Basrah Journal of Surgery

Not all that glitters is gold (Shakespeare)

Surgical operations have developed in the method which the surgeon’s hands and eyes are used to gain ‎experience and advance the skills. However, to realize a new surgical therapy in the 21st century, it is ‎necessary to use various advanced technologies. These include among many, three dimensional medical ‎images, computer simulation and virtual reality technology, and robots in surgery. This is an outline of ‎the various aspects of these technologies with some more details about robotics in surgery as it is the ‎most recent advancement in that technology arena.‎

Our objectives were to study and to evaluate thermotherapy for patients with retention of urine. The ‎ability of the patient to pass urine without significant post voiding residue was also studied. Eighty six ‎patients presented with urinary retention were treated by transurethral thermo therapy of the prostate, two ‎weeks following thermo therapy 55 patients (63.9%) were catheter free and by the third week only 9 ‎patients (10.4%) were still with catheter. It can be concluded that thermo therapy can be an option in the ‎treatment of urinary retention and keeping the catheter for one more week can raise its effectiveness

A prospective study was conducted on 60 specimens; 33 breast lumps and 27 lymph nodes, to assess the value of ‎intraoperative imprint cytology as an aid in surgical decision especially in the absence of the facility of frozen ‎section examination. Imprint cytological examinations were done intraoperatively by a single pathologist. The ‎results were ready after a period of 15-25 minutes. In all 60 specimens, 50 (83%) were correctly diagnosed, 8 were ‎diagnosed as suspicious of malignancy and 2 were misdiagnosed.‎ The sensitivity was 97%, the specificity was 94.4% and the accuracy rate was 96.1%. We concluded that imprint ‎cytology is a very simple technique and it remains a useful and cost effective tool, can aid in the surgical decision.‎

This study aimed to determine the reasons for sampling and interpretative errors in false ‎negative and false positive diagnoses of breast carcinoma on fine-needle aspiration ‎cytology (FNAC) material. The study design is that a totally 912 cases of breast FNAC were ‎performed between 2000 and 2004, and 126 cases of them were diagnosed as breast ‎carcinoma. Only those cases with cytohistological discrepancies were cytologically reviewed, ‎in which the cytological material was abnormal and to some extent misinterpreted or both. ‎There were 8 false negative diagnoses (false negative rate 6.3%) and 3 false positive ‎diagnoses (false positive rate 2.3%). The results of this study showed that among 8 false ‎negative cases, 5 showed hypocellular smears with minimal nuclear pleomorphism of the ‎cells. Histology revealed 3 infiltrating ductal carcinomas of scirrhous subtype and 2 ‎infiltrating lobular carcinomas. The smears of other 2 false negative cases, which ‎histologically verified as well-differentiated infiltrating ductal and pure intraductal carcinomas, ‎were hypercellular and composed predominantly of groups of cohesive, small, and uniform ‎cells simulating fibroadenoma or fibrocystic changes. Smear of the last false negative case ‎‎(histologically verified as infiltrating ductal carcinoma with extensive cystic degeneration) ‎revealed large sheets of macrophages and degenerated epithelial cells on inflammatory ‎background. In 3 false positive cases, 2 were histologically proved as fibroadenoma and 1 ‎fibrocystic changes. Smears of the 2 false positive fibroadenomas showed very high ‎cellularity, overlapped clusters, and frequent stripped bipolar nuclei. The fibrocystic case ‎showed tight clusters of apocrine cells and sheets of loosely aggregated macrophages that ‎were over interpreted. The conclusion of this study is that hypocellularity and relatively ‎nuclear monomorphism are the reasons for failure to diagnose breast carcinoma. Careful ‎attention should be paid to extreme nuclear monomorphism and absence of naked bipolar ‎nuclei. So awareness of smear cellularity and subtle cytological features will aid in the correct ‎preoperative diagnosis of lobular; scirrhous; and intraductal carcinomas, and false negative ‎diagnoses can be minimized. A cytologically atypical or suspicious diagnosis together with ‎positive mammographical and clinical findings should suggest a diagnosis of malignancy. ‎Hypercellular smears with overlapped clusters should be carefully assessed for uniformity of ‎the cells and detailed nuclear features. If the full-blown malignant cytomorphological features ‎are not visible, a diagnosis of suspicious or inconclusive should be made and frozen section ‎Created by Wameed Al-Hashimy intraoperative imprint cytology is recommended before ‎surgery.‎

The medical records of 324 diabetic patients admitted to Al-Sader Teaching Hospital (Saddam Teaching ‎Hospital previously) with foot lesions between April 1994 and April 2004 were studied retrospectively. ‎Data were collected for various parameters, both personal and medical. The majority of patients were ‎males, over fifty years of age and known diabetics. Peripheral neuropathy was the main predisposing ‎factor while infected ulcer and gangrene of toe / toes were the most common forms of presentation. ‎Wound swabs were positive for bacterial culture in 215 pts. (66.3%), 97.2% of which were polymicrobial. ‎Dibridement was the most common surgical procedure. There were 6 deaths (1.85%) in the study group ‎mainly due to uncontrolled sepsis with concurrent medical illnesses. It is concluded that foot ‎complication is a common problem in elderly Iraqi diabetics, particularly males, peripheral neuropathy is ‎the most common predisposing factor, foot infections are usually poly microbial and that the majority ‎will need some form of surgical intervention that is mostly conservative rather than a major amputation. ‎We suggest a team approach in the care for these patients which can be provided by establishing foot ‎care clinic in large hospital. ‎

The skeleton is one of the commonest sites for metastasis. Bone secondaries account for more than one third of the ‎malignant disease of bone.‎ Seventy-six patients with bone secondaries were admitted in the orthopaedic department of Basrah Teaching ‎Hospital from February 2000 to June 2002, age range 14-86 years; 34 were males and 42 were females. The ‎dominant sites of bone metastases were spine, 60 patients (79%) and pelvis, 16 patients (21%). The common ‎primary sites were breast, 19 patients (25%) and lung, 11 patients (14.4%); 9 patients (11.2%) had undetected ‎primary site. Most secondaries (90%) were osteolytic in type and the most common histopathological type was ‎adenocarcinoma, 47 patients (63%). In 63 patients (83%), pain was the dominant presenting feature. Late ‎presentation was a major problem; it ranges between 4-8 months. Another problem was lack of clinical awareness ‎in the early stage of the illness.‎ Serum and urinary biochemical markers of bone metabolism were significantly high in patients with bone ‎secondaries than control group, no difference whether the metastasis was single or multiple and whichever the ‎primary site or histopathological subtype. Special interest with urinary hydroxyproline, it was significantly elevated ‎in patients with bone secondaries, some of them had negative radiography. Prognosis was poor with short life ‎expectancy.‎

This is a prospective study done on 40 patients presented with lower limb length discrepancies ‎between March 1993 and September 2003. After correction of apparent shortening by ‎correcting associated deformities like flexion deformities of the knee, bone lengthening for the ‎remaining true shortening ranging from 3cm – 10.5 cm was done. The "Z" corticotomy involves ‎cutting the cortex in Z manner with preservation of the periostieum and medullar cavity as much ‎as possible, followed by manual distraction.‎ ‎ The advantages of Z corticotomy in comparison to transverse corticotomy or transverse ‎osteotomy are; That there is no need for internal fixation by plate and screws, no need for bone ‎graft to enhance osteogenesis, the chances of mal-alignment of the distracted fragments are ‎minimal as the limbs of the Z – corticotomy maintaining the alignment during the distraction, ‎and the stability of the external fixate is very important for the extent of ontogenesis but this ‎was compensated by doing Z corticotomy. ‎

‎ Haemorrhage from obstetric and gynaecological surgery is a major causes of morbidity and mortality. ‎Various methods have been described to treat women with intractable haemorrahage. Internal iliac artery ‎ligation (IAL) is an under used but potentially very effective technique, We described four cases where ‎the procedure was used in controlling sever pelvic haemorrhage when local surgical methods had failed. ‎

‎ Hydatid cyst is a disease produced by the encysted Larvae of echinococcal worms. Echinococcus ‎granuloses is endemic in areas of the Mediterranean coast and middle east, Surgical intervention to ‎remove the cyst that is commonly seen in liver and lung is the primary treatment for hydated disease .‎ ‎ Sixty- three patients underwent lateral thoracotomy for pulmonary hydatd cyst in the last 4 years at ‎Basra Teaching Hospital. Special anesthetic technique was set for them including omission of ‎premedication drugs , rapid sequence indication, preference of single lumen endotracheal tube than ‎double lumen endobronchial tube, nitrous oxide gas exclusion from maintenance of anesthesia, ready ‎stand–by good suction machine, manual low pressure ventilation, and careful monitoring .‎ ‎ Nine out of 24 cases with double lumen endobronchial tube showed severe hypoxia intraoperatively that ‎demand urgent change of this type of tubes to signal lumen endotracheal tube. Patient with endotracheal ‎tube had smooth intraoperative environment and no postoperative complications. ‎ ‎ It is concluded that using this anesthetic regimen from the start of operation for these particular cases ‎makes anesthesia management more easy and safe. ‎

This is a prospective study to test the hypothesis that topical isosorbide dinitrate (Isordil) is the best first ‎line of treatment of a chronic anal fissure. This study was done in the outpatient clinic of Sulaimani ‎Teaching Hospital, Sulaimani, Iraq, from the 1st Dec. 2000 through 30th May 2002. There were 65 cases ‎of chronic anal fissure treated with 0.5% Isordil ointment and reviewed at 2, 4, 6 and 12 weeks to assess ‎the symptoms, side-effects, fissure healing and patient acceptance. The age range was 2-65 years with ‎mean age of 31.2years, and female:male was 1.4:1. At 12 weeks 80% of patients had no fissure. In 20% ‎the treatment was unsuccessful. At 6 months follow-up there was 2.5 % recurrence. The prevalence of ‎headache was 46.1% on commencing treatment with 12.3% headache-related noncompliance. The cost ‎of treatment with this new method was 12 ID for 8 weeks while it was 36 ID for the same period of ‎traditional way of treatment. We conclude that medical sphincterotomy with 0.5% Isordil ointment is a ‎feasible, cost-effective method of treatment of chronic anal fissure with high patient acceptance and ‎satisfaction.‎

‎ Forty–eight patients living in southern Iraq with renal transplantation were studied for dematological ‎lesions between Jan. 2001 and Feb. 2002, at Basrah renal transplation follow-up center. All patients had ‎skin problems of different kinds; Cushingoid features in 85.4%, hair and nail changes in 82%, infections ‎in 20% and tumors in 28%. Among skin infections recalcitrant warts were the most frequent (17%). High ‎incidence of skin cancer was recorded (4.2%) as compared to other Iraqi studies . Kaposi”s sarcoma ‎was not seen during the study period

Active chronic suppurative otitis media poses a management problem. Different types of ‎treatment strategy were tried for 136 patients, 36 patients received systemic antibiotics, 26 ‎patients received local antibiotics, 42 patients combined local and systemic, and the last ‎group (32 patients) received no antibiotics. The majority of patients had moderate size ‎tympanic membrane perforation (59%). Eighty-two patients had severe (active) symptoms ‎‎(60%). The commonest types of bacteria isolated were streptococcus pneumoniae and ‎staphylococcus aureus (29%, 21% respectively). It is found that, the best type of treatment ‎was the local antibiotic therapy (84% improvement), followed by combined antibiotic therapy ‎‎(local and systemic) which equal to 83% improvement. There was no benefit of using ‎systemic antibiotics without aural toilet (5% improvement). It is important to mention that the ‎use of antibiotic/ steroid ear drop gave good improvement result (95%), in comparison with ‎the use of antibiotic ear drop (50%). ‎

This is a prospective study conducted in all major hospitals in Basrah (Basrah Maternity & Child ‎Hospital, Basrah Teaching hospital and Basra General hospital) to prove that ‘acute abdomen in ‎pregnancy’ is common and that the effect of delayed diagnosis can have serious implication on both ‎maternal and fetal outcome. Two hundred and fourteen pregnant females were included. Their age ranged ‎from 16-42 years (mean age was 27 years). Operations were performed whenever indicated by a registrar ‎or consultant gynecologist. Abruption placenta was the causative factor in 33.17% of cases, ectopic ‎gestation in 24.7%, acute appendicitis in 11.21% and the remaining 30.9% resulted from miscellaneous ‎conditions. Most of the patients (94.39%) presented within the first twenty-four hours of their initial ‎complaint. Delayed diagnoses were made in 12 with 50% maternal mortality and 100% perinatal mortality. ‎One hundred and sixty nine patients (78.97%) underwent emergency operations, while forty-five patients ‎‎(21.02%) were treated conservatively. Various complications were encountered; the most common was ‎wound infection (19.8%).‎

Postpartum haemorrhage & retained placenta are the most common serious abnormalities encountered ‎during the third stage of labour, the aim of this study was to compare three different management ‎protocols for retained placenta. This prospective study was carried out in Basrah Maternity & Children ‎hospital during the period from march 2001 till march 2002. A total of 75 women with retained placenta ‎after active management of third stage of labour were included, they were divided into three groups , the ‎first group received oxytocin and normal saline injected in the umbilical vein, the second received ‎normal saline and the third was the expectant group. In 56% of women in the oxytocin group, placental ‎expulsion occurred within 45 minutes compared to 16% in the expectant group and 24% in the saline ‎group respectively. Also 44% of women in the oxytocin group needed manual removal of the placenta ‎compared to 84% in the expectant and 76% in the saline group. We conclude that intraumbilical vein ‎injection in cases with retained placenta seems simple and promising technique to reduce the incidence ‎of potentially morbid procedures. ‎

Mesenteric cyst ovarian implant syndrome have been rarely reported in the literature, we report the first ‎case that occur in young female following trauma and it is the first case in which the ovarian tissue get ‎implanted higher up in the jejunal mesentry out side the pelvis.‎