Basrah Journal of Surgery

The intervertebral disc is an avascular tissue, and penetration of antibiotics occurs by passive
diffusion. Cefotaxime penetration has not been well studied. The aim is to investigate the
penetration of cefotaxime into the intervertebral disc removed from patients undergoing
discectomy.
Twenty-six patients undergoing discectomy were recruited for this study. They were given one
gram of cefotaxime intravenously as a prophylactic antibiotic. Cefotaxime was extracted from
nucleus pulposus and serum and analyzed using an HPLC method with cefuroxime axetil as
internal standard.
Cefotaxime penetrated into all the 26 samples of nucleus pulposus resulting in a mean
concentration of 0.66±0.13 µg/gm. The mean serum concentration at time of disc removal was
13.61±3.54 µg/ml. The concentration in 16 samples were below the minimum inhibitory
concentration against Staph. aureus with an average of 0.27±0.03 µg/g. There is a statistically
significant correlation between time after intravenous cefotaxime administration and its
concentration in the nucleus pulposus. The greater increase is in the third hour after
administration. Factors like age, body weight, gender, number of associated diseases and
surgical history did not seem to affect nucleus pulposus cefotaxime concentration.
In conclusion, cefotaxime can penetrate into the nucleus pulposus but its concentration is
relatively low. This concentration has a strong positive correlation with time after cefotaxime
intravenous administration. Cefotaxime, therefore, needs to be given at least two hours before
disc removal, with re-dosing immediately before operation to maintain high serum concentratio

Total knee arthroplasty (TKA) represents a major advance in the treatment of
degenerative joint disease providing excellent restoration of joint function and pain
relief.
This is a prospective study undertaken in the Department of Orthopedic Surgery in
Basrah Teaching Hospital, from October 2009 to June 2011. Thirty-three patients who
underwent primary total knee arthroplasty were included (25 females 75.7% and 8
males 24.2%). The diagnosis was osteoarthritis in 20 knees and rheumatoid arthritis in
13 knees. The operation included primary cemented TKA (25 cruciate-retaining and 8
cruciate-substituting), by anterior approach. The knee function was evaluated by knee
society score system.
Preoperative functional knee scores were uniformly poor and improved postoperatively
with excellent results in 18 knees (54.54%), good in 9 knees (27.27%), fair in 5 knees
(15.15%), and poor in 1 knee (3%). Thus, excellent and good results were achieved in
81.8% of the cases (27 of 33 knees). For knee scores, 2 knees (6%) were fair
preoperatively and another 31 knees (93.9%) were poor. Post TKA results were
excellent in 28 knees (84.84%), good in 5 knees (15.15%), fair in (0%) and poor in
(0%). Excellent and good results were achieved in 100% of cases. The most common
complications were superficial infection and deep venous thrombosis
In conclusion, this study showed good outcome for total knee replacement surgery in
our region. Excellent relief of pain, range of motion, and restoration of function

Strut graft is an important, commonly used method to increase nasal tip projection and
rotation. This study discuss its benefit by prospective analysis of a group of patients in
which strut graft was used and compare it with a control group using digitalized
photographs.
The aim of this study is to evaluate the benefit of columellar strut graft and its effect on
nasal projection and rotation using digital images.
Thirty two patients were treated with external rhinoplasty. Using their photographs, we
analyzed the projection and rotation of the nose before and after operation. The patients
were classified into two groups: group A included 18 patients who have strut and group
B included 14 patients without strut. The analysis of the photos of the two groups was
done with a computer program.
By using Goode method, nasal tip projection decreases from 0.63 to 0.62 for patients
using the strut, while in patients without strut nasal tip projection decreases from 0.64 to
0.61. Nasal tip rotation slightly increased in patients with strut graft from 99 to 99.5
degrees, while in those without the graft, nasal tip rotation markedly increased from 95
to 103 degrees.
In conclusion, external rhinoplasty decreases nasal tip projection and the use of strut
graft is unnecessary in increasing nasal tip projection but it helps in preserving the
projection and slightly increasing nasal tip rotation

Unexpected difficult endotracheal intubation remains the main concern of anesthesiologists.
This study aimed to compare validity and role of 7 bedside techniques of assessment used in
predicting difficult intubation.
This prospective study included 80 patients scheduled for surgery. Before induction of
anesthesia, bedside tests for predicting difficult intubation were done, these tests are: Prayer
sign, Thyromental distance, Mallampati test, The inter incisor distance, Palm print test, Upper lip
bite test, and Wilson scoring system. During induction of anesthesia, laryngoscopic view was
evaluated. Values for each test were calculated and compared.
The results showed that, the highest sensitivity (62.5%) was for Mallampati and thyromental
distance but despite that, they differed in their specificity and predictive values. Upper lip bite
was 12.5% sensitive but had one of the highest specificity alongside with Mallampati test.
Thyromental distance was 34.7% specific. Mallampati classes of more than class I was strongly
associated with difficult intubation. The mouth gap of more than 4 cm was marginally associated
with difficult intubation. The predictor Wilson showed a significant association with difficult
intubation if the score exceeded 3.5. The upper lip bite of more than class I was slightly
associated with difficult intubation.
In conclusion, Mallampati classification and thyromental distance are superior to other available
tests to predict difficult intubation, performing these two tests alone is relatively adequate to
predict intubation difficulty.

Many blood conservation strategies were developed in the past decades to reduce risk of
bleeding and the need for blood products among patients undergoing cardiac surgeries. This
study was conducted to define the benefit of reinfusion of preoperative collected autologous
blood in reduction of the risk of bleeding and the need for blood and blood products in
comparison with tranexamic acid.
This single centre single-blinded, randomized study was conducted in Erbil cardiac centre
during the period from 1st of November 2018 to 30th of April 2019. A total of 150 patients were
divided into three groups with 50 patients for each. The 1st group received nothing, the 2nd
group received initially infusion of 200mg/hr of tranexamic acid until reaching 1.5gm/hr, and the
3rd group received one pint of preoperative auto-transfused whole blood. Data on risk of
bleeding and the need for blood and blood products were collected using special questionnaire
prepared for the reason of this study and were analyzed using appropriate statistical tests.
Patients receiving autologous blood showed lower chest tube drainage than the other study
groups with a p value of <0.001. Similarly the need for blood and blood products intra or
postoperatively was significantly lower among patients receiving autologous blood with p value
of <0.001. Therefore, the risk of intra and postoperative bleeding was significantly lower among
those receiving autologous blood when compared to other study groups.
In conclusion, reinfusion of one pint of preoperative collected autologous blood is higher than
tranexamic acid in reducing the risk of postoperative bleeding and the need for blood and blood
products among patients undergoing cardiac surgery

Prominent ear is the most common congenital ear deformity affecting 5% of children in
western world and has profound psychological effects on the bearer. The most common
causes of protruded external ear are: an under developed or flat antihelix, an over
developed deep concha, or combination of both of these features.
The aim of this study is to evaluate clinical outcome of otoplasty in prominent ears by
two parallel interrupted full thickness cartilage incisions.
from February 2015 to November 2018, a prospective study accomplished on 40
patients (74 ears), they were 32 males and 8 females. The condition was bilateral in 34
patients and unilateral in 6 patients. Surgery was done by a modification of combined
methods of Mustarde and Furnas with partial resection of conchal cartilage .
The preoperative helical rim, temporo-mastoid surface distance was 28-40 millimeters
(mean 34.6 mm) and 10-15 mm postoperatively (mean 12.1 mm). The preoperative
cephalo-auricular angle was 50-90 degrees (mean 75.4 degrees), and was kept at 20-25
degrees (mean 22.5 degrees) postoperatively.
Good esthetic and satisfaction results were noted by the patients, their families, and the
surgical staff. No complication had occurred and no one needed surgical revision.
In conclusion, the procedure was found to be simple, easily applied with good esthetic
and satisfaction results.

The aim of this study is to describe a technique for intraoperative examination of macula and
posterior capsule during phacoemulsification surgery in eyes with dense cataract.
This work was done in Ophthalmology Department, Hamad Medical Corporation, Doha-Qatar
on 36 patients (42 Eyes) with dense cataract and obscured fundus view. No data were recorded
for macular status, and preoperative macular assessment was not conclusive by
Ophthalmoscopy, B-Scan Ultrasound, and Optical Coherence Tomography (OCT). All patients
were consented for cataract surgery plus additional vitreoretinal surgical procedure if indicated.
Fundus examination done during phacoemulsification by translimbal insertion of endo-light
probe after Irrigation/Aspiration step prior to lens implantation, capsular-bag expanded by
viscoelastic to accommodate probe insert. Posterior capsule status checked by Endolight using
microscope lens system only, macula checked by endolight with a vitreoretinal viewing lens
system.
Forty-two eyes (25 right and 17 left), (27 males, 15 females) in 39 patients were studied. The
mean age was 59 years (47-78 years). Fourteen patients (18 eyes) were diabetics. Preoperative
Visual Acuity of ≤6/60 was recorded in all patients. Cataract Density was graded by fundus
visualization and in all cases, only shadow of optic disc and/or major vessels could be seen.
Concurrent intravitreal injections was done in eight eyes (19%): seven of them were having
Diabetic Macular Edema, and one has hemorrhagic Choroidal Neovascular Membrane (CNVM)
due to age related macular degeneration. No complication was recorded in relation to
Endoillumination. Posterior Capsule visualization was improved significantly and intracapsular
lens implantation was done in all cases
In conclusion, translimbal endo-illumination technique improved view to both Macula and
posterior capsule during phacoemulsification with subsequent early surgical decision according
to endolight findings. No extra incision required

Bile leakage is a very dangerous condition after laparoscopic cholecystectomy and may lead to
fatal complications and serious care should be taken to diagnose the cause as early as possible
because it may be sign of bile duct injury which is a major concern to the surgeons as if it is not
diagnosed early, it will lead to dangerous complications such as biliary peritonitis, hepatic failure
and even death. Early diagnosis is important to decrease morbidity and mortality.
This study aimed to determine the incidence of bile leakage, its types of management and the
outcome in patients with gall stone who are submitted to laparoscopic cholecystectomy.
This prospective study was done in Basrah Al-Sadr Teaching Hospital in a two-year period
from October 2013 to October 2015 on 560 patients, they were 378 females and 182 males. All
of them have symptomatic gall stones and underwent laparoscopic cholecystectomy. All
converted cases to open cholecystectomy were excluded.
From the total number of 560 patients, nine patients developed bile leak in early post-operative
period, 6 of them have drains and the other three have no drain and they were presented with
signs and symptoms of intra-abdominal collection. The causes of leak were: common bile duct
(CBD) injury in 2 cases, accessory duct in 3 patients, leak from the gall bladder bed in 3 cases
and one case iatrogenic from intra-hepatic drain. All the patients were treated conservatively
except the two patients with CBD injury who were treated; one with the aid endoscopic
retrograde cholangio-pancreatography (ERCP) and the other by re-exploration.
In conclusion, bile leak is a serious complication after laparoscopic cholecystectomy, although
it is not common but it is important to identify the site of leak and should be treated urgently
especially by drainage to avoid more severe results which may lead to increased morbidity and
mortality

Keloid scar is one of the most challenging problems for physicians and surgeons. The current
treatment of keloids is based on many ways and modalities which includes medical therapy,
combined surgical excision with other modalities, physical treatment etc. The optimal curative
treatment remains undefined.
This study aimed to evaluate the effectiveness of the surgical excision combined with local
infiltration of verapamil to treat patients with keloid.
This prospective study involved 20 patients with keloid scars at different parts of the body.
These keloid scars were surgically excised with local infiltration of Verapamil. This study was
carried out at Al-Shaheed Ghazii Al-Harriri Hospital, Al-Wasity Hospital in Baghdad and Al-Sadr
Teaching Hospital in Basrah Between January 2017 and May 2018. The age of the patients
ranged between 11 to 44 years. Fourteen of them were females and 6 were males.
After one year follow-up period, 11 patients had good results, 5 patients had moderate results
and 4 patients had poor results. Patient’s satisfaction in those who had good results was
excellent. No serious complications were recorded, only one patient got local wound
dehiscence.
In conclusion, surgical excision of keloid scar combined with post-surgical verapamil infiltration
showed promising results in the management of keloid scar and reduction of its recurrence rate

Breast cancer is a common malignancy in female, modified radical mastectomy is widely used
for the management of this tumour. Axillary lymph nodes dissection is accompanied by frequent
postoperative morbidity including wound infection, paresthesia, seroma and upper limb
lymphedema.
This is a comparative study that was conducted to evaluate the frequency of postoperative
morbidity in a limited and extended axillary lymph nodes dissection.
One hundred and fifty patients were treated by modified radical mastectomy for invasive ductal
carcinoma of the breast between January 2008 and October 2015 in Al-Fayhaa Teaching
Hospital. This sample was divided into two groups; the first fifty patients were managed with
limited N1 axillary dissection while the other one hundred patients with extended N2 axillary
dissection. The postoperative morbidity in the form of wound infection, paresthesia, seroma
formation and upper limb lymphedema were analyzed in respect to the N1 or N2 axillary lymph
nodes dissection.
The highest occurrence was in the age group between 36 and 45 years. Wound infection
develops in 16% of patients in the first group and 12% in the second group. Seroma occurred in
20% in the first group and 23% in the second group. Paresthesia was obviously higher in the
second group (19%) when compared with 4% in the first group. Lymphedema occurred more in
the second group (26%), and less in the first group (4%).
In conclusion, limited axillary lymph nodes dissection during modified radical mastectomy for
patients with no or few axillary lymph nodes involvement is associated with low postoperative
morbidity

Nodular goiter is one of the most common presentation of thyroid gland diseases. The risk of
development of thyroid cancer is relatively rare (1%) of all types of tumors, however, it is the
most common endocrine malignancy, and usually presented as multinodular goiter. Fine needle
aspiration cytology (FNAC) considered as the golden tool in the diagnosis of thyroid nodule
though, it still has false negative rate which is variable depending on the experience and the
technique being used. This means that even if the FNAC done prior to surgery shows negative
finding, this doesn't exclude the presence of carcinoma, especially in multinodular goiter where
it is possible not to sample the involved area.
In this prospective study which was done in Almawanee Teaching Hospital between 2012-
2018, 69 patients with Multinodular goiter where considered for the risk of harboring an
incidental malignancy.
The results of patients with multinodular goiter of benign origin was 57 patients (82.86%) while
multinodular goiter which has an incidental malignancy was 12 patients (17.14%).
Conclusion: due to relatively high risk of malignancy in multinodular goiter especially with noncompliance for follow-up from patients and risk of missing incidental malignancy by FNAC in
multinodular goiter, it is preferable to do total or near total thyroidectomy

Fingertip amputation is the most common injury of the upper limb. The goals of
treating it are; covering the defect, achieve sensibility, preserving the length of the finger
by using durable coverage, obtaining the satisfactory aesthetic appearance and allow the
patient for faster return to work.
This study aimed to evaluate the use of bilateral V-Y rotation advancement flaps for the
management of fingertip amputations with exposed bones and to assess the functional
and aesthetic outcome.
Between January 2017 and August 2018, bilateral V-Y rotation advancement flaps was
performed on eleven male patients, average age 32 years, whose fingertip amputation
with variable planes and zones. Patients were followed-up for at least 6-12 months.
Twenty two flaps were made on 11 fingers, there was no partial or total flap loss.
Patients had neither cold intolerance nor scar hypersensitivity, no obvious hook nail
deformity apart of one patient. Because flap have neurovascular bundle inside it, so no
change in sensation or perfusion occur postoperatively.
In conclusion, the V-Y rotation advancement flap is simple, single stage operation that
is optimum for surgical reconstruction of any fingertip injury. It provides a good
contour, finger pulp coverage and acceptable appearance

MANAGEMENT OF CRISES DURING ANESTHESIA AND SURGERY. PART XVI: HARMS LINKED TO DRUGS ADMINISTERED DURING ANESTHESIASalam N Asfar@ & Jasim M Salman# @MB,ChB, MSc, Professor of Anesthesiology, College of Medicine, University of Basrah. #MB,ChB, DA, FICMS, Assist. Prof. & Consultant Anesthesiologist, College of Medicine, University of Basrah, Basrah, IRAQ. Unpleasant drug incidents are common during medical action. In anesthetic practice, the probability of errors is greater because of more tension and rapidity. Morbidity and even mortality are more expected in the course of anesthesia. Apart from many hazards that patients are exposed to such as; Biological hazards, Mechanical hazards, Chemical hazards, Physical hazards, and Personal Hazards1, it seems that danger of drug problems are more.