group. The mean healing duration of fissure was 04.45 weeks in diltiazem gel group and 03.45 weeks in “USIAS” group. 65% patients were free from pain after treatment with diltiazem gel whereas 95% patients were free from pain after treatment with “USIAS”.Conclusions: This prospective study, demonstrates that “USIAS” is superior to pharmacological treatment of anal fissure with good symptomatic relief, high rate of healing with very low rate of complication. Patients who are not willing to undergo surgery may be managed by 02% diltiazem as pharmacological line of management for fissure in ano.

Background: Anal fissure is a tear in anal canal just below dentate line. It can be acute or chronic. In most patients, it is located in posterior midline. Its treatment is both conservative and surgical. In conservative management, there are no clear guidelines and its goal is to break the cycle of anal sphincter spasm allowing improved blood flow to fissured area for healing. Surgery is considered for patients not responding to conservative measures and its gold standard is lateral internal sphincterotomy.Methods: This prospective study was conducted among 60 patients with acute anal fissure. Patients were randomly divided into two study groups based on treatment protocols conservative management and Bilateral LSIAS. Prior informed written consent was obtained. Demographic profile, history, investigations, diagnosis, treatment and follow-up data was recorded and analyzed.Results: Patients with Bilateral LSIAS got pain relief immediately after surgery. 57% patients with conservative management reported head-ache and perianal itching. Over 86% of patients with Bilateral LSIAS got relief from pain and discomfort after treatment; around over 46% patients with conservative approach, had pain and discomfort after 6 weeks of treatment.Conclusions: Results show that Bilateral LSIAS surgery is a better approach than conservative management of anal fissure. Further, the Bilateral LSIAS surgery has maximum chances of early recovery and pain relief and reduced chances of progression to chronic anal fissure. Hence, we can conclude that for anal acute fissure, Bilateral LSIAS surgery procedure is the treatment of choice.

Background: In 1952, Professor Bryan Brooke described his technique for everting an ileostomy in order to minimise skin excoriation1. Pouting, mucosa-everting Brooke’s ileostomy have been accepted as the best technique for stoma formation in almost all cases, save a few difficult situations – such as edematous friable bowel with bulky short mesentry! In such cases formation of standard Brooke’s ‘Pouting’ ileostomy is not only difficult, but an impossible and a dangerous surgical exercise! In these situations where the bowel is “Un-Brookeable” due to aforementioned causes. Over a period of 12 years we could device a formula – “Ray’s Criteria” to decide at operation, if a given ileum in a particular patient, is safely “Brookeable” (i.e. evertable into a neat Brooke, spouting ileostomy) or is   “Un-Brookeable”.Methods: 23 patients were included in this study over 12 years, who due to the peculiarity of their body morphology (obesity or thick abdominal fat), edematous friable bowel with bulky mesentry, the ileum could not be drawn outside the abdomen and everted as Brooke’s ileostomy. The “Brookeability” of the exteriorized ileum was decided based on satisfying two issues of Ray’s criteria.Results: By using “Ray’s criteria”, we could seggregate patients safely as “Brookeable” and “Un-Brookeable”. Those deemed “Un-Brookable” underwent “Long segment Hanging snout” end ileostomy, which is the theme of our study.Conclusions: We are emphatic in stating that by using “Ray’s criteria” we could accurately segregate cases into “Brookeable” and “Un-Brookeable” ileum.

Background: To study a simple yet effective surgical technique of management of epigastric port site bleed and how to prevent such an incidental surgical accident in patients undergoing laparoscopic cholecystectomy.Methods: This is a prospective pilot study done during last 20 years in patients undergoing laparoscopic cholecystectomy, who accidentally developed epigastric port-side bleed. A 22 Fr inflated Foley catheter under traction was used to control the bleeding. After an average 24-48 hours of traction tamponade, the catheter was deflated and removed accordingly.Results: The 23 patients had a complication of epigastric port bleeding, in which Foley’s catheter tamponade was used. In 22 (99.65%) cases, bleeding was controlled effectively with Foley catheter tamponade. Only in 01 patient bleeding could not be controlled with the usually applied traction, so an enhanced traction was introduced, with our indigenously fabricated external contraption. No case required wound exploration or any other sophisticated means of controlling epigastric port site bleed. There was no mortality.Conclusions: One of the most common complications of laparoscopic surgery is epigastric port site bleeding, which is an avoidable complication, provided proper procedure is followed in establishing this port.

Background: We are concerned about the wound management and wound healing amongst post-operative patients, as wound complications increase the morbidity of patients post-surgery. Most common wound complications post-surgery are wound seromas, hematomas and surgical site infections (SSIs). SSIs lead to increased hospital stay and increased morbidity alongside increasing unnecessary patient suffering and a decreased quality of life. The underlying principle for the use of subcutaneous drains is based on the belief that removal of serum or debris and eradication of dead space in subcutaneous plane will bring down the rate of infection and wound complications.Methods: A randomized control study was conducted at the General Surgery Department at SGT Medical College, Gurgoan, Haryana. In total, 60 patients were selected (after taking informed written consent) among those admitted to the Surgery Department for laparotomy procedure. Patients were divided randomly into two groups i.e., group-A (study group) and group-B (control group). In group-A patients, subcutaneous wounds were closed over a drain (32-F multi-perforated drain), while in group-B patients no drain was used. Intra-operative and post-operative findings were recorded and analysed to draw study conclusions.Results: SSIs were observed significantly higher among patients without subcutaneous drain (group-B). Patients of group-B had significantly higher incidence of seroma and pus as compared to group-A patients. Experience of pain was reported higher among the patients without subcutaneous drain (group-B).Conclusions: Subcutaneous drains play an important role in reducing the incidence of SSIs, wound complications, wound pain; thereby lead to better healing of the surgical wound.