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Introduction: Different techniques have been tried to blunt undesirable hemodynamic effects like tachycardia, hypertension and dysarrhythmias during and after laryngoscopy and tracheal intubation. Objective: To find out the effect of oral clonidine premedication on hemodynamic stress response to laryngoscopy and tracheal intubation. Methodology: It was a prospective, randomized, double-blind comparative study conducted in patients undergoing laparoscopic cholecystectomy. Either oral clonidine 300 mcg (n=30) or placebo (n=30) was given one hour before the surgery. Depth of anesthesia was monitored and maintained at 40-60 level using bispectral index (BIS) monitor. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MABP) and oxygen saturation (SpO2) at baseline, one hour after premedication, on operation theatre (OT) table, just before and after one, two and five minutes after laryngoscopy and intubation were compared in Clonidine and placebo group using Paired t test and Chi-square test. SPSS was used for statistical analysis at P-value0.05). Conclusion: Oral clonidine premedication was effective in blunting undesirable hemodynamic stress response to laryngoscopy and tracheal intubation compared to the placebo.

Background: Predictions of difficult cholecystectomy preoperative make the surgeon prepared, thereby making a more careful dissection, back up from senior surgeons, and a low threshold for early conversion. Objectives: To utilise an operative grading scale to predict open conversion, duration of surgery, total length of stay, complications and to validate Nassar score. Methods: This was a prospective cross-sectional study done from 2020 July 9 to 2021 January 30 after ethical clearance among all patients of BPKIHS planned for laparoscopic cholecystectomy for symptomatic gallstone disease. Nassar scale was used for risk evaluation of difficult cholecystectomy. The intraoperative outcome parameters were bleeding, bile spillage, stone spillage, presence of bowel or biliary injury, operative time and conversion to open surgery. Postoperative outcomes noted were total length of stay, 30-day complications, reintervention, and mortality. The data were entered in Microsoft Excel sheet 2010 and analysis was done in SPSS v.26. Results: Seventy-four patients were analysed. Comparison of Nassar scoring system with outcomes revealed a significant association of rising Nassar grade with bile spillage, stone spillage, bleeding, post-surgical drain placement, conversion to open, duration of surgery, and total length of stay. Operative time was significantly more in male, cholecystitis, and interval cholecystectomy. Conversion to open was significantly associated with Nassar grade 4, acute cholecystitis, and interval cholecystectomy. There was no mortality, 30-day reintervention, and complication. Conclusion: Nassar operating scale is simple scale that can be used by all level of surgeons to predict difficult laparoscopic cholecystectomy. Rising grades have significant correlation with difficulty and complications.

Peritoneal flap mesh hernioplasty is a technique to deal with complex ventral hernias in which primary closure of the defect is not attainable. We are here presenting a case report of a 50-year-old gentleman with huge complex ventral hernia with loss of domain. The patient also had overlying ulcerated and blackish colored skin. Botulinum toxin was infiltrated into the muscles of anterior abdominal wall and was followed by peritoneal flap mesh hernioplasty after one month. The final outcome was complete closure of the midline with a healthy skin with no evidence of abdominal compartment syndrome. There was no evidence of early recurrence on follow up. Owing to the favorable outcome in this case, suitability of peritoneal flap mesh hernioplasty technique in treatment of complex ventral hernia could be explored further where closure of the primary defect is difficult.

BackgroundPancreaticoduodenectomy is a complex high risk surgical procedure usually done for malignant disease carrying significant postoperative morbidity and mortality. An audit and analysis of rate of postoperative morbidity and mortality and the impact of case volume can provide information about the lacunas in patient care and methods to improve it for safe and early discharge of patients. This study was conducted to find out demographic profile, the rate of perioperative morbidities, mortality and impact of case volume on patients undergoing pancreaticoduodenectomy for malignant disease which may serve as a guide to uplift the patient care in our center.MethodsRetrospective analysis of prospectively collected data of patients undergoing pancreaticoduodenectomy from 2015 to 2019 was performed. A total of 62 patients were included in the study. Patients clinic-demographic details, intraoperative and postoperative events were recorded. Rate of various postoperative morbidities and mortality and year wise trend of these factors were analyzed.ResultsMost of the patients were in sixth decade of life (38.7%) with male preponderance (61.3%). Pancreatic cancer was most commonly seen followed by cholangiocarcinoma (46.8%). SSI (32.3%), intraabdominal collection (25.8%), anastomotic leak (14.5%), pancreatic fistula (22.6%), postpancreatectomy hemorrhage (8.1% ) were the major postoperative events. Mortality was found in 12.9% patients. ConclusionThere has been a decrease in rate of all these postoperative adverse events and improvement in the intraoperative blood loss and surgical duration with advancing years and increasing number of cases.

Scrotal skin loss following Fournier’s gangrene is very distressing to the patients. The management is complex and challenging shown by the multiplicity of flaps and techniques described in the literature. We included a total of 14 patients with the diagnosis of Fournier’s gangrene over a period of 1 year in our department. We used a modified pudendal thigh flap to reconstruct neo-scrotum in patients with scrotal defects resulting from excision and debridement of Fournier’s gangrene. The average age group of the patients in our study was 41.8 years. The average body mass index in our study was 22.36 kg/m2. The average defect size in our study was 7.05 × 13.07 cm2. There was a single case of flap necrosis. Modified pudendal thigh flap produces a neo-scrotum that looks natural in appearance, provides good quality skin cover and cushion to the testes as well as protective sensation.

Amyand’s hernia in a child is a very rare entity. It poses a diagnostic challenge to the surgeon due to its variety of presentation. We are presenting a case of a 5-year-old child who presented to our institute with right-sided irreducible inguinal hernia. On exploration, the content of the hernia was caecum with normal appendix for which herniotomy with appendectomy was done.

Diaphragmatic hernia can be congenital or acquired. Usual clinical presentation may range from asymptomatic cases to serious respiratory/gastrointestinal symptoms and occasionally atypical presentation as lumbar hernia also. The diagnosis of diaphragmatic hernia is based on clinical investigation and is confirmed by plain X-ray film and computed tomography scan. Various treatment approaches, open, laparoscopic and combination, are available for this condition. However, laparoscopic approach has recently gained in popularity. Surgical repair typically involves primary or patch closure of the diaphragm through an open or endoscopic abdominal or thoracic approach. This paper reflects our experience of repair of diaphragmatic hernias to evaluate its safety, efficacy and outcomes.

Background and Objective(s). Rouviere’s sulcus (RS) is an important anatomical landmark. The aim of this study was to find the distribution of anatomical characteristics of RS seen during laparoscopic cholecystectomy in the population of our part of the world and its association with complications. Methods. This is a prospective observational study involving patients of age ≥16 years who underwent laparoscopic cholecystectomy for uncomplicated gall stone at BPKIHS between May and July 2019. Result. 230 cases were analyzed, and RS was present in 90.4%. Open sulcus type was the commonest (54%), followed by scar type (22.9%), closed sulcus type (12.5%), and slit type (10.6%), respectively. In 59.1% of cases, it was oblique to the anterior, inferior, and external edge of the liver, while in the remaining cases, it was transverse. The mean ± SD values for operative time and duration of hospital stay in the RS visible and the RS not visible groups were 29.16 ± 8.736 and 42.9 ± 23.646 minutes, and 1.26 ± 0.440 and 1.90 ± 0.910 days, respectively (p value ≤0.001). One minor complication occurred in each group: RS initially visible group and RS visible on the adhesion release group, while 3 minor complications occurred in the RS not visible group. Only one major complication occurred in the RS not visible group. Conclusion. Identification of RS by operating surgeons is a predictor of safe laparoscopic cholecystectomy.

Introduction: Groin hernias are common problem worldwide with approximate incidence of 5%. Indirect inguinal hernia is the commonest hernia irrespective of gender. The prevalence as well as complication of inguinal hernia will increase with increasing age. Strangulation, the most common serious complication of inguinal hernia occurs in 1 to 3 % of the patients. Outcome of the treatment depends on the duration of presentation, co-morbidities and extent of the surgery.Objective: The objectives were to study the different clinical presentation, surgical options and outcome of complicated groin hernia in tertiary care centre.Methodology: This retrospective review of case sheet was conducted in the department of surgery. We reviewed the record file of complicated groin hernia patients, irrespective of age and gender from January 2008 to December 2016 (8 years). Ethical Clearance was obtained from institutional review committee. Statistical analysis was performed using SPSS for windows, version 11.5(SPSS Inc.,Chicago,IL). The data were presented in percentage, mean and standard deviation.Results Out of 45 patients, majority were male 37(82.2%) and commonly effected age group was more than 60 years 18(40%) followed by infants and adolescents. Majorities had complicated inguinal hernias 42 (93.3%) followed by femoral hernia, i.e. 3(7%). Majority of patient underwent inguino-scrotal exploration 26(57.77%) followed by herniotomy 9(20%) and hernioplasty 7(15.55%). Most of the patients were discharged from the hospital 37(82.2%).Conclusion: Most common type of complicated hernia is inguinal hernia; irreducibility and pain were commonest symptoms at presentation. Commonly performed operation is inguinoscrotal exploration and herniorraphy with good surgical outcome.BJHS 2018;3(2)6:395-398.

Background: Hydatid disease is an endemic disease in several parts of the world. Surgeons and physicians in the non-endemic areas may encounter the disease. Surgery remains the mainstay of therapy. Recently, laparoscopic treatment of hepatic hydatid disease has been increasingly popular and has undergone a revolutionary parallel to the progress in laparoscopic surgery. It is a new and encouraging approach with minimum morbidity and mortality.Objective: To assess the outcome of laparoscopic management of hydatid cyst.Methods: A retrospective & prospective case series study included all patients of hydatid liver cysts who were managed laparoscopically from 1st January 2008- 31st June 2013 (five & half yrs). Patients with deep intraparenchymal location of the cyst, more than 3 cysts and cysts with calcified walls were excluded.Results: Thirty two patients were included in this study to know the results of the laparoscopic management of hepatic hydatid cyst disease. Majority of patients in the age group of 21-40 years. The mean age was of 38± 5.25 with range being 19-65 years. The commonest presentation of dull aching pain in right upper quadrant was seen in 21(62.5%) patients followed by hepatomegaly in 12 (37.5%) patients & right upper abdominal lump in 8 (25%) patients. Twenty seven (84.3%) patients had single cyst & 5 (15.6%) patients had two cysts. The mean diameter of the cyst was 9.2±2.72 cm in size. The mean operative time was (65.42±12.67min) with range being 45-125 mins.Conclusion: The laparoscopic approach is safe & feasible in selected patients. The treatment choices of hydatid disease of the liver have increased in the last 2 decades including medical treatment, percutaneous drainage, or a combination.Health Renaissance 2015;13 (1): 86-94

Background: Chest trauma is a major public health problem. It includes injury to chest wall, pleura, tracheobronchial tree, lungs, diaphragm, esophagus, heart and great vessels. It comprises 10-15% of all traumas and 25% of death due to trauma occurs because of chest injury. Chest trauma is seen with increasing frequency in urban hospitals. Methods: A prospective study of all pati with chest injury irrespective of age, sex and mode of injury presenting to BPKIHS emergency were included in this study from 15th March 2007 to 14 th March 2008. Results: During the study period of one year total trauma patients presented to emergency were 1524. Out of this 122 patients were of chest injury. It comprises 8% of all trauma patients. Majority of patients belonged to the age group (21-40) years. Out of 122 patients, 57 (46.7%) patients sustained injury due to fall from height and was the commonest cause of trauma in this study followed by road traffic accident which was 38 (31.1%), 15 (12.3%) had physical assault and similar number of 6 patients (4.9%) sustained injury due to gunshot injury and stab injury. Out of 122 patients, 34 (27.9%) patients had associated injury. The most common chest injury was pneumothorax followed by isolated multiple rib fracture, hemothorax, isolated single rib fracture hemopneumothorax, flail chest, subcutaneous emphysema, lung contusion, open pneumothorax and tension pneumothorax. Conclusion: Majority of chest trauma patients were young adults with male preponderance. Blunt trauma chest was most common chest injury. Pneumothorax was the most common chest injury. Majority of patients were managed with tube thoracostomy, analgesics and chest physiotherapy. Health Renaissance 2015;13 (3): 107-113

Introduction: Inflammatory Bowel Disease (IBD) is a chronic, relapsing inflammatory disorder of gastrointestinal tract that encompasses chronic Ulcerative Colitis (UC) and Crohn’s Disease (CD). Traditionally, it was believed to occur mainly in western countries like North America and Europe, but now perhaps with increasing westernisation, it has become a global disease with accelerating incidence in Africa and Asian countries like India and Nepal, which has also mirrored the growth compared to its neighbouring countries, where there has been an increased detection of this disease over the past few years. Aim: To review the experience in the disease profile and management of IBD in our surgical unit. Materials and Methods: This was a retrospective analysis of prospectively maintained data from January 2009 to May 2017 at BP Koirala Institute of Health Sciences, a tertiary care centre at the Eastern region of Nepal. The patients were grouped into two periods (first: January 2009 to March 2015; second: April 2015 to May 2017). We managed 30 cases (UC-19 and CD-11) in the surgical unit. Results: Eleven vs nineteen IBD patients were managed in the first and second time periods respectively. The median age of the patient with UC was 45.1 years. The most common presenting symptom was rectal bleeding. Pancolitis and left sided colitis was each seen in 42% and 52.6% of patients, respectively. Severe to fulminant colitis was seen in 36% of patients. Seven patients requiring surgical intervention (staged restorative total proctocolectomy-6 and total proctocolectomy with end ileostomy-1), while the remaining 12 cases were managed with a non operative treatment. Similarly, the median age of patient with CD was 55 years. The most common presenting symptom was pain abdomen. Eight patients had predominant small bowel involvement, two colonic, while one patient had both small and large bowel involvement. All patients required surgical intervention for symptoms related to it. At one year of follow-up, three patients had recurrence, two requiring initiation of anti-tumour necrosis factor therapy. Conclusion: IBD is no more a rare disease in a country like Nepal. With the global rise in incidence, there has been increased detection of IBD cases at our centre (9.5 cases/ year in the second period vs 1.8 cases/year in the first period) probably due to increased awareness and establishment of a separate Gastrointestinal unit with a specialist team trained from high volume centre.

This study aims to compare the operative results and oncological outcomes of patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer. Anterior resection has become the preferred treatment option for rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. Resection of primary rectal and rectosigmoid cancer was performed in 298 patients from January 2003 to November 2010. These 298 patients (163 men and 135 women; median age, 67 years) underwent anterior resection. The curative resection was performed in 269 patients (90.3 %). TME was performed in 202 patients (67.8 %). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8 % and 32.6 %, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1 % and 1.3 % of patients with TME and PME, respectively (P

Background: Colorectal cancers (CRCs) are the third most commonly diagnosed cancer in human and major public health problems worldwide. The number of people afflicted with cancer is increasing in the country, and if the trend continues, cancer could soon be among Nepal’s main killer diseases. The purpose of this study was to know the management and outcome of colorectal surgery for colorectal cancer at our centre.Methods: The study was conducted in the Department of Surgery, B.P.K.I.H.S. Dharan, after ethical approval from institutional ethical review board. All patients of colorectal cancer who were operated in our hospital, between 15th June 2012-15th June 2017 (5 years) were included in this study. Each patient’s medical record was reviewed retrospectively. Data on the patients presenting complaints, disease status, radiological findings, treatments provided, co morbidities, operative details, postoperative mortality and morbidity, histological results, outcomes and follow up was retrieved from the available case record files and was recorded in predesigned performa. Only histopathological confirmed cases were included in the study.Results: Total of 109 patients of colorectal carcinoma was registered in our hospital in last five years but only 69 patients underwent curative colorectal surgery at our centre. Out of 69 patients, 41(59.42%) were male and 28(40.58%) were females. The range of the age was 22 to 86; the median age at the diagnosis was 56.5 years. Out of 69 patients, 19 patients underwent right sided hemicolectomy, 12 patients underwent left sided hemicolectomy, 29 patients underwent anterior resection (high/low) and 9 patients underwent abdominoperineal resection. About 95.42% cases were adenocarcinoma on histology. The overall morbidity and mortality were 21.52% and 8.45% respectively.Conclusions: Colorectal cancer is common cancer and there is increasing trend. We believes that until and unless a population-based cancer registry is created and maintained, it will be difficult to project the exact number of people living with colorectal cancer and the necessary measures to be taken.

Congenital omental cysts are rare intra-abdominal pathology, which are difficult to diagnose preoperatively; as such a high index of suspicion is required for accurate preoperative diagnosis. We present a case of congenital omental cyst in a 3-year-old girl who presented with huge abdominal distension. We performed diagnostic examinations including ultrasonography and CT of the abdomen. An omental cyst was diagnosed because of its position and connection to the surrounding tissues. She was operated and cyst was excised completely. Histological examination revealed an omental cyst with endothelial lining and haemorrhagic fluid inside. She had an uneventful recovery and doing well, without recurrence at follow-up of 24emsp14;months. Clinicians must rigorously pursue a preoperative diagnosis, as it may prevent a surprise upon laparotomy and result in proper management.

Boerhaave's syndrome is the rare and often fatal condition of spontaneous oesophageal rupture. When present with atypical symptoms, diagnosis is frequently late, which contributes to the high morbidity and mortality. The authors describe a unique case of a 50-year-old man presented with atypical Boerhaave's syndrome, in which the diagnosis was made several days following presentation by observing a large pleural effusion that had evolved rapidly on chest radiographs. He was managed without thoracotomy. Although survival has been reported with non-operative management of contained oesophageal perforations, to our knowledge, this is the rare case report of surviving Boerhaave's syndrome with free pleural rupture, without thoracotomy.