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Introduction Creating pneumoperitoneum is the most challenging step during laparoscopy. The periumbilical area is the classic site for Veress needle insertion. We adopted a new access point for peritoneal insufflation. Methods We introduced a new point for Veress needle insertion to create pneumoperitoneum during difficult laparoscopic procedures. The needle is placed between the xiphoid process and the right costal margin, and it then proceeds toward the patient’s right axilla. We collected data to compare using this new method of peritoneal insufflation with using Palmer's point for pneumoperitoneum. Results Since 2013, we have used this new technique in 570 patients (first group) and Palmer’s point in 459 patients (second group). Among these patients, 196 patients (20%) had had previous abdominal operations, 98 patients (10%) had irreducible ventral hernia, and 735 patients (70%) were morbidly obese. The two groups were comparable in terms of patient characteristics. The mean time to create pneumoperitoneum in the first group was 0.8 ± 0.002 min compared to 1.08 ± 0.007 min in the second group (P ≤ 0.5). The mean number of punctures was 1.57 ± 1.02 in the first group compared to 2.9 ± 1.5 in the second group (P≤ 0.5); in the first group, 97% were successful on the first attempt entry, whereas this figure was 91% in second group. In the first group, the liver was punctured in 13 patients without any further complications; no other viscera were punctured. In the second group, gastric puncture occurred in 5 cases, transverse colon in 2 cases, and omental injury in 12 cases. Conclusion This new access point may represent a safe, fast, and easy way to create pneumoperitoneum, as well as a promising alternative to Palmer’s point in patients who are not candidates for classic midline entry.

The Global Alliance for Infections in Surgery appreciates the great effort of the task force who derived and validated the Sepsis-3 definitions and considers the new definitions an important step forward in the evolution of our understanding of sepsis. Nevertheless, more than a year after their publication, we have a few concerns regarding the use of the Sepsis-3 definitions.

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.

Background and Objectives: Pregnant women with paraumbilical hernia usually postpone hernia repair until after delivery, but some patients request that it be done during cesarean delivery. Therefore, we evaluated the outcome of combined cesarean delivery and paraumbilical hernia repair in a prospective study at a tertiary referral university hospital. Patients and Methods: In a prospective study, we compared the outcome of 48 patients undergoing cesarean delivery combined with paraumbilical hernia repair versus 100 low-risk patients undergoing cesarean delivery alone. The main outcome measures were operation time, blood loss, severity of pain, peripartum com--plications, , hospital stay, hernia recurrence, and patient satisfaction. Results: The combined procedure took significantly longer than cesarean delivery alone (75.2 minutes versus 60.5 minutes, P< .001)). There were no major complications. Wound infection occurred in 6 patients (4.1%). Hospital stay did not differ significantly from those of controls. Pain at the hernia site repair occurred in two pa--tients, and one hernia recurred in the hernia repair group during a mean follow-up period of 22 months (range, 6-36 months). All hernia patients reported that they preferred the combined operation. Conclusions: Combined cesarean delivery and paraumbilical hernia repair had the advantage of a single in--cision, single anesthesia, and a single hospital stay while avoiding re-hospitalization for a separate hernia repair. Our results indicate that the combination approach is safe, effective, and well accepted.

Design & Objectives : A prospective study to evaluate the outcome of combined caesarean section and paraumbilicalhernia repair in tertiary referral university hospital.Patients and methods: 48 patients undergoing caesarean section combined with paraumbilical hernia repair versus 100patients undergoing caesarean section alone.Main Outcome Measures: Operation time, Apgar Score, blood loss, uterine atony, breast feeding initiation, painsensation, peripartum complications, prolonged lochia (more than 42 days), deep venous thrombosis, hospital stay,hernia recurrence, and patient choice.Results: The combined procedure consumed significantly longer time than caesarean section alone in the meshhernioplasty subgroup. There were no major complications. Apgar Score, uterine atony, initiation of breastfeeding,prolonged lochia, wound infection and hospital stay did not differ significantly from those of controls. Pain at herniasite repair in two patients, one hernia recurred in the primary repair subgroup during follow up the period up to 3 years.All hernia group patients reported that they preferred the combined operation.Conclusion: Combined caesrean section and paraumbilical hernia repair had the advantage of single incision, singleanesthesia, and single hospital stay. The combination approach proved to tbe safte, effective, and well accepted.

Caustic material ingestion injuries (CMI) are uncommon. Only 5,000 cases are reported in the United States each year and most acute care healthcare facilities admit only a few cases annually. Accordingly, no single institution can claim extensive experience, and management protocols are most probably based on either expert opinion or literature reports. In this study, we will attempt to review opinions and practices of representatives of the board members of the World Society of Emergency Surgery and compare them to the current literature.

Contains fulltext : 154431.pdf (Publisher’s version ) (Open Access) In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.

Objectives. Tonsillitis is a common infection in all age groups, especially under the age of five. Organisms causing this condition vary from place to place. Our aim is to find out the main causative agents of this condition in our hospital. Patients and Methods. Fifty-two consenting patients who needed tonsillectomy in Khamis civil hospital, Kingdom of Saudi Arabia, between September 2006 and April 2007, were enrolled for the study. Swabs were taken from their inner surfaces and cultured for anaerobes and aerobes according to standard microbiological techniques. Results. Fifty-two patients, consisting of 30 males and 22 females were enrolled. Their mean age was 9.81±6.47. Nearly 65% of patients had positive cultures while 35% were negative. The commonest bacteria isolated were Staphylococcus aureus (44.1%); and Group B Streptococcus (35.3 %). Two Gram-negative bacteria, Klebsiella pneumoniae, (8.82%), and Pseudomonas aeruginosa (2.94 %), were also isolated. No anaerobe was isolated. Conclusion. Gram-positive cocci, consisting of Staphylococcus aureus and Group B Streptococcus (Streptococcus agalactiae), are the major causes of tonsillitis requiring surgery in our hospital. Antibiotic treatment of this condition should be directed largely against these organisms.

Situs inversus totalis (SIT) is an uncommon anomaly characterised by transposition of organs to the opposite side of the body in a mirror image of normal. It may cause difficulties in the diagnostic and therapeutic management of abdominal pathology due to the mirror-image anatomy. We report the management of a case of symptomatic cholilithiasis with emphasis on its surgical technique.

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high. The World Society of Emergency Surgery (WSES) has designed the CIAOW study in order to describe the clinical, microbiological, and management-related profiles of both community- and healthcare-acquired complicated intra-abdominal infections in a worldwide context. The CIAOW study (Complicated Intra-Abdominal infection Observational Worldwide Study) is a multicenter observational study currently underway in 57 medical institutions worldwide. The study includes patients undergoing surgery or interventional drainage to address complicated intra-abdominal infections. This preliminary report includes all data from almost the first two months of the six-month study period. Patients who met inclusion criteria with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study. 702 patients with a mean age of 49.2 years (range 18–98) were enrolled in the study. 272 patients (38.7%) were women and 430 (62.3%) were men. Among these patients, 615 (87.6%) were affected by community-acquired IAIs while the remaining 87 (12.4%) suffered from healthcare-associated infections. Generalized peritonitis was observed in 304 patients (43.3%), whereas localized peritonitis or abscesses was registered in 398 (57.7%) patients. The overall mortality rate was 10.1% (71/702). The final results of the CIAOW Study will be published following the conclusion of the study period in March 2013.

Emergency repair of complicated abdominal hernias is associated with poor prognosis and a high rate of post-operative complications. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013, during the 2nd Congress of the World Society of Emergency Surgery with the goal of defining recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel.

Background : Appendicitis in the elderly continues to be a challenging surgical problem. Patients continued to present late with atypical presentations. Results might improve with earlier consideration of the diagnosis in elderly patients with abdominal pain, followed by prompt surgical operation. We aimed to present our experience with a series of elderly patients with acute appendicitis who were subjected to appendectomy to find out the difference in the course and outcome of acute appendicitis in elderly patients. Patients and methods : We reviewed medical records of elderly patients (aged >60 years) who underwent appendectomy for acute appendicitis at our hospital. Variables selected for analysis included age, sex, presenting symptoms, operative approach, operative findings, duration of hospitalization. Patients were compared to a control group, less than 31 years admitted during the same period. Results : Twenty-three patients’ records aged > 60 years with acute appendicitis were compared to a group of 40 patients aged< 30 years. There were significant differences between the two groups with regard to duration of symptoms preoperative hospital stay and total hospital stay. All young patients group had an uneventful postoperative recovery only two cases (5%) had wound infection. There was one death in the elderly group thus mortality rate was 4.3%. These two groups of patients showed significant differences in relation to the stage of disease at operation and postoperative complications. Elderly group of patients had perforated appendix in 16 cases (69.5%) while in group II patients eight cases (20%) had perforated appendix Conclusion : Acute appendicitis in the elderly remains a challenge for practicing surgeons and continues to be associated with high morbidity and mortality. Results might improve with earlier consideration of the use of CT abdomen for diagnosis in elderly patients with abdominal pain, followed by prompt surgical operation.

Rhinoliths are uncommon clinical entities reported in clinical practice as unusual cause of unilateral nasal obstruction and foul smell nasal discharge. Rhinolith is calcified material found in the nasal cavity incidentally or due to patient complaint. It should be suspected when patient presents with nasal symptoms and found to have stony mass showed radiologically. We reported a 28-year-old Saudi male with left sided (LT) nasal obstruction and foul smell discharge for 5 years suspected as being due to foreign body presence since childhood due to head trauma following car accident in sandy area.

Background: Carcinoma of the gallbladder is the most common malignancy of the biliary tract. Most of the cases are diagnosed as an incidental case among patients undergoing cholecystectomy. The objectives of this study were to report the rate of incidental carcinoma of gallbladder in patients undergoing cholecystectomy and to study the demographic profile and prognosis of these patients in our locality. Methods: A retrospective study was carried out in our general hospital during 2007-2012. The hospital records and histopathology reports of 1982 patients who had undergone elective laparoscopic cholecystectomy were studied. Results: Out of 1982 cases of cholecystectomy, gallbladder cancer was detected in 10 (0.5%) cases and was more common in females (M:F ratio = 2:8) .The mean age of occurrence was 73.6 years. Most of the cases diagnosed, were at their early stages and only two of them were in pT3 pathological stage. Five of those patients survived to date with a mean follow up duration of 26 months. Conclusion: The rate of incidental carcinoma of gallbladder is 0.5% in our locality and nearly half of patients were early stage with acceptable five year survival rates. Routine postoperative histopathology of gall bladder is mandatory.

Background: To evaluate our experience with non-operative management of blunt liver trauma at a level II trauma hospital in the Kingdom of Saudi Arabia. Materials and Methods: We prospectively evaluated 56 patients treated for blunt liver trauma at our hospital over a 4-year period (April 2008 to April 2012). Patients who were hemodynamically stable [non-operative group I (NOP)] were treated conservatively in the intensive or intermediate care unit (ICU or IMCU). Patients who were hemodynamically unstable or needed laparotomy for other injuries were treated by urgent laparotomy [operative group II (OP)]. All NOP group patients had computed tomography (CT) of the abdomen with oral and intravenous contrast. Injuries grades were classified according to the American Association for the Surgery of Trauma (AAST). Follow-up CT of the abdomen was performed after 2 weeks in some cases. Results: A total of 56 patients were treated over a 4-year period. Twenty patients (35.7%) were treated by immediate surgery. NOP group of 36 patients (64.3%) were managed in the ICU by close monitoring. Surgically treated group had more patients with complex liver injury (90% versus 58.3%), required more units of blood (6.05 versus 1.5), but had a longer hospital stay (16.6 days versus 15.1 days). None of the patients from the non-operated group developed complications nor did they need operation. The only mortality (in two patients) was in the operated group. Conclusion: The NOP treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The NOP treatment should be the treatment of choice in such patients whenever CT and ICU facilities are available.

Background: Undescended testes are a common problem, affecting up to 3% of newborn males. The goals of orchiopexy in humans are to provide adequate scrotal fi xation, to prevent recurrent torsion of the testis and spermatic cord or ascent of the testis, and to achieve these goals with minimal trauma to the testis. The best method of achieving fi xation remains controversial. Purpose: The aim of our study is to evaluate our modifi ed extra Dartos pouch technique in retaining testis in the scrotum. Patients and Methods: A prospective randomized study included 159 patients with 185 orchiopexies age ranging from 5 months to 14 years with the mean age of 49.5 ± 33.3 months (4.08 years). They were divided into two groups: Group I for whom the extra Dartos pouch technique was applied were compared to Group II for whom classic sub-Dartos pouch technique was done. Results: Testis was located in the superfi cial inguinal pouch in 102 cases (64.1%) and intra-canalicular in 57 cases (35.6%). Hernial sac was found in 153 cases (96.2%), postoperative wound infection occurred in 3 cases (1.9%) and hematoma formation in three cases (1.9%); one case reported ascent of the testis and another one had testicular atrophy in the follow-up period which extends now up to 3 years and we are still in follow-up with those cases. Conclusion: Our modifi ed technique for extra Dartos pouch fi xation seems to be a fast reliable method for orchiopexy; however, comparative studies and long-term assessment is still needed to establish this method.Key words: Extra Dartos orchiopexy, orchiopexy, sub-Dartos pouch, surgery, undescended testis

Background: Fournier's gangrene (FG), caused by synergistic aerobic and anaerobic organisms, is a life-threatening disorder in which infection of the perineum and scrotum (can affect penis alone) spreads along fascial planes, leading to soft-tissue necrosis. Despite antibiotics and aggressive debridement, the mortality rate of FG remains high. Materials and Methods: We analyzed 74 patients admitted to our institution's emergency surgical unit presenting with FG between January 2002 and January 2007, considering the anatomical site of infective gangrene, predisposing factors, etiological agents, and outcomes. Results: All the 74 patients included in this study were males; their mean age was 51±10.8 years (21-72 years). The mean duration from the onset of symptoms to admission to the hospital was 3.74±2.09 days (1-8 days). The mean hospitalization time was 9.2± 6.6 days (1-31). Forty patients (54.05%) had FG secondary to anorectal conditions. No etiologic factors for FG were found in 27 patients (36.5%). Diabetes mellitus as a predisposing factor was found in 38 patients (51.35%). There was no definite predisposing factor in 24 patients (32.43%). The microbiological finding was polymicrobial in 48 patients (64.8%) and monomicrobial in 26 patients (35.1%). The most frequent bacterial organisms were Escherichia coli (75.6%). Simple sigmoid loop colostomy was done in one patient (1.4%). Unilateral orchidectomy was done in one case (1.4%). The overall mortality rate was 16 patients (21.6%). Conclusion: FG is a rapidly progressive, fulminant infection. Even with aggressive surgical and medical treatment, mortality of the disease is high. In the present cases, such a high ratio of 21.6% means that this disease is still serious and fatal in Egypt.

The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.