Overlap sphincteroplasty has a good outcome in majority of the patients with incontinence due to a structural sphincter defect. Additional anterior levatorplasty may improve outcomes. Previous failed repairs or use of a gracilis muscle augmentation may have a worse outcome secondary to poor native sphincter muscle. Improvement in resting and squeeze pressures on anal manometry may be associated with a good outcome.

Introduction: There are several described techniques for ventral hernia mesh repair in both laparoscopic and open approach. Both approaches have their own pros and cons. Ventralex patch repair is an open technique using dual mesh in the intraperitoneal plane for ventral hernia repair. Aim: To describe an open technique with the use of ventalex patch in the repair of selected ventral hernias and to compare the open technique in terms of cost, operating time, complications and duration of hospital stay with the similar studies using Ventral patch and available literature for open and laparoscopic repair. Materials and Methods: This retrospective study was conducted on 248 patients over a period of seven years who underwent open ventral hernia repair with the Ventralex Patch, at a tertiary care hospital. A retrospective chart review and telephonic interview was conducted postoperatively and at the end of at least 24 months to assess for outcomes, particularly recurrence. Descriptive statistics reported using frequency and percentage for categorical variables. Continuous variables were reported using mean±Standard Deviation (SD). Results: A total of 248 patients underwent hernioplasty with ventralex patch. The mean age was 50.57 years and mean BMI was 28.37 kg/m2. The average duration of operation was 27.5 minutes and hospital stay was 2.275 days. The most common defect size was 2 cm (47.2%). The cost analysis of this technique revealed an average cost of INR 35,142 as opposed to an average cost of INR 88,601 for laparoscopic repair (including disposables) and INR 30,174 for open traditional sub-lay repair. Twenty-one patients developed surgical site infection (8.5%), and 27 patients (10.9%) developed seroma formation. A total of six patients developed superficial skin necrosis. The cumulative hernia recurrence rate at the end of 24 months was 6.5% (16/248). Conclusion: Ventralex patch repair is very efficient and effective in the treatment of selective umbilical, periumbilical, epigastric and incisional hernias with a comparable complication profile in terms of short term complications and recurrence rate compared to available literature.

A 26-year-old man who was previously well presented to the emergency in septic shock. He had a preceding history of fever, right upper abdominal pain and jaundice. On examination, there was tenderness over the right hypochondrium and epigastrium, without features of generalised peritonitis. His blood tests were suggestive of sepsis with deranged liver function tests. CT scan of the abdomen showed multiples abscesses in various segments of the liver and a thrombus in the inferior venacava, without any other intraabdominal focus of infection. The abscess was aspirated under sonographic guidance, and the cultures grew Streptococcus constellatus species of S. milleri group (SMG). He received crystalline penicillin, based on culture sensitivity and underwent drainage of the abscess. There was a clinical improvement and he was subsequently discharged in a stable condition. On 3 months follow-up, there was a complete resolution of the liver abscess and normalisation of the liver function tests.

Background: Abdominal cocoon is a rare cause of intestinal obstruction characterized by fibro collagenous membrane encapsulating the abdominal contents to varying degrees. The most commonly identified etiology remains to be ‘idiopathic’ and hence it is also known as idiopathic sclerosing encapsulating peritonitis.. Few case reports of abdominal cocoon secondary to gastrointestinal malignancy and tuberculosis have also been reported. The objective of the study was to study the spectrum of clinical presentation, identify the various aetio pathogenesis described and their impact on outcome of surgically managed patients with abdominal cocoon.Methods: The clinical data of twelve different cases of abdominal cocoon presented to a general surgery unit from January 2012 to December 2017 with minimum of 1 year follow up were analyzed.Results: In our series we had 12 patients with cocoon who underwent surgical intervention out of which 8 were primary and 4 were secondary to TB. In primary type one out of eight patients had acute presentation, but in secondary three out of four had acute presentation. In primary 6 out of 7 patient’s pre-operative CT showed cocoon, but in secondary only 1 out of 3 showed cocoon. In patients with primary cocoon 3 out of 8 patients had bowel resection and only one had post-operative morbidity. In patients with secondary cocoon three patients had bowel resection, stoma creation and reoperations with stormy post operative period. All 4 had post-operative morbidity, however all of them received ATT and definitive surgery was performed 1-2 years later with minimal resection and serial images also showed resolution of cocoon formation with ATT. Primary group up to 5 years follow up, there was no recurrence of symptoms. Both groups did not have any mortality.Conclusions: Abdominal cocoon is a rare disorder and the cause may be primary or secondary. In our series tuberculosis is the aetiology for secondary cocoon. Primary cocoon is easier to diagnose, manage and associated with less post operative complications compare to secondary cocoon. Damage control first surgery, nutritional build up and treatment with anti tubercular drugs are needed for management of cocoon secondary to TB for a better outcome in acute presentations. Definitive surgery can be performed once the nutritional status improves with less morbidity.

We report a retroviral positive patient who presented to us with recurrent skin lesions along with intermittent, colicky periumbilical abdominal pain associated with non-projectile, postprandial vomiting. Contrast-enhanced CT (CECT) of abdomen and pelvis was suggestive of proximal jejunal obstruction. Double balloon enteroscopy done which showed extensive deep ulceration with surrounding nodular surface and friable mucosa at 60 cm from pylorus with luminal narrowing. The biopsy from this region as well as the skin lesion on the forehead grew Talaromyces marneffei. She was initially treated with liposomal amphotericin B for 2 weeks following which she received itraconazole for 3 weeks for disseminated talaromycosis infection. She had already been started on antiretroviral therapy (ART) 1 year back however her cluster of differentiation 4 (CD4) counts did not show any improvement. Proximal bowel obstruction leading to poor nutritional status compounded with ineffective ART therapy due to suboptimal absorption, dictated the staged management of her condition. Feeding jejunostomy was done with a plan to offer her resection and anastomosis of affected jejunal segment, should she require one, after optimising her nutritional and immunological status.

Aggressive angiomyxoma (AAM) is a very rare, benign, locally infiltrative mesenchymal tumour with a high chance of recurrence following surgical excision. In the male population, it is so rare that less than only 50 cases have been reported so far. We present a case of a large recurrent perineal AAM in a man who presented with swelling in the perineal region following surgical excision 3 years ago. After evaluation, the diagnostic dilemma of a possible perineal hernia or recurrence remained. Surgical exploration ruled out hernia and the tumour was excised with difficulty. Immunohistochemical examination showed tumour cells with diffuse nuclear positivity for oestrogen receptor and patchy cytoplasmic positivity for desmin (A2). Histological and immunohistochemical features confirmed the diagnosis. Being very rare, AAMs need to be considered as a differential diagnosis of pelvic/perineal tumours among males. With no standardised therapy for AAM, complete resection would be the goal of therapy.

Background: Mycetoma is a chronic granulomatous infection of skin, subcutaneous tissue and bone caused by either fungi (eumycetoma) or bacteria (actinomycetoma). Here we present our experience in the management of this rare condition.Methods: Patients managed for mycetoma foot from August 2011 to January 2018 in authors’ general surgery department were included. The data was collected retrospectively from the hospitals electronic database.Results: Eight patients were recruited with the mean age of the patient was 52years and had male predominance. Most common clinical presentation was swelling with discharging sinuses in the foot. Imaging performed were X ray foot and MRI. Osteomyelitis was noted in 4 patients (50%). Eumycetoma and actinomycetoma were equal in distribution. Out of 4 patients with eumycetoma, one had grown Acremonium species in the culture and out of 4 actinomycetoma patients, 3 had grown Actinomadura pelletieri and one had Nocardia. Surgical procedures performed were 3 biopsies (37.5%), 3 debridement (37.5%) and 2 amputations (25%). Eumycetoma patients were treated with Itraconazole monotherapy and actinomycetoma patients were treated with Trimethoprim-Sulfamethoxazole and cyclical administration of amikacin. Good response was noted in 6 patients and two patients with Eumycetoma had progression of disease with medical therapy and underwent amputation.Conclusions: High clinical suspicion and tissue for histopathological and microbiological evaluation is mandatory to confirm the diagnosis. Medical therapy plays a major role in the treatment of mycetoma foot even if the bone is involved. Surgical procedures like debridement and amputation are indicated only for failed medical therapy with progression of disease (seen most often with eumycetoma) and if there are secondary bacterial infections.

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