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Background and Aims: Modified radical mastectomy (MRM) is associated with significant acute post-operative pain that may progress to chronic pain syndromes in 25-60% of patients. Serratus anterior muscle (SAM) block has proved to be an excellent analgesic option in patients undergoing MRM. Although many adjuvants have been utilized for the prolongation of analgesia, the role of tramadol in SAM has not been studied as yet. We hypothesize that the addition of tramadol to ropivacaine for SAM block may reduce morphine consumption in the post-operative period in patients undergoing elective MRM surgeries. The primary aim of the study was to compare cumulative post-operative morphine consumption over 24 h in patients receiving SAM block with or without tramadol. The secondary aims were to observe adverse events related to the procedure or medications. The other parameters recorded were non-invasive blood pressure (NIBP), pulse rate, respiratory rate, and nausea or vomiting. Material and Methods: Patients scheduled to undergo MRM were randomly allocated by block randomization into two groups. The study group (Group T) received a SAM block with 0.25% ropivacaine (18 ml) with tramadol 100 mg while the control group (Group P) received a SAM block with 18 ml of 0.25% ropivacaine and 2 ml of saline. Patients were assessed for pain scores, analgesic requirement, time to first analgesic request, hemodynamic variables, and any side-effects at 30 min, 1 h, 4 h, 8 h, 12 h, and 24 h post-operatively. Results: Cumulative morphine consumption over 24 h in the post-operative period was less in the group T (3.06 ± 1.53 mg vs 4.34 ± 1.53 mg; P 0.001). Time to the first analgesic requirement was more in group T (10.44 ± 5.04 h vs 6.11 ± 2.73 h; P < 0.001). Pain scores were significantly lower in the group T at all time points. Conclusion: Tramadol, when used as an adjuvant to ropivacaine for SAM block reduces post-operative pain scores in the first 24 h and prolongs the time of first morphine requirement. [ABSTRACT FROM AUTHOR]

Background and Objectives: The present study was undertaken to compare the analgesic efficacy of erector spinae plane (ESP) block with serratus anterior muscle (SAM) block in patients undergoing modified radical mastectomy (MRM). We hypothesized that ESP block would provide better postoperative pain relief than SAM block following MRM. Methods: Eighty American Society of Anaesthesiologists (ASA) Ⅰ–Ⅱ adult females, scheduled for MRM, were randomly allocated to receive either ultrasound‑guided ipsilateral single‑shot ESP or SAM block after induction in the respective planes, using 20 ml of 0.25% ropivacaine. Both the groups received postoperative intravenous patient‑controlled analgesia (IV‑PCA)(morphine) for 24 h. The primary outcome was to assess pain severity using a visual analogue scale (VAS) score. Postoperative 24‑h opioid consumption, time to first opioid analgesia, hemodynamic variables, total dose of antiemetics, and safety profile of both the blocks were also evaluated. Data analysis was carried out using Statistical Package for the Social Sciences version 21.0 (SPSS Inc. Chicago, Illinois, USA). Results: VAS scores were lower in the ESP block group, at rest and on movement, and the difference was statistically significant (p < 0.05). Postoperative morphine consumption was also significantly less in patients receiving ESP block as compared to SAM block (3.13 ± 1.44 mg vs 4.33 ± 1.69 mg; P = 0.001). The time to first analgesia request was significantly prolonged in the ESP group as compared to the SAM group (9.58 ± 4.11 h vs 6.46 ± 2.95 h; P = 0.001). No major side effects were observed in any of the study groups. Conclusions: ESP block provides better analgesia as compared to SAM block after MRM. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) has established itself firmly as the ′gold standard′ for the treatment of gallstone disease, but it can, at times, be associated with significant morbidity and mortality. Existing literature has focused almost exclusively on the biliary complications of this procedure, but other complications such as significant haemorrhage can also be encountered, with an immediate mortality if not recognized and treated in a timely manner. Materials and Methods: Publications in English language literature that have reported the complication of bleeding during or after the performance of LC were identified and accessed. The results thus obtained were tabulated and analyzed to get a true picture of this complication, its mechanism and preventive measures. Results: Bleeding has been reported to occur with an incidence of up to nearly 10% in various series, and can occur at any time during LC (during trocar insertion, dissection technique or slippage of clips/ ligatures) or in the postoperative period. It can range from minor haematomas to life-threatening injuries to major intra-abdominal vessels (such as aorta, vena cava and iliacs). Conclusion: Good surgical technique, awareness and early recognition and management of such cases are keys to success when dealing with this problem.

Byline: Divya. Arora, Robin. Kaushik, Ravinder. Kaur, Atul. Sachdev Background: Despite being the most commonly performed operations, sometimes cholecystectomy fails to relieve symptoms; this is now a well-recognised clinical entity [...]

Byline: Reetu. Kundu, Sanjay. Gupta, Robin. Kaushik, Rajpal. Punia, Ravinder. KaurNeurofibromas are benign neoplasms that are usually seen in hereditary disorders such as von Recklinghausen's disease [neurofibromatosis type 1 (NF1)]. [...]

ABSTRACT Leiomyomas are benign neoplasms of smooth muscle that are rarely seen in the duodenum. They are usually asymptomatic and detected incidentally either on routine radiological investigations or at laparotomy [...]

Abstract Background/objective Perforation peritonitis is the most common surgical emergency in India. The spectrum of etiology of perforation in Tropical countries continues to be different from its Western counterpart. The objective of the study was to highlight the spectrum of perforation peritonitis as encountered by us at Government Medical College and Hospital (GMCH), Chandigarh. Methods Five hundred and four consecutive cases of perforation peritonitis over a period of five years were reviewed in terms of clinical presentation, operative findings and postoperative course retrospectively at GMCH, Chandigarh. Results The most common cause of perforation in our series was perforated duodenal ulcer (289 cases) followed by appendicitis (59 cases), gastrointestinal perforation due to blunt trauma abdomen (45 cases), typhoid fever (41 cases) and tuberculosis (20 cases). Despite delay in seeking medical treatment (53%), the overall mortality (10%) was favourably comparable with other published series though the overall morbidity (50%) was unusually high. Conclusion In contrast to western literature, where lower gastrointestinal tract perforations predominate, upper gastrointestinal tract perforations constitute the majority of cases in India. The increasing incidence of post-traumatic gastro-enteric injuries may be due to an increase in high speed motor vehicle accidents which warrant early recognition and prompt treatment to avoid serious complications and death.

Abstract Tuberculosis of the appendix remains a rarity despite the frequency of intestinal tuberculosis. We report a case of acute appendicitis that underwent appendectomy at our hospital, and the histopathology of the specimen revealed tuberculosis.

Abstract The abdominal cocoon is a rare cause of intestinal obstruction that is usually diagnosed at the time of laparotomy. It is usually of unknown origin, although at times, it may be seen secondary to a variety of conditions. Tuberculosis is an infrequently implicated cause of abdominal cocoon, and has only occasionally been reported previously in the Literature. This paper presents our experience with tubercular cocoon as a cause of intestinal obstruction, and discusses the surgical implications of the same.

Abstract Peritonitis is a common emergency encountered by surgeons the world over. This paper aims to provide an overview of the spectrum of peritonitis seen in the East. Studies dealing with the overall spectrum of secondary peritonitis in various countries of this region were identified using Pubmed and Google. These were analyzed for the site and cause of perforation and the mortality. It was observed that perforation of duodenal ulcers was the most the commonly encountered perforations. These are followed by small bowel and appendicular perforations. Colonic perforations were uncommon. The overall mortality ranges between 6–27%.

Abstract Background Duodenal ulcer perforations are a common surgical emergency, but literature is silent on the exact definition, incidence, management and complications of large perforations of duodenal ulcers. Methods The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years (2001 – 2003) were retrospectively reviewed and sorted into groups based on the size of the perforations – one group was defined as 'small 'perforations (less than 1 cm in diameter), another 'large' (when the perforation was more than 1 cm but less than 3 cms), and the third, 'giant'(when the perforation exceeded 3 cm). These groups of patients were then compared with each other in regard to the patient particulars, duration of symptoms, surgery performed and the outcome. Results A total of 40 patients were identified to have duodenal ulcer perforations more than 1 cm in size, thus accounting for nearly 25 % of all duodenal ulcer perforations operated during this period. These patients had a significantly higher incidence of leak, morbidity and mortality when compared to those with smaller perforations. Conclusion There are three distinct types of perforations of duodenal ulcers that are encountered in clinical practice. The first, are the 'small' perforations that are easy to manage and have low morbidity and mortality. The second are the 'large' perforations, that are also not uncommon, and omental patch closure gives the best results even in this subset of patients. The word 'giant' should be reserved for perforations that exceed 3 cms in diameter, and these are extremely uncommon.

Background: In sepsis, lactate measurements correlate with mortality; however, the role of lactate in predicting mortality in patients of secondary peritonitis is not yet fully established. Methods: Data were maintained prospectively on 224 patients of secondary peritonitis over a period of 10 years. Arterial lactate measurements were performed twice in each patient – once, initially on admission (ALI) and the other, 24 h after surgery (AL24); from these values, percentage lactate clearance was calculated. These lactate indices and other demographic factors were correlated with mortality. Results: Overall mortality was 16.07% (36 patients) and morbidity was 63.39% (pulmonary complications commonest); preoperative lactate (more than 2.35 mmol/L), 24‐h postoperative lactate (more than 2.05 mmol/L), need for vasopressors and mechanical ventilation independently correlated with morbidity and mortality. A simple prognostic scale constructed using cut‐off values of ALI, AL24, need for vasopressor support and mechanical ventilation showed a sensitivity of 97.22% and specificity of 52.13% for predicting mortality. Conclusion: Preoperative and postoperative arterial lactate levels, need for vasopressors and mechanical ventilation, are independent predictors of mortality. Using these parameters, it may be possible to identify high risk patients that can benefit from early, goal directed therapy to reduce the mortality of secondary peritonitis. [ABSTRACT FROM AUTHOR]

Byline: Rajeev. Sharma, Atul. Sachdev, Sanjay. Gupta, Robin. Kaushik, Ashok. Attri The problem of retained surgical sponges (gossypiboma) in the abdominal cavity is not only a cause of morbidity in [...]

Byline: Robin. Kaushik Background: Citations are an important measure of the quality and content of scientific communications. Since no study regarding the most cited articles in surgical literature from India [...]

Byline: Sanjay. Gupta, Robin. Kaushik, Rajeev. Sharma Rectus sheath hematoma is a well documented but unusual cause of a painful abdominal lump that occurs as a result of accumulation of [...]

Byline: Robin. Kaushik, Ashok. Attri Retroperitoneal abscess arising as a consequence of biliary tract disease has been termed choleretroperitoneum. It is rare, and was first reported about 170 years ago. [...]

Byline: Sanjay. Gupta, Rajpal Singh. Punia, Robin. Kaushik Gastrointestinal Stromal Tumours are the commonest mesenchymal tumors of the gastrointestinal tract, the stomach and small intestine being the favored sites. They [...]

Byline: Robin. Kaushik Sir, At the very outset, I would like to congratulate the author[1] for her words on William Halsted, a person who contributed tremendously to the development of [...]

Byline: Robin. Kaushik, Ashok. Attri We report the case of a 50-year-old lady who developed spontaneous right-sided pneumothorax during laparoscopic cholecystectomy. This was detected intra-operatively by a fall in her [...]

Mucor is an uncommon cause of surgical site infection. We present such a case after intramedullary nailing of the femur and discuss its presentation and management. [ABSTRACT FROM AUTHOR]

Osseous Metaplasia (OM) or heterotopic ossification is a rare phenomenon with unknown aetiology that is characterised by the formation of mature bone elements in the stroma of different tumors. Awareness of this condition is important to avoid diagnostic confusion with carcinosarcoma and local bone invasions that have different lines of treatment and prognosis. Here, authors report two cases of heterotopic ossification in adenocarcinoma of sigmoid colon and lung and provide salient features that could help to detect the condition. [ABSTRACT FROM AUTHOR]

Chronic venous insufficiency presents with spectrum of clinical features ranging from pain/heaviness of affected limb to nonhealing ulcers. Venous hypertension due to valvular reflux or obstruction is pathophysiological event leading to development of Chronic venous insufficiency. Perforator incompetence plays a major role in this insufficiency. Hauer introduced minimally invasive technique of perforator ligation i.e Sub fascial Endoscopic perforator ligation(SEPS) in 1985.An observational study over a period of year involving 38 patients (48 limbs) of Chronic venous insufficiency with CEAP Class C4 to C6 undergoing SEPS was conducted with follow up ranging from 11months to 2 months. 48 limbs in 38 patients of Chronic venous insufficiency with following distribution of CEAP classification, C6-4, C5-6 and C4-8 underwent Subfascial Endoscopic perforator surgery (SEPS) using Harmonic scalpel along with or without ligation and stripping procedures. These patients were observed for ulcer healing and symptom relief. 8(33%) patients with ulcer showed complete healing in 8 weeks and 24 (92%) at 12 weeks and 26 (100%) at 16 weeks. Venous Clinical Severity Score (VCSS) showed significant decrease at 12 weeks. One patient had surgical site infection. One patient showed recurrence of ulcer after complete healing which was attributed to Saphenofemoral insufficiency which developed 7 months after SEPS. SEPS is an excellent minimally invasive procedure for perforator ablation in patients with severe (C5,C6) chronic venous insufficiency [ABSTRACT FROM AUTHOR]

Peritonitis is a common emergency encountered by surgeons the world over. This paper aims to provide an overview of the spectrum of peritonitis seen in the East. Studies dealing with the overall spectrum of secondary peritonitis in various countries of this region were identified using Pubmed and Google. These were analyzed for the site and cause of perforation and the mortality. It was observed that perforation of duodenal ulcers was the most the commonly encountered perforations. These are followed by small bowel and appendicular perforations. Colonic perforations were uncommon. The overall mortality ranges between 6-27%. [ABSTRACT FROM AUTHOR]

Background/objective: Perforation peritonitis is the most common surgical emergency in India. The spectrum of etiology of perforation in Tropical countries continues to be different from its Western counterpart. The objective of the study was to highlight the spectrum of perforation peritonitis as encountered by us at Government Medical College and Hospital (GMCH), Chandigarh. Methods: Five hundred and four consecutive cases of perforation peritonitis over a period of five years were reviewed in terms of clinical presentation, operative findings and postoperative course retrospectively at GMCH, Chandigarh. Results: The most common cause of perforation in our series was perforated duodenal ulcer (289 cases) followed by appendicitis (59 cases), gastrointestinal perforation due to blunt trauma abdomen (45 cases), typhoid fever (41 cases) and tuberculosis (20 cases). Despite delay in seeking medical treatment (53%), the overall mortality (10%) was favourably comparable with other published series though the overall morbidity (50%) was unusually high. Conclusion: In contrast to western literature, where lower gastrointestinal tract perforations predominate, upper gastrointestinal tract perforations constitute the majority of cases in India. The increasing incidence of post-traumatic gastro-enteric injuries may be due to an increase in high speed motor vehicle accidents which warrant early recognition and prompt treatment to avoid serious complications and death. [ABSTRACT FROM AUTHOR]

Background: Duodenal ulcer perforations are a common surgical emergency, but literature is silent on the exact definition, incidence, management and complications of large perforations of duodenal ulcers. Methods: The case files of 162 patients who underwent emergency laparotomy for duodenal ulcer perforations over a period of three years (2001 - 2003) were retrospectively reviewed and sorted into groups based on the size of the perforations - one group was defined as 'small 'perforations (less than 1 cm in diameter), another 'large' (when the perforation was more than 1 cm but less than 3 cms), and the third, 'giant'(when the perforation exceeded 3 cm). These groups of patients were then compared with each other in regard to the patient particulars, duration of symptoms, surgery performed and the outcome. Results: A total of 40 patients were identified to have duodenal ulcer perforations more than 1 cm in size, thus accounting for nearly 25 % of all duodenal ulcer perforations operated during this period. These patients had a significantly higher incidence of leak, morbidity and mortality when compared to those with smaller perforations. Conclusion: There are three distinct types of perforations of duodenal ulcers that are encountered in clinical practice. The first, are the 'small' perforations that are easy to manage and have low morbidity and mortality. The second are the 'large' perforations, that are also not uncommon, and omental patch closure gives the best results even in this subset of patients. The word 'giant' should be reserved for perforations that exceed 3 cms in diameter, and these are extremely uncommon. [ABSTRACT FROM AUTHOR]