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Background: Laparoscopic surgery has revolutionized the way it is performed for an increasing number of patients. In this study, we determined the various reasons for conversion of laparoscopic cholecystectomy in our setup. Material & Methods: This was a descriptive study, conducted at Ghulam Muhammad Mahar Medical College Hospital and Hira Medical Centre, Sukkur, from January 2006 to June 2010. The study included 1224 patients with symptomatic cholelithiasis, who underwent laparoscopic cholecystectomy. All patients were operated by experienced laparoscopic surgeons with experience of more than 300 Laparoscopic cholecystectomies. Cases that required conversion from laparoscopic to open surgery were analyzed and the factors responsible for such conversion were studied. Results: The mean age of patients was 45 years and male to female ratio 1:4. The mean operating time was 45 minutes and average hospital stay was 2 days. Out of 1224 patients, 8(0.65%) required open conversion. Factors responsible for open conversion were dense adhesions in 3(0.25%), fibrosed gall-bladder with cholecystoduodenal fistula in 1(0.081%), CBD injury 1(0.081%), Mirizzi’s syndrome 1(0.081%), and instrument failure as well as power breakdown with backup failure in 2(0.16%) conversions. Conclusion: Open conversion rate of laparoscopic cholecystectomy in this study was 0.65%. The commonest cause of conversion was dense adhesions around the gall-bladder. Preventable factors like instrument failure or power breakdown can be addressed by a reliable back up.

Background: Hepatitis C virus is one of the major etiological agents for parenterally acquired hepatitis. Viral hepatitis during pregnancy is associated with high risk of maternal complications. This study was conducted to determine the prevalence of HCV infection in pregnant women, and to find out its risk factors. Patients & Methods: It was a prospective observational study conducted at Department of Obstetrics and Gynecology, Peoples Medical College Nawabshah, from May 2008 to June 2oo9. Pregnant women were screened for HCV antibodies during antenatal visits. Detailed history of HCV positive patients was taken to find out the risk factors. Results: Among 3020 pregnant women, 102 were positive for HCV antibodies. Of these 73(71.52%) were positive for HCV-RNA by PCR. Among anti-HCV positive women, 8(7.84%) were also positive for HBS Ag. The age range was 17-35. The mean parity of study group was 0.8+0.9. Of 102 women, 10(9.8%) had delivery, 19(18.62%) previous surgery, 20(19.60%) blood transfusions, 10(9.8%) underwent D&C, 5(4.9%) had dental surgery, 6(5.86%) received injection by quack, and 32(31.5%) had unknown risk factor. Conclusion: Prevalence of Hepatitis C virus infection in pregnant ladies is 3.44%. Past history of blood transfusion, surgery, and delivery by traditional birth attendant are the most important risk factors for transmission of infection.

Background: To determine the frequency of carcinoma of gallbladder in patients with cholelithiasis. Material & Methods: It was a descriptive study conducted at the Department of Pathology Peoples Medical College Nawabshah, from January 1985 to December 2004. During the above mentioned period 1138 specimens of cholecystectomy for cholelithiasis with cholecystitis were received, out of which 1109 were included in the study being 89.5% females and 10.5% were males. The clinical data, surgical pathology reports and haemotoxylin & eosin stained slides were obtained from the record, all the cases were reviewed and results were tabulated. Results: No case presented with gallbladder mass. The commonest complaint was pain in epigastrium in 70% of cases. Carcinoma was found in 65 cases. The frequency of carcinoma of gallbladder was found in 5.9% of cases. Conclusion: Present study highlights the importance of careful gross and histopathologic evaluation of gallbladders otherwise removed with the history of chronic or acute cholecystitis. It is further concluded that the frequency of carcinoma of gallbladder is less common in this part of the country.

Background: A salivary gland swelling may result from various causes and create a diagnostic challenge. This study was conducted to evaluate the usefulness of ultrasound-guided core needle biopsy as a diagnostic modality. Material and Methods: It was a cross-sectional study conducted in Nawabshah Medical College, Pakistan, from January 2004 to December 2007. One hundred and eight patients were included, ages 13-72 years (Mean 52.2). Ultrasound-guided core needle biopsy was performed. These patients also underwent excision biopsy. Histological diagnosis of ultrasound-guided core needle biopsy was compared with that of excisional biopsy. Results: Out of 108 patients, 70(64.8%) lesion were in parotid and 38(35.2%) in sub-mandibular gland. Histological findings of ultrasound-guided core needle biopsy showed non-neoplastic lesions in 29(26.8%) cases; 12 reactive lymph nodes, 9 chronic non-specific sialadenitis, 4 tuberculosis, 3 retention cysts and one salivary gland abscess. Benign neoplastic lesions were found in 54(50%); 35 pleomorphic adenomas, 12 Warthin tumors, 5 monomorphic adenomas, and 2 hemangiomas. Malignant lesions were found in 25(23.1%); 8 mucoepidermoid carcinoma, 6 lymphoma, 4 adenoid cystic carcinoma, 4 malignant mixed tumor and 3 adenocarcinoma. Excisional biopsy confirmed the diagnosis of ultrasound-guided core needle biopsy, except in one case of Warthin tumor which was mucoepidermoid carcinoma on excisional biopsy. Conclusion: Ultrasound-guided core needle biopsy is a safe, simple and accurate procedure for the diagnosis of salivary gland lesions and can be performed as an outpatient procedure.

Background: Hepatitis C virus is inherently unstable, giving rise to multiple genotypes and more than 50 subtypes have been identified on the basis of molecular relatedness. This study was conducted to correlate genotype of HCV infection with grading and staging of chronic hepatitis induced in interior Sindh. Material & Methods: It was a prospective cross-sectional, observational study carried out from August 2006 to June 2008, at Research Medical Center LUMHS Jamshoro, Departments of pathology, Nawabshah Medical College, Nawabshah and Biotechnology Department, University of Karachi. A total of 344 HCV-PCR positive patients with different genotypes were evaluated, 239 men and 105 women, ages between 18–55 years were included in the study. All patients had HCV antibodies by ELISA and also determination of HCV RNA and genotypes. Liver biopsy was performed in chronic hepatitis patients and submitted to histopathological procedures. Results: Out of 242 cases of genotype 3a, 122 presented with grade A2, 62 with A3, 36 with A1 and 22 with grade A4. Stage F1 was seen in 91, F2 in 81, F3 in 43 cases, 14 with stage F0 and 13 with F4. Genotype 3b presented with grade A2 in 9 cases, A3 in 7, A1 in 2 and A4 in 1 case. Stage F2 in 7 cases, F3 in 6, F1 in 3 and F4 in 3. Out of 10 cases of genotype 1a, 6 cases presented with grade A3, 3 with A4 and 1 with A2. Stage F3, 2 cases, F4 and 1 each with F1 and F2. Five patients of genotype 1b presented with grade A3 in 3 and A4 in 2, and stage F3. While genotype-2 patients presented with grade A2 in 2 cases and A3 in 2, stage F1 in 2 cases and F2 in 2 cases. All the 3 cases of genotype 5 were in grade A2 and stage F2. Nine patients with genotype mixed type revealed grade A3 in 4, A4 in 4 and A2 in one case, 4 cases with stage F4, 3 with F2 and 1 each with F4 and F1. Out of 52 untypable genotype 33 cases presented with grade A3, 13 with A2 and 6 with A4, 24 cases presented with stage F2, 16 with F3, 8 with F4, and 4 with F1. Conclusion: There is no correlation of genotype with grading and staging of the disease in chronic hepatitis C.

Background: This study was conducted to highlight the importance of mammary tuberculosis, by determination of its frequency, clinical presentation and laboratory investigations in our set-up. Material and Methods: It was a retrospective study performed at Department of Pathology, Nawabshah Medical College, Nawabshah. The data was collected from the file record of these patients from January 1997 to December 2006 and the results were tabulated. Results: Nine cases of tuberculosis were diagnosed in 396 lumpectomy/mastectomy specimens. Age of these patients ranged from 18 to 42 years. All were married women belonging to poor socio-economic class, bearing on average five children. One patient was pregnant and three lactating mothers. Associated pulmonary tuberculosis was present in three cases. Previous history of tuberculosis was present in one case and history of tuberculosis in the family was seen in five cases. Mass with or without ulceration /abscess / discharging sinus was the clinical presentation in all the cases. Axillary lymphadenopathy was seen in five cases. Fever and pain with history of weight loss was seen in all the cases. All the patients were found to be anaemic with high erythrocytes sedimentation rate. The total leukocytes count ranged from 4.2 - 7.2 x 109/l. Mantoux test was positive in all the cases. Acid fast bacilli in the breast tissue were seen in only one case. The diagnosis was made on histological grounds by the presence of chronic granulomatous inflammation with caseating epithelioid granulomas and Langhan’s type of giant cells. Conclusion: The frequency of tuberculosis in our study is 2.3% in the patients with lump in the breast. Doctors should keep tuberculosis in the differential diagnosis of breast lump.

Background: Typhoid perforation of ileum is a serious complication of typhoid fever. There are different surgical methods of repairing the perforation. The aim of this study was to report the surgical experience regarding treatment of typhoid ileal perforation in our setup. Material & Methods: It wa a retrospective, observational study carried out at Departments of Surgery Unit I and Pathology, Peoples Medical College and Hospital Nawabshah from July 2003 to June 2008. Forty-four patients were admitted through causality as cases of acute abdomen, 28 (63.63%) were males and 16 (36.36%) females, with age range of 10-45 years. The diagnosis of typhoid perforation was made on clinical grounds, laboratory investigations, x-ray, ultrasound examination, and operative findings. Exploratory laparotomy was carried out and perforations were managed. The variables studied in the post operative period were wound infection, wound dehiscence, entero-cutaneous fistula, residual abscess, mortality, hospital stay and incisional hernia. Results: Fever with abdominal pain and distension were the symptoms in all subjects followed by diarrhoea, vomiting and constipation Widal test more than 1:320 was positive in 35(79.45%) cases and typhi dot (IgM in all cases and IgG in 15) was positive in all cases. Blood culture was positive in 32 (72.7%) cases. X-ray abdomen revealed pneumoperitoneum in 22 (50%) cases. Ultrasound shows free peritoneal collection in 40 (90.90%) cases. On operation the abdominal cavity was heavily contaminated in 12 (27.27%) patients while in 32 (72.72%) patients the peritoneal cavity was having moderate contamination. 36 (81.81%) patients had single perforation & 8 (18.18%) patients had more than one perforation. In 32 (72.72%) patients perforations after freshening the ulcer were closed by single layered interrupted extra mucosal technique with vicryle 2/0, 4 (9.09%) needed resection & anastomosis & in remaining 8 (18.18%) loop ileostomy was made. Conclusion: The typhoid ileal perforation still carries high morbidity and mortality. The typhoid ileal perforation should always be treated surgically. There are many operative techniques to deal typhoid ileal perforation but no one is fool proof. Regardless of the operative technique timely surgery within 24 hours with adequate and aggressive resuscitation is a way to decrease the morbidity and mortality.

Background: The aim of the study was to find out the frequency and histopathologic type of various testicular tumors in correlation with age of the patients in our setup. Material and Methods: It was a retrospective, descriptive study carried out at the Department of Pathology, Peoples Medical College, Nawabshah, Pakistan. All testicular tumors diagnosed from January 1991 to December 2005 were included in the study. The clinical data and surgical pathology reports with haematoxylin & eosin stained slides were obtained from the record. All the cases were reviewed and results tabulated. The patients were divided into six age groups and the tumors classified according to the pathological classification of testicular tumors. Results: During this period 73 cases of testicular tumors were diagnosed in the department. All cases were diagnosed as germ cell tumors (100%); consisting of 57 (78.1%) cases of single histologic type and 16 (21.9%) cases of mixed germ cell tumors. Most of the cases presented in the 3rd and 4th decades. Seminoma was found to be the commonest tumor in 27 (37%) cases, embryonal carcinoma in 29 (27.4%) cases, teratocarcinoma in 11 (15.1%) cases, yolk sac tumor and teratoma each in 5 (6.8%) cases, embryonal carcinoma with seminoma in 3 (4.1%) cases and teratoma with seminoma in 2 (2.8%) cases. Conclusion: In this study the ages of the patients and the frequency and histopathological findings in testicular tumors, with few exceptions are similar to other studies from different parts of the world, confirming the worldwide similarity of these parameters.

Foreign body in urinary bladder being unusual in clinical setting presents as a diagnostic dilemma with vague history. Bladder calculi are uncommon in adults and usually result either from obstruction or foreign bodies. The present case report describes a young girl presenting with cysticism. Investigations revealed a bladder calculus encrusted on trans-urethrally inserted abortion stick in the urinary bladder that warranted surgery. Endoscopic manipulation was successful. Postoperative period was uneventful.

Background: To evaluate the efficacy, safety and results of a newer technique, using Mauermayer stone punch for percutaneous bladder stone removal in children. Material and Methods: It was a prospective study from November 2000 to November 2004, in the Department of Urology, Peoples Medical college hospital Nawabshah, Pakistan. One hundred and thirty children having vesical calculi of various sizes were included in this study. The procedure is based on principal of percutaneous removal of bladder stones, using ordinary trocar cannula under video-cystoscopic visualization and Stone punch to extract/fragment the stones. These children were evaluated by detailed history, clinical examination, ultrasonography, Radiography of urinary tract, urine routine examination, urine culture and blood urea. These patients, who were otherwise candidates for open cystolithotomy, were treated percutaneously using suprapubicapproach. Results: Satisfactory results were obtained in almost all cases having solitary and multiple stones. In selected cases urethral damage, operating time, hospital stay and cost can be decreased to minimum with this simple technique. Conclusion: This study shows that suprapubic percutaneous route can be employed as an alternative procedure to previously reported different percutaneous modalities where percutaneous nephrolithotomy instruments, laparoscopic instruments, percutaneous vacuum sheaths and other trocar and stone forceps have been utilized for removal of vesical calculi.