Basrah Journal of Surgery

Editorial

The field of minimally invasive surgery has seen tremendous development and refinement since the first laparoscopic cholecystectomy was performed in 1987. Laparoscopic surgery has several advantages over traditional surgery. The next logical step in the evolution of minimally invasive surgery may be to eliminate all abdominal incisions. The terms being used in the literature include �incisionless�, �endoluminal�, �transluminal�, and �Natural Orifice Transluminal Endoscopic Surgery� (NOTES). This article aims to summarize the background and current status of NOTES.

Thyroid resection is one of the most common operations performed throughout the world. This procedure is classically realized through a transverse cervical incision and associated with a very low morbidity and mortality rate. However, the visible scar on the anterior surface of the neck is disliked by many patients, especially by young women in whom this

Background context: Both systemic hypertension and degenerative spinal canal stenosis are common diseases in the population, however, the cross relationship had not been reported. Purpose: To determine the incidence of systemic hypertension among patients with degenerative spinal canal stenosis and to describe the pattern of this degenerative spinal canal stenosis in south of iraq. Study design: Retrospective and prospective review. Patient sample: A total of 1699 persons (644 females and 1055 males) whom their blood pressure measured. A 326 patients had degenerative spinal canal stenosis and 1373 not had spinal stenosis {599 patients had prolapsed intervertebral disc prolapse operated on(control no.1 group) and 774 persons were normal (control no.2 group)}. Outcome measure: Postoperative blood pressure monitoring. Methods: Systemic blood pressure measurement were reviewed for all of the 1699 persons with postoperative follow up of their blood pressure, also the level of pathology was recorded. Results: Systemic hypertension was present in 46% of patients with degenerative spinal canal stenosis, 18.1% of patients with intervertebral disc prolapse (control no.1) and in 17.4% of normal persons(control no.2). Postoperativly, hypertension resolved spontaneously or easily controlled with less number and lower doses of antihypertensive drugs. Conclusion: Systemic hypertension highly prevalent among patients with spinal stenosis and disappear or becomes lower after operative treatment.

Despite numerous methods of wound care post appendectomy, no definite technique documented to be the best. Wound irrigation under pressure with syringe is regarded recently as an acceptable physical and biological way to prevent post appendectomy wound infection. This study compares the best of several method of wound infection prevention on 418 patients subjected to appendectomy and divided in different groups, including the use of systemic antibiotic, local antibiotic, povidone iodine, and saline pressure irrigation. We concluded that: syringe pressure irrigation to the wound significantly decrease post operative infection, and is best in comparison to other methods.

Missile hand injuries (MHI) have increased in our locality, in this prospective study 130 patients (140 hands) with MHI were included, they were 86% male, and 42% were between 21 to 30 years of age. Forty nine percent were injured by bullet and 26% by explosions of different objects. Combined tissue injuries were presented in 62% of the patients with associated fractures in 63%. In 70% of the hands initial surgical wound debridment was performed, 24% of the fractures were stabilized by K- wire and with the simple skeletal external fixations in 18%. Serial different types of secondary and definitive surgical treatment were performed in 62% of the patients. After the follow up period, most of the patients had multiple complains and only 14% had a satisfactory functional hand. The initial, definitive management, the severity and mechanism of the injury that lead to multiple tissue damage had a great affect on final functional recovery.

Incisional hernia is frequently met by the general surgeon, its frequently complicate (3.8-11.5%) of patients after abdominal surgery. Repair of large incisional hernia is a difficult surgical problem with recurrence being a common. Numerous methods of repair have been described simple opposition in one layer or complex opposition and the use of prosthetic mesh. The aim of this study is to report our experience with use of mesh repair and risk factors that influence post operative complications. A prospective study done in Basrah General Hospital, Department of Surgery between January 2003 to December 2006.One hundred and ten patients with prosthetic repair of incisional hernia were included in this study. History was taken and thorough examination was done, all patients were asked for history of diabetes mellitus, obesity, corticosteroid use, their original operations, primary or recurrent hernia and examined for their body mass index, size and duration of the hernial defect were recorded. A proforma was completed for each patient, noting prophylactic antibiotics had been given or not, type of the sac and whether opened or inverted, type and size of mesh had been used, intraoperative and postoperative complications and postoperative hospital stay. Of (110) patients, (62) were females, (48)were males,their median age was (45.5) years for women and (58) years for men,(31)patients(28.2%)weighted more than their ideal body weight and had body mass index equal or more than(30).Forty eight patients (43.6%) were diabetic and (24)patients(21.8%)were corticosteroid used. The original operations were bowel related and gynecological in the majority of patients. Previous incisions were long midline in(38). Twenty patients had one past operation, (13)had two,(5) had three and one patient had four past repair, the remaining were new Incisional hernia patients. The main hernia size was (12.3) cm and (4.6) cm in vertical and horizontal direction respectively. Forty four patients had additional surgical procedures, consisted of Fallopian tube ligation in (12) ,division of small bowel adhesions in (8) ,suturing of small bowel perforation in (4) and abdominoplasty in (20) patients. In the majority of patients (78), standard polypropylene mesh had been used and vicryl-prolene (Vypro) mesh in the remaining (32) patients. The main postoperative complications were seroma formation (17.3%), wound haematoma (10%), wound infection (9.1%), chest infection (6.4%), one patient developed intestinal fistula and mesh need to be removed. Five recurrent incisional hernias occurred. Most patients developed complications were obese, diabetic and corticosteroid used. No death in our series. It is concluded that tension free incisional hernia repair using prosthetic mesh is a safe and easy procedure with no major morbidity or recurrence. The patient-doctor should advice weight loss to help reduce risks of surgery and improve the surgical results. Control of diabetes, corticosteroid drug use and smoking cessation are recommended for better results. Rigid sterile condition, precise and meticulous technique with the use of closed suction drains is important.

This study aimed to investigate the tonsils as an origin of halitosis and to assess the efficacy of tonsillectomy for the treatment of oral bad breath caused by chronic tonsillitis. After excluding dental, periodontal, sinonasal, oral, pulmonary, and gastroenterological diseases as the origin of halitosis, fourty-four patients with halitosis caused by chronic tonsillitis which proved by positive Finkelstein's tonsil smelling test (pressing the tonsils and smelling the squeezed discharge), were included in the study. All patients were treated by tonsillectomy. Subjective and objective postoperative assessment was based on self-and-family report and clinical assessment. Patients were reviewed after 4 and 8 weeks postoperatively. Complete improvement of halitosis occurred in 31 patients (70.4%) after 4 weeks, this value increased to 35 patients (79.5%) in the second review after 8 weeks. It is concluded that tonsillectomy is significantly effective procedure for the treatment of halitosis caused by chronic tonsillitis.

Blunt abdominal trauma may result in multiple severe injuries which make the abdomen difficult to assess and easy to overlook. Unrecognized intra-abdominal injury is a significant cause of preventable death in blunt trauma. This study aimed to find the frequency and features of lapratomy findings for different internal abdominal organs� injuries in patients subjected to blunt abdominal injury. A total of 450 patients subjected to blunt abdominal trauma were admitted to the emergency surgical department of Sulaimania Surgical Teaching Hospital following, 140 of them were decided to undergo exploratory laparotomy depending on their clinical and imaging findings that suggesting a visceral injury. Thirty one percent of the patients who subjected to blunt abdominal trauma need exploratory laparotomy, 80.7% of them were male, and 67.9% were young. The predominant causative factor of blunt abdominal trauma was the motor vehicle accidents. Spleen and liver were the frequent injured solid organs. Almost all of the patients had positive laparotomy results. Traumatic head and neck injuries were the most common associated non abdominal injuries. Morality rate was only 5% while complication rate was only 7%. It is concluded that males at young active productive age are the main persons suffer from blunt abdominal trauma. This has an important economic impact on the productivity of the community. Spleen injury being the most commonly intra abdominal solid injured organ followed by liver, other visceral structures are uncommonly involved.j1

Ureteric stents have been used since many years in urologic practice. Many complications encountered during its use. This study carried out in the Department of urology at Basrah General Hospital from 2003 to 2007. During this period 213 patients required D-J stents insertion were fallowed up. Complications encountered include loin pain in 21.6%, irritative symptoms in 30.5%, febrile UTI in 10.8%, bacteriuria in 27.7%, upward migration in 3.3%, slipping in 4.2%. We conclude that indwelling ureteric stents carried a significant risk of complications and accurate timing of removal or changing is mandatory.

The aim of this study is to evaluate the use of onlay mesh in the management of large or complex incisional hernia. A prospective study of 80 patients with incisional hernia operated on at al-Sadr Teaching Hospital treated with onlay mesh between Jan 2001 to Jan 2006. Thorough history and physical examination was done, data sheet was designed include numerous factors that effect operative and healing process. Of 80 patients, 61.2% female &38.8 % male with median age 40.1 years for female & 53 years for male. Patients were with different associated medical problems. Main incision was lower midline incision 26.2% &main post operative complications was seroma 7.5% & wound infection 7.5% while recurrence of hernia observed in 2.5%.This study showed that, the big incisional hernias can be efficiently treated by the onlay positioning of polypropylene mesh.

Cancellation of operations increases theatre costs and decreases efficiency as well as causing emotional trauma to the patients and there families. Elective surgery cancellation is a significant multifactor problem with far-reaching consequences1. Obviously, all cancellations can not be avoided. Patients may have a change in their medical condition on the day of surgery which can not be expected or there is unpredictable condition in the hospital. Most problems, however, can be prevented with a little initiative as we noticed that in private hospitals all these reasons may be of negligible significance. Postponing

During the second half of the 20th century, as a result of improved nutrition, reduced crowding, public health measures, and effective chemotherapy, a dramatic decrease in the incidence of tuberculosis was seen in the world. But in recent years, increased incidence of tuberculosis has been attributed to several causes, including AIDS epidemic, intravenous drug abuse and increase in the number of immunocompromised. Hepatic tuberculosis is the most common manifestation of upper abdominal parenchymatous organ tuberculosis and its incidence has been increasing. Lack of familiarity with this condition was apparently responsible for the diagnosis of hepatic tuberculosis being made at autopsy or surgery in the past. Since tuberculosis remains a potentially curable disease, an awareness of its protean manifestations is essential.

CASE REPORT

Since abdominoplasty has been shown to have a positive impact on patient's self-image and quality of life, and a large hanging panniculus can cause problems such as intertrigo, chronic infection, and immobility, it is no surprise that the annual number of these procedures performed has continued to increase. A 45 year female patient with history of recurrent lower abdominal pain and irregular menses and she was diagnosed to have a big right ovarian cyst amenable for surgery, also she had previous history of two abdominal surgeries for the same complaint. She is a heavy smoker and she was obese with BMI> 35. A decision for ovarian cystectomy and abdominoplasty was taken, the patient was subjected to surgery by Gynecologist alone in Almuthana Hospital. The patient