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Background: The use of synthetic mesh was a landmark breakthrough in management of hernia repair and has significantly reduced recurrence rates. It is a foreign material, and a slightest breach in asepsis can lead to favourable environment for bacterial proliferation and forms a ‘biofilm’ and thus mesh infection. Identifying the risk factors associated with mesh infection will help us prevent the vicious cycle of hernia surgery leading to mesh infection, re surgery to address the infected mesh and so on. Methods: A retrospective descriptive study was conducted in our centre for a period of two years (November 2017 to November 2019) to study the incidence of mesh infection after hernia repair and the factors associated with it. All primary hernia repairs were done on elective basis and antibiotics was given as per the protocol of our hospital. Patient demographics like age, sex and other factors associated with mesh infection like history of tobacco consumption, BMI, ASA grade, duration of surgery, type of hernia, type of repair, type of mesh used, were taken from medical records and their association with mesh infection was analysed. The results were statistically expressed in the form of mean, standard deviations and percentages. Results: A total of 10 cases of mesh infection were recorded out of 485 hernia surgeries. In contrary to other studies, in our study mesh infection was more common after laparoscopic surgeries. It was detected that there was a lapse in the sterilisation of laparoscopic instruments which led to the infection, which was rectified by vigilant sterilisation of the laparoscopic instruments and. Two laparoscopic hernioplasty were performed as the second surgery in the day, i.e was followed by laparoscopic cholecystectomy which was suspected be one of the cause for increased incidence in mesh infection after laparoscopic surgery. Laparoscopic instruments were reused in these two procedures which were avoided thereafter. It was more common in obese patients with an average BMI of 31.70+/-1.68 kg/m2. Supporting other studies our study had higher incidence among elderly men, obese patients, uncontrolled Type2 DM, patients with tobacco consumption, higher BMI and higher ASA grade. Conclusions: Strict sterilisation of laparoscopic instruments is a must for laparoscopic hernia surgery. Laparoscopic hernia repair should be preferably performed as the first surgery of the day. Modifiable causes of prolonged duration of surgery like orientation of the operating and nursing staff to the procedure, availability of the instruments can prevent unnecessary delay in the procedure and thus prevent mesh infection. Optimization of the patient factors like reduction of weight, quitting tobacco consumption and tight control of Type 2 DM are measures to be taken to prevent mesh infection.

Intussusception is defined as the telescoping of a segment of the gastrointestinal tract (intussusceptum) into an immediately adjacent distal bowel (intussuscipiens), causing venous congestion, edema, and blood supply reduction. Adult intussusception is a rare entity which can be with or without lead-point. Cases without lead-point frequently occurs in children or adults with celiac disease and Crohn’s disease and with lead point is caused by an underlying neoplasm, benign or malignant frequently presenting with bowel obstruction and acute abdomen. A 41-years-old male presented to our outpatient clinic with a history of recurrent abdominal pain. The clinical presentation and CT scan findings led to the diagnosis of ileoileal intussusception. Subsequently he underwent laparotomy which revealed an ileal intussusception, which was investigated and was found to be of Crohn’s etiology.

Midgut malrotation is a congenital anomaly seen usually in childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually identified intra operatively. A high index of suspicion is always required when dealing with any case of acute intestinal obstruction. We report a case of young adult who presented with symptoms of acute intestinal obstruction and was diagnosed intra-operatively as cecal volvulus with impending perforation caused by midgut malrotation. Malrotation of the intestinal tract is seen due to aberrant embryology. The presentation of intestinal malrotation in adults is very rare. Contrast enhanced Computed tomography (CT) can show the abnormal anatomy clearly. Anomalies like midgut malrotation can present as an operative dilemma and awareness regarding these conditions can help surgeons deal with these conditions.

Background: Loss of continuity of abdominal wall significantly affects the functions of protection of viscera, postural stabilization, and maintenance of intra-abdominal pressure. The newer understanding of abdominal wall reconstruction (AWR) aims at restoring abdominal wall anatomy and function, instead of simply patching the defect. We want to showcase the changing trends and results in hernia repair at a Medical Institution.Methods: This is an observational retrospective study conducted in RRMCH, Bengaluru from July 2018-2019 including all patients with ventral hernia undergoing the specified hernia repairs.Results: A total of 54 patients with ventral hernias undergoing routine hernia repairs/AWR surgeries were retrospectively analysed. The overall mean age was 46.62±12.44 year. Majority subjects were females (n=37; 68.5%), and overweight (Mean BMI=28.07±3.01/m2). 14 patients (25.92%), all males, had history of tobacco consumption. There were 38 (70.37%) primary ventral hernias and 7 recurrent hernias. Overall mean defect size was 10.2±0.4 cm. Most frequently performed was open retro rectus Hernioplasty (n=18; 33.33%), followed by open Preperitoneal Hernioplasty (n=17; 31.48%), laparoscopic intraperitoneal onlay mesh (IPOM) (n=16; 29.62%) and open transversus abdominis release (TAR) (n=3; 5.5%). On statistical analysis, it was found that Open repairs had higher post-operative pain (p=0.0005), longer hospitalization (p=0.0002) and higher incidence of surgical site events (p=0.0134) when compared to Laparoscopic repairs.Conclusion: As known already, minimally invasive techniques of hernia surgeries are shown to have acceptable outcomes when compared to radical open surgeries. Newer techniques of AWR are being employed to routine cases in larger numbers, and not just for complex reconstruction, at most centres with acceptable outcomes.

Background: Healthcare professionals are at the receiving end of a large number of violent incidents directed against them. One of the reasons cited is the abysmal levels of communication skills of young qualified doctors. We feel there is an urgent need for training them in this area of behavioral skill.Methods: It was a quantitative interventional study. We measured the communication skills before and after training, by a scale devised for the study and pre validated by peers and piloted as a project.Results: The training is effective in improving their knowledge and communication skills giving them confidence to face the challenges of day to day clinical work in surgical setting.Conclusions: This small training module on consent taking needs to be incorporated in the internship training. Faculty need to be sensitised regarding improvement of communication skills and knowledge of the students by adopting this training module and workplace based assessment for all surgical interns.

Gastric outlet obstruction is the clinical and pathophysiological consequence of any disease process that produces mechanical impediment to gastric emptying. It may be acute from inflammatory swelling and peristaltic dysfunction or chronic from cicatrix. Chronic inflammation of the duodenum may lead to recurrent episodes of healing followed by repair and scarring ultimately leading to fibrosis and stenosis of the duodenal lumen. We would like to present a unique case of an elderly lady presenting with intractable vomiting over 3 months, gradually progressive which aggravated on consuming solids initially to consuming liquids later. After thorough investigations a provisional diagnosis of chronic duodenal ulcer with gastric outlet obstruction probably due to cicatrix was made. On laparotomy there was a chronic scarred duodenal ulcer following a previously contained perforation which was causing the gastric outlet obstruction. Cholecystectomy, duodenoplasty and loop gastrojejunostomy was performed with no complications post-operatively. This is a rare case of previous contained duodenal perforation causing gastric outlet obstruction.

Background: The objective of the study was to validate Amit Jain’s staging system for cellulitis in diabetic and non-diabetic lower limbs and to predict the outcomes associated with cellulitis and surgical procedures done in them.Methods: We conducted a prospective study in department of surgery at Raja Rajeswari Medical College and Hospital Bengaluru, India. The study period was from December 2018 to November 2019. Statistical analysis was done using SPSS 22 and R environment ver.3.2.2.Results: A total of 36 patients were included in this study of which 21 were diabetics and were in placed in group A and 15 were non diabetics and placed in group B. 83.3% of the patients were males. 73.3% of non-diabetics had stage 1 cellulitis and 33.3% of diabetics had stage 1 and 2 each. 47.2% of patients underwent debridement and it was significantly common in diabetics (p=0.037) and also it was common in higher stages of cellulitis (p=0.001). 8.3% had amputation in this series. All the major amputations were done in stage 4 cellulitis (p=0.002).Conclusions: In this validation study, it can be seen that cellulitis is common in both diabetics and non-diabetics but it is severe in diabetic patients. Stage 3 was more common in diabetics compared to non-diabetics. Amit Jain’s staging system of cellulitis is a simple, easy, practical, focal classification that guides therapy and predicts amputation.

Background: The aim of this study is to develop a scoring system wherein axillary lymph node metastasis in carcinoma breast can be predicted preoperatively using simple variables.Methods: A prospective study carried out from December 2017-November 2018 at Rajarajeswari Medical College and Hospital. All clinically node negative cases were included. Data from clinical examination, histopathology report and immunohistochemistry (obtained from trucut biopsy preoperatively) is correlated with presence or absence of lymph node metastasis obtained after modified radical mastectomy. And a scoring system is proposed according to the results obtained. Results: Out of 36 cases studied, 12 cases had score 14, indicating that more than 50% of cases were over treated with axillary lymph node dissection.Conclusions: Lymph node metastasis in carcinoma breast can be predicted clinically using a scoring system. Further a recommendation for or against axillary node dissection can be made according to the respective scores.

Background: The prolonged and frequent use of laparoscopic equipment raises ergonomic risks that may cause physical distress for surgeons. We aimed to assess the prevalence of laparoscopic surgeons’ physical distress associated with ergonomic problems in the operating room (OR) and their awareness of the ergonomic guidelines in laparoscopy. Methods: A sample of 150 laparoscopic surgeons was assessed using a questionnaire on demographic information, ergonomic issues in the OR, musculoskeletal symptoms, and awareness of the ergonomic guidelines for the OR. Results: There were 112 survey respondents (74.3%) with valid questionnaires. Among the respondents 50% had completed laparoscopic training programs while 39.2% had no laparoscopic training. 61.5% respondents placed the operating table at umbilicus height during the actual operation. The majority of the respondents used only one monitor during the procedure. Only 4.3% placed the monitor below the eye level. 3% of the respondents attributed pain due to foot pedal design. The respondents experienced discomfort in the following regions in descending order: right shoulder (87.2%), left shoulder (78.3%), neck (67.4%), back (46.8%), hand (30.3%), leg (21.6%), and wrist (15.8%). The respondents with more than 5yrs of experience complained less discomfort than those with less than 5yrs. Only 54.6% of respondents were aware of the ergonomic guidelines. However, almost all of the respondents (100%) regarded the ergonomic guidelines to be important in the OR. Conclusions: Most of the laparoscopic surgeons were not aware of the ergonomic guidelines for the laproscopic OR; especially, junior laparoscopic surgeons and surgeons with

Background: Nontuberculous mycobacteria (NTM) are a rare cause of chronic surgical infection in humans. These infections are commonly seen in the setting of laparoscopic surgery, due to poor sterilization techniques. This case series analyses the clinical features and management of patients with biopsy proven NTM infection, with a review of the current literature.Methods: Patients with chronic surgical site infections admitted to our surgical unit, over a 5-year period from January 2008 to December 2012 were analyzed in this study. A total of 24 patients with biopsy proven NTM were included. The clinical details, management protocol is discussed.Results: A total of 24 patients were analysed. Most of our patients were females (n=16) and this infection was most commonly seen following laparoscopic cholecystectomy (n=10). The symptoms were usually benign but persistent watery or purulent discharge. Mycobacterium fortuitum and Mycobacterium chelonae were the predominant organisms isolated. All patients in this series were treated with extensive surgical debridement and long-term antibiotics. A multidrug antibiotic regimen consisting of Ciprofloxacin, Clarithromycin and Amikacin was used. All of our patients showed good response to treatment during stay and recurrence was seen in 3 patients who had delayed healing wounds.Conclusions: NTM is not an uncommon infection and can occur following laparoscopic or open surgical procedures. Improper sterilization and reuse of laparoscopic or open instruments accounts for the majority of the cases. When laparoscopic instruments are reused, following strict sterilization protocols is necessary to prevent this infection. When established, this infection should be treated aggressively with adequate surgical debridement, followed by long term antibiotics.