Surgery

Complex Liver Injury—a Quagmire to a Trauma Surgeon Abstract Non-operative management has become a norm in patients with liver trauma and operative management is guided by hemodynamic status. Introduction of haemodynamic status. Introduction of contrast enhanced computed tomography (CECT) abdomen has made NOM possible by helping in exclusion of other injuries and identification of vascular injuries. Haemodynamic instability is now considered as an only absolute indication for operative intervention in liver injuries. However, liver trauma is associated with a large number of complications in the form of perihepatic abscess, hepatic necrosis, bile leak, etc. Patient's undergoing operative intervention for liver trauma are more at risk for these complications. As such regular dynamic assessment is required for early identification and management of these complications. We present a case of a complex liver injury in a 27-year-old male who underwent operative intervention for liver trauma and had a varied number of liver trauma associated complications, with enterohepatic fistula as one of the rarest associated complications.

Elevation of Thin Pudendal Artery Flap Using Fat Thickness Data in Vulvovaginal Reconstruction Abstract Majority of defects after excision of vulvovaginal skin cancers is shallow in depth. A thin flap is thus suitable for pudendal defects. To create a thin pudendal artery flap, the relationship between fat thickness and age or body mass index (BMI) was examined. A total of 12 flaps in 7 cases were enrolled. In the initial 3 cases, five flaps were elevated in the subfascial plane of the gluteus maximus muscle based on the conventional method. In the 4th case with thick adipose tissue, the flap was elevated in the plane just below Camper's fascia (CF). We then adopted this modified flap elevation method in 7 flaps of the 4th to 7th cases. By using computed tomography, we evaluated the perineal fat thickness (PFT) and gluteal fat thickness (GFT) to determine the thickness of the flap. All flaps survived completely. In all flaps prepared with the modified method, debulking was not required. The mean PFT (34.4 ± 2.8 mm) of the patients less than 70 years of age was significantly higher than that of patients of 70 years or more (21.0 ± 3.5 mm). The mean GFT (18.4 ± 1.1 mm) of the patients with BMI ≥ 25 was significantly higher than that of patients with BMI < 25 (11.8 ± 1.2 mm). To create a thin pudendal artery flap, the method of elevating the flap in the plane just deep to CF should be adopted, especially in patients less than 70 years of age or with BMI ≥ 25.

Posterior Epidural Migration of a Lumber Disc Fragment Causing Cauda Equina: a Case Report and Literature Review Abstract Cauda equina syndrome manifests as bilateral leg pain and sensory disturbances in the perianal region. In this article, authors describe patient with posterior epidural disc migration of a lumber disc fragment causing cauda equina syndrome and provide review of the literature.

Sialolipoma of Parotid Gland: a Lesser Known Entity Abstract Around 51 cases of sialolipoma of the salivary gland have been reported worldwide as per the literature reviewed. Majority of cases (n = 25) arise from the parotid gland (51.4%) clinically behaving like pleomorphic adenoma with very less incidence of facial nerve entrapment (14%). Sialolipoma is a rare neoplasm of the salivary glands, described as a distinct entity by Nagao et al. in 2001. Lipomatous neoplasms of the parotid gland are rare tumours accounting 0.6 to 4.4% of all parotid neoplasms with most series reporting an incidence of 1%. It is extremely rare in females, being 10 times more common in males, and the most common age of presentation is the fifth to sixth decade. Numerous histological variants of salivary gland lipoma have been described. Sialolipoma is a rare variant having proliferation of mature adipocytes with secondary entrapment of the normal salivary gland element. We report a rare case of sialolipoma in the left parotid of a 49-year-old woman presented to General Surgery Department who was treated with superficial parotidectomy.

Residents Feedback on Faculty and Working Environment: the Urology Training Program in India Abstract The purpose of our study was to know the residents' feedback regarding urology residency in India. Such information is presently scarce. The feedback included evaluating domains like faculty participation in academic activities and resident-friendly learning workplace. It also asked residents what change they wished to see in faculty and an overall rating of their residency program. An online survey was conducted using SurveyMonkey® platform. E-mails with an online link to survey were sent to 1469 associate members of Urological Society of India. There were 12 queries. The responses between residents in M.Ch. and D.N.B. programs, the two officially recognized teaching programs in India, were also compared. Seventy-eight current residents or those who completed residency within 1 year finished the survey. The unfavorable responses towards faculty involvement in academic activities, teaching and creating a friendly work place varied from 20 to 30% for most questions. When asked about what change in faculty the residents wanted, 45.5% reported "better involvement in teaching" followed by creation of a friendly workplace environment (37%). The overall mean satisfaction rating with the program on a scale of 0–100 was 66.04 ± 22.51. The responses of residents from the M.Ch. and D.N.B. programs were similar (p > 0.05). Our results provide some insight on the resident's perspective of their training/teaching programs in Indian urology centers. Although, a comprehensive validated questionnaire was not used but our observations can be used to improve the learning of students doing residency in urology.

Quality Improvement in Laparoscopic Donor Nephrectomy by Self-Imposed Proctored Preceptorship Model Abstract Initiation of an advanced laparoscopic surgery program requires skill and proper training. Despite description of multiple surgical training modules, an ideal method for training of surgeons for advanced laparoscopic procedures is lacking. We propose an abbreviated self-imposed proctored preceptorship training model as the optimum training method for training skilled laparoscopic surgeons in advanced laparoscopic procedures like laparoscopic donor nephrectomy. The laparoscopic donor nephrectomy program was started at the Institute using preceptorship-proctorship model. One hundred left laparoscopic donor nephrectomies were performed over the course of 2 years. Outcomes in terms of performance related (Surgeon) outcomes in the form of learning curve and patient outcomes in terms of donor outcomes and recipient results and were studied. Learning curve was calculated using the moving average method and calculation of mean operative time of every five consecutive cases. Mean operative time for laparoscopic donor nephrectomy was 108.1 ± 26.5 min, the warm ischemia time averaged at 3.5 ± 1.3 min and the mean blood loss was 130.1 ± 54.9 ml. Moving average analysis revealed that approximately 20 LDN cases were needed to complete the learning phase. According to the mean operative time of every five consecutive cases, learning phase of LDN was completed between 26 and 30 cases. We believe that the abbreviated self-imposed proctored preceptorship model of training is an optimum model for starting a new advanced laparoscopic surgery program and can help surgeons to overcome the initial learning curve.

Giant Pleomorphic Liposarcoma of the Chest Wall in an Octogenarian Woman Abstract Liposarcomas usually originate in the extremities and retroperitoneum. Primary malignant soft-tissue sarcoma of the chest is a rare entity. We described a case of an 80-year-old woman with a large and painless mass on right posterior chest wall.

Bilateral Fungating Metastatic Breast Cancer: Case Report Abstract Breast cancer is the most common cancer among females; while incidence of breast cancer increase with age, yet screening programs in most countries stop inviting patients beyond the age of 70 years. In spite all the efforts and resources geared for early detection of breast cancer, fungating locally advanced breast cancer remains a clinical challenge with the majority of patients either have metastatic disease at presentation or develop distant metastases despite appropriate therapy, leading to poor outcome. We are presenting a case of a patient who presented with locally advanced, fungating, metastatic breast cancer in spite of a very efficient screening program.

A Bibliometric Analysis of Pectoral Nerve Blocks Abstract Pectoral nerve blocks (Pecs I and Pecs II) are superficial thoracic wall blocks which block the pectoral and intercostal nerves. They can be used as analgesia/anesthesia for breast surgery and other procedures/surgeries involving the anterior chest wall (arteriovenous graft creation surgery, minimally invasive cardiac surgery and thoracotomy, etc.). The aim of this study is to evaluate publications in the scientific field of pectoral nerve blocks. ISI Web of Knowledge-Science was used for the analysis. All scientific works published included in the Science Citation Index Expanded (SCI-E) from 1975 to January 27, 2019, were analyzed. A retrospective search was performed using key words "pectoral nerve block," "PECS I," "PECS II," "pecs block," "PECS block,""Pecs I," "Pecs II," "PECS 1," "PECS 2," and "modified pecs I block." We further analyzed these results by the "analyze" function of the software in terms of number of papers for each country, type of documentation, number of publications per year, and name of journals and authors. The number of citations to published works was also calculated by using the citation function of the same software. 72 papers were found related to pectoral nerve block. The biggest contribution was from India (24.28%), and followed by Japan (14.28%), USA (14.28%), Canada (7.14%), Egypt (7.14%), Italy (5.71%), and South Korea (5.71%). The total number of publications increased sharply in years from 2014 (n = 1) to 2018 (n = 28). We have detected that papers on the use of pecs block in breast cancer surgery, which is one of the most common surgical procedure in the world, are few in the literature. With this study, we hope to increase the awareness on this area. We believe that pecs block applications will become widespread with the increasing use of ultrasound in anesthesia and the increase in education in this field.

Aggressive Mucinous Carcinoma of Male Breast Abstract We report of a mucinous carcinoma of the breast in a 62-year-old male, who presented with left breast mass and incisional biopsy scar. Incisional biopsy showed invasive mucinous carcinoma with endocrine differentiation. Patient underwent a simple mastectomy and sentinel lymph node biopsy (SLNB). In definitive pathologic examination, tumor showed estrogen- and progesterone-positive and her2-neu-negative receptor status. This was followed by adjuvant chemotherapy. After 2 weeks of the first cure chemotherapy treatment, patient admitted with respiratory distress and diagnosed as having thoracentesis requiring massive pleural effusion. In the detailed examination, multiple hepatic metastases were detected. In this report, we present a male patient with mucinous breast carcinoma and multiple distant metastases.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
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6948891480

alsfakia@gmail.com