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Abdominal trauma management has seen a paradigm shift over the last few decades. There is wide variation in the treatment depending on the level of healthcare facilities available. With an aim to standardise the treatment of solid organ injuries in blunt abdominal trauma, Indian Society for Trauma and Acute Care (ISTAC®) formulated consensus guidelines to benefit doctors engaged in trauma care in the country.

Objectives Delayed primary closure (DPC) of the skin has been suggested to decrease superficial surgical site infection (SSSI) in patients undergoing surgery for peritonitis secondary to hollow viscus perforation, but there is no consensus. The aim of this study was to compare the outcomes of primary closure (PC) and DPC of the skin in terms of SSSI, fascial dehiscence and length of hospital stay (LOS). Material and methods Sixty patients, undergoing emergency surgery for perforation peritonitis, were randomized to PC (n= 30) and DPC (n= 30). Patients in the DPC group underwent skin closure four or more days after surgery when the wound was clinically considered appropriate for closure. Patients in the PC group had skin closure at the time of surgery. Results Incidence of SSSI was significantly less in the DPC group (7.4%) compared to the PC (42.9%) (p= 0.004). However, the median time of DPC was the 10th POD, i.e., these wounds required considerable time to become clinically suitable for closure. Incidence of fascial dehiscence was comparable between the two groups (p= 0.67). Length of hospital stay (LOS) was 13.8 days in the DPC group compared to 13.5 days in PC; the difference was not significant (p= 0.825). Conclusion DPC of the skin incision resulted in the reduction of SSSI. However, this did not translate into a reduction in hospital stay, as it took considerable time for these wounds to become appropriate for DPC, thus bringing into question any real advantage of DPC over PC.

Haemophilic pseudotumours (HPT) are rare, but are seen in severe haemophiliacs due to spontaneous bleeding into joints and muscles. They are known to affect the musculoskeletal more, but rare incidence of intra-abdominal HPT has been reported. Intra-abdominal HPT arising from the mesentery has not been reported in literature. A high clinical suspicion and detailed imaging can help in diagnosis, though they are commonly mistaken for chronic abscesses. Needle aspiration/biopsy are contraindicated to avoid severe bleeding. Early institution of Factor VIII replacement is the cornerstone of treatment. Surgical excision, though risky, is indicated if there are symptoms due to progressive enlargement of the HPT or complications due to it. Radiotherapy and angioembolization are other treatment options that can be considered in selective cases.We report the case of a previously undiagnosed young, moderate haemophiliac male who presented with features of acute intestinal obstruction due to HPT of the mesentery.

Cutaneous metastasis (CM) from pancreatic adenocarcinoma is very rare. They often present as an umbilical nodule and are associated with other evidence of distant metastasis. We present the case of a 60-year-old male who presented with multiple non-umbilical cutaneous nodules, in an undiagnosed case of pancreatic adenocarcinoma, with no other evidence of distant metastasis.

Objective: The aim of our study was to evaluate whether insertion of a subcutaneous closed suction vacuum drain at incisional surgical site reduces the incidence of surgical site infection (SSI) in post operative cases of exploratory laparotomy for perforative peritonitis. Methods: An institutional based randomized control study was performed with two hundred patients each included in the study (with drain) and control (without drain) group. Both groups were statistically similar in terms of various variables and thus comparable. All continuous variables were reported as mean ± SD and compared across groups using unpaired t-test. All categorical variables were reports as n (%) compared across groups using Chi-square test for independence of attributes. Result: Use of a subcutaneous closed suction vacuum drain results in statistically significant reduction in wound infection (58% vs 16%; p < 0.001). The most common organism causing SSI was found to be Escherichia Coli accounting for 62.5% and 62.7% of cases in drain group and control group respectively, followed by Klebsiella (12.5% vs 24.14%). Conclusion: Use of a subcutaneous closed suction vacuum drain is effective in reducing SSI in contaminated surgery like that for perforative peritonitis and also leads to reduction in SSI related complications like wound disruption, patient discomfort, bad cosmesis, prolonged hospital stay, antibiotic use and increased cost. Bangladesh Journal of Medical Science Vol.16(1) 2017 p.85-90

Adult presentation of congenital diaphragmatic hernia (CDH) is rare. Out of the three varieties of CDH, Morgagni hernia is the rarest of all. Though most of them are asymptomatic and may be incidentally detected, they may also present in the emergency setting with respiratory or gastrointestinal features like obstruction or strangulation. Gastric outlet obstruction is a rare manifestation of adult Morgagni hernia. We present a case of adult left-sided Morgagni hernia with features of gastric outlet obstruction complicated with perforation.

Internal herniation is a rare cause of small bowel obstruction, with an incidence of 0.2-0.9%. Obstruction due to congenital internal hernias is even rarer. The commonest type of congenital internal hernia is the paraduodenal or the mesocolic hernia. The left and right mesocolic hernias constitute 75% and 25% of the mesocolic hernias respectively. Middle mesocolic hernias are an extremely rare and unusual variant of mesocolic hernia, and literature search revealed only three reported cases. In view of its rarity, a high level of clinical suspicion, supported by radiological evidence is required to diagnose it preoperatively. Prompt surgical management is mandatory to reduce complications and their associated morbidity and mortality.

Background Seroma formation is a well-known complication after modified radical mastectomy (MRM) for breast cancer. Another well known complication is shoulder movement dysfunction following the same operation. Traditionally, patients were asked to perform exercises of the shoulders as early as possible after surgery in the belief that it reduces subsequent shoulder dysfunction. The aim of this study was to evaluate whether delayed shoulder exercises after MRM could reduce seroma formation without compromising the outcome of shoulder mobility.

Subcutaneous and deep fungal infections in the hand are rare among children. These are usually found in immunocompromised adults or in persons engaged in soil handling activities, due to direct exposure, especially in the tropics. Delay in diagnosis is usual because pyogenic and other granulomatous infections are considered first.The authors present the case of a healthy, immunocompetent 2½-year-old child who presented with progressive swelling of the right hand mimicking a localized gigantism of the entire hand. Multiple operative drainage procedures done previously had failed to resolve the condition. A biopsy established the presence of fungal hyphae, thus confirming the diagnosis of deep fungal infection of the hand and guided proper therapeutic intervention. A strong index of suspicion needs to be maintained in cases not responding to conventional antibacterial therapy, and both microbiologic and histopathologic samples need to be obtained to establish the diagnosis.

Aim The aim of the study is to evaluate the results of the multimodality approach to diabetic limb ulcers.

A diaphragmatic hernia is defined as a communication between the abdominal and thoracic cavities, with or without abdominal contents in the thorax. It is usually diagnosed among newborns, but late presentation of congenital diaphragmatic hernias has also been reported with an incidence of 5 to 25%. Intestinal obstruction due to obstructed diaphragmatic hernia is very rare and represents a considerable diagnostic challenge. Herein, we report the case of an obstructed diaphragmatic Bochdalek-type hernia complicated by acute intestinal obstruction.

Though lipomas are one of the commonest mesenchymal tumours in adults, a lipoma of the head and neck region is relatively rare. Among those lipomas that develop in the neck, the posterior triangle is the most common location; occurrence in the anterior triangle is very rare. Though most lipomas are 10cm have also been reported in different parts of the body. Giant lipomas of the neck, particularly those >20cm, are extremely rare. Most patients of giant lipoma of the neck either present with complaints of cosmetic disfigurement or features of compression on deeper structures. Most lipomas do not pose any diagnostic dilemma. However, when a patient presents with a large, rapidly progressing lipoma of the head and neck region, the possibility of malignancy should be kept in mind. Surgical excision remains the treatment of choice.

Leiomyoma of the urinary bladder is a rare neoplasm of the bladder and accounts for 0.04 - 0.5% of bladder neo- plasms. Though most patients present with obstructive or irritative urinary symptoms, dyspareunia may be an un- usual presentation that should be kept in mind to avoid missing the diagnosis. Though MRI is considered to be the imaging modality of choice, cystourethroscopy with guided biopsy usually clinches the diagnosis. Surgical excision is the treatment of choice in this prognostically favourable tumour.

Parathyroid carcinoma is a rare disease. But multiglandular parathyroid neoplasm is even rarer. A high level of suspicion, on the basis of clinical, hematological tests and intraoperative findings is necessary to treat this disease entity, particularly in the absence of palpable neck masses. Preoperative localization is important. Bilateral neck exploration should be done routinely and all 4 glands seen to avoid missing out other pathological glands.

Unilateral renal agenesis is usually asymptomatic and may be found incidentally during examination for other causes. The incidence of testicular tumors arising from cryptorchidism is well established, but if it is coexistent with ipsilateral renal agenesis, the diagnosis and management becomes a challenge. Only three cases of such association have been reported in literature so far. This association has to be kept in mind when dealing with a case of testicular tumor arising from abdominal cryptorchidism, so that the function of the other kidney can be assessed before surgery, and protection given to it in the event of using radiotherapy in an adjuvant setting.

Internal herniation of small intestine is a very rare entity, and it poses a real diagnostic challenge clinically. Recurrent entrapment of the bowel may lead to partial to complete intestinal obstruction and eventually strangulation of the small bowel. Of this rare clinical entity, left paraduodenal hernia is more common. High index of suspicion with prompt management may prevent bowel strangulation and gangrene. We present a case of acute intestinal obstruction due to left paraduodenal hernia with malrotation of midgut in a 55-year-old male patient.

Gallstone ileus is an uncommon cause of small bowel obstruction and is rarely suspected preoperatively. Patients are usually elderly and present with features of small bowel obstruction. Commonest site of impaction of the gallstone is the terminal ileum. We report a case of gallstone ileus in a 37-year-old female who presented with vomiting and anuria, and without any symptoms of intestinal obstruction. Intraoperatively the gallstone was found impacted at the duodeno-jejunal flexure. Impaction of gallstone at the duodeno-jejunal flexure is yet to be reported in literature.