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ORIGINAL ARTICLES
Temporary facial nerve paralysis after parotidectomy: the mansoura experience, a prospective study
Mokhtar Fareed, Khalid Mowaphy, Hesham Abdallah, Mohamed Mostafa
April-June 2014, 33(2):117-124
DOI:10.4103/1110-1121.131677  
Background Parotidectomy was first introduced into the world literature by Berard in 1823 who removed a parotid tumor of 8 years' duration. Since then the procedure has been modified and applied to a variety of benign and malignant conditions affecting the gland; superficial parotidectomy, subtotal parotidectomy, and total parotidectomy are now the options available to the head and neck surgeon. The primary goal of parotid surgery is the complete removal of tumors while preserving facial nerve function. Despite efforts to preserve the anatomic and functional integrity of the facial nerve, facial nerve paralysis continues to be a daunting complication of parotidectomy. Purpose The aim of the study was to evaluate our experience in parotid surgery, aiming to lower the incidence of facial nerve palsy and study postoperative complications. Patients and methods This prospective study was conducted on 30 patients from July 2012 to June 2013 with parotid swelling persistent over 1 year; patients were submitted to careful history taking, complete clinical examination, and examination of facial nerve integrity before surgery. Over a period of 1 year these 30 patients with parotid swelling underwent parotidectomy by means of an antegrade technique of whom 26 underwent superficial conservative parotidectomy (nine men and 17 women) and four underwent total conservative parotidectomy (two men and two women). Results Most patients (26) underwent superficial conservative parotidectomy. Four patients underwent total conservative parotidectomy with excision of the superficial lobe, dissection of facial nerve branches, and excision of the deep lobe of the gland from between the branches of the facial nerve. In our study population (30) 10 patients had temporary facial nerve paralysis (33.3%) of whom five were HB II (16.7%), three were House-brackmann Scale HB III (10%), and two were HB IV (6.6%). Conclusion In our study, we adopted certain precautions to lower the incidence of temporary facial nerve paresis. One of these precautions is vertical retraction to reduce the risk of traction injury. Once the nerve trunk was identified we did not use diathermy at all; hemostasis was performed with surgical ligatures (5/0 polygalactin).
  7,118 276 -
Pilonidal sinus: minimal excision and primary closure under local anesthesia
Hussein G Elgohary, Ehab M Oraby
October-December 2015, 34(4):287-292
DOI:10.4103/1110-1121.167393  
Introduction Many surgeons treat pilonidal sinus (PNS) by wide excision, leaving a lay open or a primary sutured midline wound. Others use more sophisticated techniques such as skin flap reconstruction. Objectives The aim of the study was to determine the method of excising PNS minimally under local anesthesia and study its subsequent effects on wound closure and the healing process. Patients and methods This prospective study was carried out on 30 consecutive patients with primary nonrecurrent sacrococcygeal PNS. All patients were treated surgically with minimal excision and primary closure under local anesthesia. Parameters of follow-up included wound seroma, infection, or disruption, in addition to pain, difficulty in mobilization, time off work, and recurrence. Results The mean operative time was 38 min. Hospital stay ranged from 2 to 4 h. Healing time was 14-20 days. Three cases presented with wound seroma. One patient had a wound infection. One patient had significant wound infection and wound disruption; this patient had a recurrence after 6 months, which was treated with wide excision and rhomboid flap reconstruction. Conclusion Minimal excision and primary closure for uncomplicated cases of PNS under local anesthesia is a safe and easy operative procedure with shorter operative time, short duration of hospital stay, less postoperative time off work, low complication rates, and low chances of recurrence.
  2,631 104 -
CASE REPORT
A large posterior perforation of gastric ulcer: a rare surgical emergency
Amr A Badawy
January-March 2016, 35(1):74-76
DOI:10.4103/1110-1121.176828  
A 65-year-old woman was admitted with a complaint of a constant dull aching pain in the epigastrium for 4 days, with subsequent worsening and generalization of the pain. Clinically the abdomen was tender all over with board-like rigidity. Chest radiography revealed pneumoperitoneum and a decision was made to explore the patient. During laparotomy we found mild peritoneal collection with no perforation in the anterior surface of the stomach, duodenum, or the entire gastrointestinal tract. After opening the gastrocolic omentum, we found a large perforation of the posterior wall of the stomach. After direct repair with an omental patch, the patient recovered and was discharged after 14 days, with only wound infection. Posterior perforation of a gastric ulcer is a very rare condition.
  2,328 102 -
ORIGINAL ARTICLES
Retrospective study of different methods for managing Egyptian patients with pseudomyxoma peritonei: feasibility and overall outcome
Galal Abouelnagah, Mohamed Kasem, Sherif Anis, Sherif ElZawawy
July-September 2014, 33(3):194-200
DOI:10.4103/1110-1121.141912  
Introduction Pseudomyxoma peritonei (PMP) is a rare disease with poor outcome when not treated properly and is characterized by mucinous ascites and peritoneal implants. Treatment for PMP is variable, both because of the rarity of the disease and because of its often slow-growing nature. There is no consensus regarding the proper management of aggressive cases. Our study was designed to analyze the symptoms and signs of PMP, as well as the diagnostic tools, and evaluate the effect of treatment and factors influencing postoperative recurrence of and survival from PMP in Egyptian patients. Patients and Methods We reviewed consecutive cases of PMP that presented at the surgical department of the Main Alexandria University Hospital from January 1990 to December 2012. Results This study included 62 patients with PMP: 43 were women (69%) and 19 were men (31%). Their mean age at the time of diagnosis was 47.3 ± 11.6 years (median 49, range 29-67). The predominance of women was statistically significant (P = 0.08). A total of 69 surgical procedures had been performed in 46 cases, including 46 primary operations, 10 secondary operations, one tertiary cytoreduction and peritonectomy, and 12 debulking procedures for recurrence. Conclusion Surgical debulking is the standard treatment for PMP in primary and recurrent tumors. Intraperitoneal chemotherapy either intraoperative or postoperative is accompanied by better disease-free survival and overall survival. Referring of patients to specialized centers that treat these patients on a regular basis is essential to prevent high morbidity and mortality. Recurrence is common and requires reoperation with or without adjuvant chemotherapy.
  1,833 85 -
Laparoscopic resection rectopexy versus laparoscopic mesh rectopexy for rectoanal intussusception
Sameh Hany, Saleh El-Awady, Sabry Ahmed, Mohamed Abo-Elkheir, Hosam Ghazy, Mohamed Farid
January-March 2015, 34(1):48-55
DOI:10.4103/1110-1121.153371  
Background and aim Rectoanal intussusception (RI) can be treated by laparoscopic rectopexy successfully following different techniques. This study aims to compare laparoscopic resection rectopexy with laparoscopic ventral mesh rectopexy in patients with RI. Patients and methods From February 2012 to February 2014, 28 patients with RI were admitted to the Colorectal Surgery Unit, Mansoura University. The patients were divided into two groups: the ventral mesh rectopexy group and the resection rectopexy group. Postoperative improvement in clinical symptoms, symptoms scores, anorectal manometry, and defecography were evaluated over 12 months. Results Eleven (39.3%) patients were male and 17 (60.7%) were female, with a mean age of 43.42 years. Improvement in obstructed defecation symptoms was observed in 22 (78.5%) patients overall: 85.7% in the resection rectopexy group and 71.4% in the ventral mesh rectopexy group (P = 0.648). The mean Wexner score dropped from 15.57 to 4.8 at 3 months (P = 0.0025). The mean operative time was 2.97 h in the resection rectopexy group versus 2.14 h in the ventral mesh rectopexy group (P = 0.0003). Minor morbidities were detected in five cases and no mortality was reported. Recurrence was diagnosed in six (21.4%) patients at 1 year. Conclusion Laparoscopic resection rectopexy is superior to ventral mesh rectopexy despite longer operative time, longer hospital stay, and higher risk of complications
  1,660 102 -
Bascom's cleft lift versus rhomboid flap procedure for the management of primary sacrococcygeal pilonidal sinus
Mohamed Rabea
July-September 2015, 34(3):146-151
DOI:10.4103/1110-1121.163111  
Objective The aim of this study was to evaluate and compare clinical safety and efficacy after Bascom's cleft lift and rhomboid flap (Limberg) procedures for the treatment of primary sacrococcygeal pilonidal sinus (SCPS). Patients and methods This study included 100 adult patients with primary (nonrecurrent) SCPS who were randomized to Bascom's cleft lift procedure (n = 50) or to rhomboid flap procedure (rhomboid-shaped excision and Limberg flap) (n = 50). Through the follow-up period, which ranged from 6 to 12 months, with an average of 9.1 ± 1.7 months, patients were evaluated for wound-related complications and recurrence of symptoms after complete wound healing. Results There were insignificant differences in the baseline characteristics between both groups. Compared with Bascom's cleft lift procedure, the rhomboid flap procedure involved a longer duration of operation (61.14 ± 16.36 vs. 40.78 ± 11.96 min; P < 0.001). A significant clinical outcome was achieved after the rhomboid flap procedure in terms of less duration to pain relief (12.42 ± 1.59 vs. 17.86 ± 3.10; P < 0.001) and less healing time (17.42 ± 4.68 vs. 20.06 ± 5.94; P < 0.05). The incidences of postoperative wound-related complications and recurrence were 6 and 2%, respectively, after the Bascom's cleft lift procedure and 4 and 2%, respectively, after the rhomboid flap procedure, with insignificant differences. Conclusion Although Bascom's cleft lift operation involves a shorter duration of operation, the rhomboid-shaped excision with the Limberg flap procedure was superior in terms of early wound healing, with similar incidences of wound-related complications and recurrence after treatment of primary SCPS.
  1,623 105 -
Splenectomy for patients with β-thalassemia major: long-term outcomes
Samir A Ammar, Khalid I Elsayh, Asmaa M Zahran, Mostafa Embaby
October-December 2014, 33(4):232-236
DOI:10.4103/1110-1121.147614  
Background/aim The use of splenectomy for thalassemia major is restricted over concerns of its long-term outcome. The aim of this study was to assess the long-term outcomes of splenectomy for patients with β-thalassemia major. Patients and methods This study included 70 patients with β-thalassemia major. Patients were classified into two groups: 35 patients underwent splenectomy (S group) and 35 patients did not undergo splenectomy (NS group). Patients were assessed by review of medical records, assessment of medical history, and a clinical examination. In addition to complete blood count, liver function tests and serum ferritin were performed. Assessment of lymphocyte populations was carried out by flow cytometry. These investigations were performed at least 2 years after splenectomy in the S group. Results The mean age of the patients who underwent splenectomy was 6.68 ± 2.54 years and the mean postoperative follow-up period was 6.26 ± 3.03 years. Splenectomy improves anemia, but does not reduce iron burden; more patients were found to be on regular iron chelation after splenectomy. Hematocrit and red blood cell indices were significantly increased after splenectomy. Platelet count increased significantly in the S group (644.700 ± 299.400/mm 3 ). There were no significant differences in T-lymphocyte populations between both groups. IgM memory B lymphocytes were lower in the S group compared with the NS group. No overwhelming postsplenectomy infection was reported in this series. Postsplenectomy portal vein thrombosis was reported in one (2.9%) case. Conclusion With long-term follow-up after splenectomy for treatment of thalassemia major, thrombocytosis and the risk of thromboembolic persist. Splenectomy improves anemia, but does not reduce iron burden or the requirement for blood transfusion. Proper preoperative vaccination can reduce the risk of overwhelming postsplenectomy infection.
  1,499 226 3
Closed versus open lateral internal anal sphincterotomy for chronic anal fissure in female patients
Jamila Al Sanabani, Saleh Al Salami, Azzan Al Saadi
July-September 2014, 33(3):178-181
DOI:10.4103/1110-1121.141905  
Objective The aim of the study was to determine the best technique for surgical treatment of chronic anal fissure in female patients. Study designs The study was designed as a prospective randomized study. Place and duration of study The study was conducted in Surgical Unit, Al Kuwait University Hospital and Al Huribi Hospital (Sana'a, Yemen) from January 2007 to December 2010. Patients and methods A total of 205 female patients undergoing surgery were divided into two groups. In group A, there were 100 patients who were treated by closed lateral internal anal sphincterotomy, and in group B there were 105 patients who were managed by open lateral internal anal sphincterotomy method. Patients were followed up for 6 months following surgery to observe for pain, bleeding, infection, incontinence, and recurrence. The exclusion criteria were patients who had in addition hemorrhoids or any other anorectal diseases. Results There was acceptable difference in postoperative acute complications between the two methods of internal anal sphincterotomy. However, in group A, six patients (6%) were complicated with very low anal fistula postoperatively, whereas the recurrence rate was 6 versus 1.9% in group A versus group B, respectively (P = 0.015). Conclusion Lateral internal sphincterotomy either with open or closed method is the treatment of choice for chronic anal fissure in female patients and can be performed effectively and safely with acceptable rate of complications; however, the open method is considered to have less morbidity and rate of recurrence.
  1,545 167 1
Thyroglossal Cyst and Fistula: Surgical pitfalls and causes of recurrence
Tamer Alnaimy, Basem M Sieda, Taha Baiomy
January-March 2016, 35(1):49-53
DOI:10.4103/1110-1121.176807  
Background: The thyroglossal duct cyst (TDC) results from a failure of complete obliteration of thyroglossal duct. It represents the most common type of developmental cyst seen in the neck region. Objective: Evaluate our experience in the management of primary and recurrent thyroglossal cyst and fistula and to determine the role of pre- and postoperative infection as an important factor associated with thyroglossal duct recurrence after surgery. Methods: During the period from January 2013- April 2014, in General and Pediatric Surgery Department, 50 patients with thyroglossal duct cyst (35 patients) and fistulae (15 patients) were diagnosed and treated. All records were reviewed for age and sex, diagnostic methods, surgical management and postoperative infection and recurrences. Results: The recurrence rate was high in cases with infection occurred preoperative or postoperative. Conclusion: Infection very important leading factor for recurrence of thyroglossal cyst.
  1,594 98 -
Outcome of karydakis lateral flap versus open technique in the treatment of pilonidal sinus
Hady S Abou Ashour, Moharram A Abelshahid
October-December 2015, 34(4):251-257
DOI:10.4103/1110-1121.167386  
Introduction Pilonidal sinus disease is a chronic, recurrent disorder of the sacrococcygeal region, which commonly occurs in young adults following puberty. The male population is affected more frequently compared with the female population. A large number of surgical techniques (with varying complexity) have been described in the literature for the treatment of this disease. Such diversity suggests that no single technique has emerged as the preferred method in preventing recurrence of this condition. Objectives The aim of this study was to compare karydakis lateral flap technique with open technique in the treatment of noncomplicated pilonidal sinus. Patients and methods A total of 70 patients with uncomplicated pilonidal sinus, attending Minoufiya University Hospital and other private hospitals, were included in this study. They were divided into two groups: the karydakis group and the open procedure group. Results A total of 57 male and 13 female patients were included in this study. The mean operative time in the karydakis and the open group was 45 ± 7.27 and 23.4 ± 4 min, respectively. There was a significantly lower rate of wound infection in the karydakis group. Two patients (5.7%) showed recurrence in the karydakis group, whereas eight patients (22.8%) had recurrence in the open group. There was no significant difference between the two groups as regards scar pain and numbness (P > 0.05), but there was a significantly lower recurrence rate in the karydakis group (P = 0.022). The healing time and duration of work-off was significantly shorter in the karydakis group (P < 0.001). Conclusion Karydakis technique showed shorter hospital stay, earlier healing, shorter duration of work-off, and lower rate of complications compared with the open technique.
  1,540 124 -
Reconstruction methods after pancreaticoduodenectomy for pancreatic carcinoma: better method to prevent serious complications
Hamed Rashad, El-Sayed A Abd El-Mabood, Taher H Elwan, Ayman M Adbelmofeed, Refaat S Salama, Emad H Gad
April-June 2014, 33(2):94-99
DOI:10.4103/1110-1121.131662  
Purposes The of aim of this study was to assess the safety of pancreatic anastomosis after pancreaticoduodenectomy (PD) and to compare the results of pancreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) following PD in a prospective and randomized setting. Background Pancreatic fistula after PD represents a critical trigger of potentially life-threatening complications and is also associated with markedly prolonged hospitalization. The best method for dealing with the pancreatic stump after PD remains in question. Patients and methods The study included 50 patients, 33 (64%) men and 18 (36%) women with a mean age of 66.3 ± 4 years. All patients underwent clinical evaluation, laboratory assessment, and computed tomography or MRI examination. All patients undergoing PD with soft residual tissue were randomized to receive either pancreaticogastrostomy (group PG) or end-to-side pancreaticojejunostomy (group PJ). The postoperative follow-up ranged from 6 to 12 months. Results No mortality was recorded. The mean ICU stay duration was 2.4 ± 0.8 days. The duration of hospital and ICU stay was shorter in group PG (P = 0.03). The mortality because of surgical causes was higher in group PJ (P = 0.02). The frequency of postoperative complications - that is, pancreatic fistula (P = 0.0343), intra-abdominal bleeding and collection (P = 0.0376) - was higher in group PJ; however, there was no significance between both groups in the frequency of abdominal wall abscess and biliary leakage (P = 0.39). The patients with intra-abdominal collection were treated well by conservative measures in group PG (P = 0.023); however, patients who needed open drainage were less (P = 0.0376) and there was no significance between both groups in computed tomography-guided drainage (P = 0.56). Conclusion Pancreaticogastrostomy could be considered better as a reconstruction method; with shorter hospital stay, No Necrosis of pancreatic remnant, Less frequency of post operative complications & so Re-do with its complication is less.
  1,474 140 -
Risk factors for post-ERCP pancreatitis: a prospective multicenter study in upper Egypt
Mohammed A Omar, Ahmed E Ahmed, Omar A Said, Hussein El-Amin
January-March 2015, 34(1):1-10
DOI:10.4103/1110-1121.153364  
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) has become widely available for diagnosis and treatment of pancreatic and biliary diseases. Pancreatitis is the most common and serious complication to occur after ERCP resulting in substantial morbidity and occasional mortality. The aim of this study was to evaluate the potential patient and procedure-related risk factors for postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) in a prospective multicenter study. Patients and methods Consecutive ERCP procedures were prospectively studied at five centers (two universities, three private). Data were collected on patient characteristics and endoscopic techniques before the procedure, at the time of procedure, and 24-72 h after discharge. PEP was diagnosed and its severity graded according to consensus criteria. Results Pancreatitis occurred after 104 (8.9%) of 1162 consecutive ERCP procedures and was graded mild in 66 (63.5%), moderate in 30 (28.8%), and severe in eight (7.7%) cases. On univariate analysis, 11 of 18 evaluated variables were found to be significantly associated with PEP. On multivariate analysis, significant risk factors with adjusted odds ratio (OR) were: difficult cannulation (OR: 10.2), previous PEP (OR: 8.1), previous pancreatitis (OR: 7.9), at least two pancreatic duct injections (OR: 3.1), pancreatic duct cannulation (OR: 2.7), difficult stone extraction (OR: 2.2), and precut sphincterotomy (OR: 1.2). Conclusion Technique-related risk factors are probably more numerous and potent than patient-related ones in determining high-risk predictors for PEP.
  1,478 135 -
Evaluation of intracorporeal knotting and metallic clipping of the appendicular stump in laparoscopic appendicectomy
Hady S Abou Ashour
July-September 2014, 33(3):188-193
DOI:10.4103/1110-1121.141908  
Background Laparoscopic appendicectomy has gained popularity, especially among laparoscopic surgeons, due to the advantages of minimal-access surgery and the simplicity of the technique. Together with endoloop, various techniques have been tried to secure the base of the appendix. Some laparoscopic surgeons apply ligature or clips owing to its lower cost and feasibility. In this study, we applied intracorporeal ligature (knotting) or metallic clips for secure closure of the base of the appendix during laparoscopic appendicectomy. Aim The aim of this work was to evaluate the application of both techniques, together with recording of any specific complications related to each. Patients and methods During the period from February 2010 to November 2013, in Minoufiya University Hospital and other private hospitals, 200 laparoscopic appendicectomy patients were included in this prospective study. In total, 117 patients were female and the overall average age was 27.4 years. Patients were divided into two equal groups (group A and group B): group A underwent intracorporeal knotting of the base and the metallic clip closure technique was the alternative in group B. Results The mean operative time was 45 min in group A and 37 min in group B (P < 0.05). The mean hospital stay was 2.07 days in group A and 2 days in group B, and this was not significant (P > 0.05). Complications varied between port-site wound infection and delayed intestinal sounds, and there were no significant differences or major complications. Conclusion In our study, both intracorporeal knotting and the metallic clip closure technique were successful, feasible, and economic in securing the appendicular stump, except for a wide, severely edematous, or gangrenous base, wherein the metallic clip closure technique was not appropriate.
  1,406 185 -
Technical tips associated with reduction in leak rate after laparoscopic sleeve gastrectomy: lessons to learn from a nested case-control study
Mohamed Bekheit, Khaled Katri, Wael Abdel-Salam, Tamer Nabil Abdelbaki, Bruno Sgromo, Jean-Marc Catheline, Galal Abou ElNagah, El Said El Kayal
April-June 2014, 33(2):125-130
DOI:10.4103/1110-1121.131682  
Background Laparoscopic sleeve gastrectomy (LSG) is one of the common bariatric procedures for the treatment of morbid obesity. One of the most drastic complications of this procedure is leak. Objective The aim of the study was to discuss the possible technical factors that might contribute to the occurrence of postoperative leak and how to avoid it through analyzing our series. Materials and methods Analysis of the influence of technical adaptations on the outcome of LSG was performed in a nested case-control group of patients. The main modification adapted was performing invaginating sutures over the staple line. The primary outcome was the occurrence of leak. The secondary outcomes were bleeding, operative time, prolonged hospital stay, back pain, and mortality. Results The group who had invaginating sutures (group 2) had a significantly lower frequency of leak (0%) than those without invaginating sutures (7.3%; group 1) (PF = 0.016). There was no significant difference in the occurrence of postoperative bleeding or mortality between the groups (PF = 0.162 and 0.250, respectively). The frequencies of a hospital stay longer than 48 h and back pain were significantly higher in group 1 (PF = 0.004, PF < 0.001, respectively). There were no significant differences between groups in the preoperative BMI (Student's t = 0−0.763, P = 0.45) or the age (Student's t = −0.5, P = 0.61). The operative time was longer in group 1 (Student's t = 3.56, P < 0.001). There was also a significantly lower intraoperative blood loss in group 2 (Student's t = 1.99, P = 0.048). Conclusion From our experience, leak after LSG could be minimized by invaginating sutures of the staple line and by adapting the ergonomic trocar positioning described herein.
  1,428 140 1
Splenic bed lavage: a new technique to avoid postsplenectomy subphrenic abscess in patients with portal hypertension
Wael E Lotfy, Wael M Awad, Abdelwahab M Hamed, Ghada K Gouhar, Hoda A Salem
April-June 2014, 33(2):81-85
DOI:10.4103/1110-1121.131653  
Aim The aim of the study was to evaluate the effectiveness of splenic bed lavage (SBL) (new technique) in prophylaxis against postsplenectomy subphrenic abscess. Study type This was a randomized control trial. Patients and methods A total of 44 patients with splenomegaly due to portal hypertension underwent splenectomy. They were randomized into two groups: group I included 25 patients who underwent SBL postoperatively and group II included 19 patients who underwent only tube drainage of the splenic bed. All patients were followed up by ultrasonography to check for occurrence of subphrenic collection. Results None of the group I patients developed subphrenic abscess (0% risk), whereas three patients in group II developed subphrenic abscesses, which needed either ultrasonography-guided drainage or open surgical drainage. Conclusion SBL is an effective technique to prevent subphrenic abscess after splenectomy in patients with portal hypertension.
  1,440 103 -
Laparoscopic transabdominal preperitoneal inguinal hernia repair
Ahmed Eisa, Ahmed Gaber, Tarek T Harb
April-June 2014, 33(2):86-89
DOI:10.4103/1110-1121.131656  
Background The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is an evolving technique associated with well-known advantages of a minimally invasive approach. The present prospective randomized study was conducted to assess the feasibility and safety of performing laparoscopic TAPP repair. Patients and methods The present prospective randomized study was conducted between April 2009 and March 2011 and included 45 patients suffering from uncomplicated primary groin hernia who underwent TAPP repair. Intraoperative incidents, postoperative pain, complications, and recovery in general as well as patient satisfaction at follow-up examination were prospectively recorded. Results There was no injury to vas deferens, other cord structures, or bladder. Eight of the 45 patients developed seroma during the immediate postoperative period. Pain medication was given once to all patients on the first postoperative day. During postoperative follow-up for 24 months, no recurrence was detected. Conclusion TAPP repair is a feasible and safe technique, resulting in less postoperative pain and less postoperative complications; we recommend it as a procedure of choice especially in recurrent and bilateral cases.
  1,421 103 -
CASE REPORT
Laparoscopic excision of benign multicystic peritoneal mesothelioma
Ahmed El Geidie, Hosam Hamed, Ahmed Shehta
October-December 2014, 33(4):277-280
DOI:10.4103/1110-1121.147620  
Benign multicystic peritoneal mesothelioma is a rare disease that arises from the peritoneal mesothelium. We report on a 52-year-old woman who presented with a large abdominal multicystic mass presumed to be a pancreatic pseudocyst. Laparoscopic exploration revealed a multicystic mass with area of calcification originating from the lesser curvature of the stomach. The whole tumor was successfully excised laparoscopically. Histopathology revealed benign multicystic peritoneal mesothelioma with an area of calcification. Treatment by a minimal access approach allowed the patient to recover rapidly with a short convalescence. Our case confirms the feasibility and safety of a minimal access surgical approach to a rare pathological entity.
  1,429 87 -
ORIGINAL ARTICLES
Use of laparoscopy in the management of abdominal trauma: a center experience
Morsi Mohamed, Wael Mansy, Yahia Zakaria
January-March 2015, 34(1):11-16
DOI:10.4103/1110-1121.153365  
Background The role of laparoscopy in diagnosis as well as therapeutic interventions has increased markedly in the last few years. In trauma, it has become a viable alternative for the diagnosis of intra-abdominal injury following penetrating and blunt trauma. The number of negative and/or nontherapeutic laparotomies performed has decreased since the use of laparoscopy in diagnosis and management. Patients and methods Sixty-five patients with abdominal trauma (21 blunt trauma, 44 penetrating trauma) were treated by the Trauma Team at the Emergency Unit of Zagazig University from November 2011 to August 2014 using laparoscopy for diagnosis. All patients underwent a physical examination, ultrasound, and computed tomography (abdomen and pelvis). Laparoscopy was used in the management of these patients through three trocars: one for 30° scope and two working trocars. Results In our series, we avoided laparotomy in 81.5% (53/65) of cases. Therapeutic laparoscopy was effective in 15 patients: six patients with stomach penetrations, four with liver lacerations, three with diaphragmatic injuries, and two with splenic lacerations. Conclusion Laparoscopy can be performed safely and effectively in stable patients with abdominal trauma.
  1,287 201 2
Healing and recurrence rates following radiofrequency ablation of the saphenous vein and ultrasound-guided foam sclerotherapy of perforator reflux in patients with venous ulceration
Wael Elshimy, Mohamed E El Sherbeni, Abdelrahman M Gameel, Ayman Salem
April-June 2014, 33(2):110-116
DOI:10.4103/1110-1121.131671  
Background Chronic venous ulcer (CVU) is responsible for significant healthcare expenditure worldwide. Compression therapy is the mainstay of treatment, but long-term compliance with this therapy is difficult. Surgery for axial and perforator reflux has been used as an adjuvant to compression to fasten healing and reduce recurrence rates. The treatment of varicose veins has also undergone dramatic changes with the introduction of percutaneous endovenous ablation techniques, including radiofrequency ablation (RFA) and ultrasound-guided foam sclerotherapy (UGFS). The role of these techniques in the treatment of CVU is just beginning to be defined. Patients and methods Sixty-six patients with CVU with 71 active leg ulcers who presented at our vascular clinic were included in this study. All patients underwent duplex scanning for venous insufficiency. Ulcer dimensions at each visit were recorded and used to calculate healing rates. The presence or absence of ulcer recurrence at 1-year follow-up was recorded. Ulcers treated with compression alone (the 'compression group') were compared with those treated with compression and minimally invasive interventions, such as RFA of superficial axial reflux and UGFS of incompetent perforating veins and varicosities (the 'intervention group'). Results The average age in the intervention and compression groups was 36.7 and 41 years, respectively (P = NS). Ulcers were recurrent in 41.7% of the patients in the intervention group and in 25.5% of patients in the compression group (P = NS). In the intervention group 14.7% underwent RFA of the axial reflux, 38.2% underwent UGFS of perforators, and 41.1% underwent both treatments. The only complication of intervention was a single case of cellulitis requiring hospitalization. No significant difference (P = 0.73) was seen in the proportion of ulcers that did not heal within 24 weeks (24.3% compression vs. 17.5% intervention). Within 1 year a significantly higher rate of recurrence was seen in the compression group compared with the intervention group (46 vs. 20.5%; P = 0.004). Conclusion Minimally invasive ablation of superficial axial and perforator vein reflux in patients with active CVU is safe and leads to faster healing and decreased ulcer recurrence when combined with compression alone in the treatment of CVU.
  1,368 94 -
Tension-free primary closure compared with modified Limberg flap for pilonidal sinus disease: a prospective balanced randomized study
Tamer Youssef, Saleh El-Awady, Mohamed Farid
April-June 2015, 34(2):85-89
DOI:10.4103/1110-1121.155716  
Background Pilonidal sinus disease (PSD) is a common disease that affects the patient's quality of life. We analyzed the outcome of the tension-free primary closure (TF 1ry) in comparison with the modified Limberg flap (MLF) technique. Patients and methods A total of 120 patients suffering PSD were assigned to one of two equal groups by closed envelope balanced randomization. Group I represents TF 1ry method and group II represents MLF. Results There were 102 (85%) male patients and 18 (15%) female patients elected for surgery. The mean follow-up period was 43.5 ± 3.4 months. There were no statistically significant differences between the two groups regarding patients' demographic data, clinical presentation, immediate postoperative complications, and disease recurrences. The operative time, blood loss, hospital stay, surgeon's performance scale, wound hypothesia, wound cosmoses score, patient satisfaction score, and patient quality of life (bodily pain and social functioning) were better in the TF 1ry group. The MLF group had better clinical results regarding frequency of seroma formation and time to drain removal. Conclusion Flap techniques are effective and efficient for PSD. TF 1ry closure can be tailored for female PSD patients and a junior surgeon. MLF can be tailored for male PSD patients and a senior surgeon.
  1,335 124 1
Evaluation of delayed lipomodelling for breast reconstruction after different oncological surgical interventions for breast cancer patients
Yasser S Ahmed, Mohamed H Sultan, Samy E Ibrahim, Khaled E Soliman, Medhat M Anwar, Rabie R Abdelwahed, Ahmed Karmouty, Hamza Alaa
July-September 2014, 33(3):182-187
DOI:10.4103/1110-1121.141906  
Background Oncoplastic techniques, autologous flaps and implants are commonly used plastic surgery techniques in patients undergoing breast reconstruction. Lipomodelling is a currently used technique to correct soft-tissue defects. Restoring an acceptable appearance after breast cancer surgery has become an integral part of the treatment process. Even though advances in autologous and implant-based surgical techniques have markedly improved breast reconstructions over the past decennia, they have ultimately raised the patients' expectations. Patients and methods The study included 30 female patients undergoing delayed lipomodelling after breast cancer surgery using the Coleman technique. Patients, after mastectomy and after breast conservative surgery with tissue defect and/or deformities, will undergo delayed lipomodelling at least 6 months after completion of radiotherapy. Results In our study, 43 lipofilling sessions were performed in 30 patients. Twenty-four patients had invasive ductal carcinoma and six patients had DCIS. The mean amount of fat injected ranged from 50 to 400 ml and sessions of lipofilling ranged from one session to three sessions according to the indication. The follow-up interval was 16 months. The most common complication was macrocalcification and oil cyst formation in three patients. No cases of local recurrence were detected. The satisfaction rate was excellent in 36.6% and good in 43.3% of the patients. Conclusion Fat grafting can be used as an alternative method of breast reconstruction in selected cases as it is an easy and cheap method with a very high rate of acceptance from the patient because it is an easy day surgery technique, with minimal complications to the recipient and the donor site. An excellent aesthetic result as well as longevity can also be achieved.
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Laparoscopic sleeve gastrectomy for morbid obesity: does the size of the bougie matter?
Ali El-Anwar, Hassan Shaker
January-March 2016, 35(1):35-43
DOI:10.4103/1110-1121.176801  
Background Laparoscopic sleeve gastrectomy (LSG) is a safe and effective surgical treatment modality for morbid obesity. Variations in surgical technique could affect the results. The optimal size of the bougie remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies. Patients and methods Between March 2011 and January 2014, 102 morbidly obese patients underwent LSG. These patients were divided into two groups: group 1 (50 patients) and group 2 (52 patients). In group 1, 32-Fr bougies (orogastric calibration tube) were used, and in group 2 40-Fr bougies were used. Patients completed at least 6 months of follow-up visits. Results The excess body weight loss percentage in group 1 was 53.6 ± 10.96% at 6 months and 69.4 ± 15.6% at 1 year postoperatively, whereas in group 2 it was 52.7 ± 11.27% at 6 months and 66.4 ± 13.4% at 1 year postoperatively, with no statistically significant difference between the two groups. There were neither intraoperative complications nor postoperative mortalities. The overall complication rate was 14.7% (15 patients) with no statistically significant difference between the two groups (14% in group 1 vs. 15.4% in group 2). The postoperative hospital stay was 2.3 days in group 1 versus 2.2 days in group 2. There was 58.8% complete resolution of diabetes mellitus, 60% resolution of hypertension, and 87.5% resolution of sleep apnea 6 months after sleeve gastrectomy with no statistically significant difference between the two groups. Conclusion LSG is a safe and effective treatment method for morbid obesity. Bougie size does not affect the short-term outcomes.
  1,338 88 1
Open preperitoneal mesh repair versus laparoscopic transabdominal preperitoneal repair of groin hernia under spinal anesthesia: results of a prospective randomized multicenter trial
Abd-Elrahman Sarhan, Tarek Sherif, Yaser El-Kenany
April-June 2016, 35(2):132-139
DOI:10.4103/1110-1121.182788  
Background It is difficult to decide on which is the best surgical procedure for groin hernia repair. Several studies have compared laparoscopic groin herniorrhaphy with open Lichtenstein repair. The Lichtenstein procedure is premuscular but laparoscopic repair is preperitoneal. This prospective study compared open preperitoneal modified Kugel procedure with transabdominal preperitoneal (TAPP) laparoscopic repair under spinal anesthesia. Patients and methods A total of 200 patients scheduled for unilateral inguinal hernia repair were randomly divided into two groups to undergo either laparoscopic TAPP (group A) or open modified Kugel procedure (group B) under spinal anesthesia in our hospitals (three hospitals) between September 2010 and September 2012. Recurrence was the outcome measure in our comparison, and short-term and long-term complications were also assessed. Results There was no significant difference between the two groups in terms of their demographic data. Operative time was significantly shorter in the TAPP group than in the open group (37.8 ΁ 18.4 vs. 64.1 ΁ 20.1 min; P < 0.001). There was significant difference between the two groups in terms of postoperative pain, hospital stay, and recovery with return to work (P < 0.001), but no significant difference in terms of intraoperative complications (P = 0.54), short-term postoperative complications (P = 0.72), wound infection (P = 1.0), and urine retention (P = 0.62). During the follow-up period of 32 months (range = 22-50 months), there were no cases of mortality and no significant difference in terms of recurrence (P = 1.0). Chronic pain and dysesthesia were significantly higher in the open group (P = 0.03 and 0.02, respectively). Conclusion Both open and laparoscopic preperitoneal groin hernia repair under spinal anesthesia are effective and safe with low recurrence rates. The laparoscopic approach is better in terms of operative time, return to normal activity, and chronic pain.
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Liposuction excision of gynecomastia through an axillary liposuction opening: A novel technique
Hady S Abou Ashour
July-September 2015, 34(3):170-176
DOI:10.4103/1110-1121.163122  
Introduction Gynecomastia has a negative impact on male self-esteem and social health. In the absence of a medically treatable condition, surgery is the only effective treatment. Treatment includes either liposuction, excision of male breast gland, or both. Excision of the breast tissue is usually performed through a circumareolar incision, which could be a site of infection, unsightly scar, nipple, areola inversion, or necrosis. Aim This study aimed to evaluate the outcome of liposuction excision of gynecomastia through a small axillary approach. Patients and methods One hundred and forty-three patients with gynecomastia, through the period from March 2010 to March 2014, in Minoufiya university hospital and other private hospitals were included in this study; their mean age was 24.3 years. After clinical and laboratory evaluation, liposuction and excision of glandular tissue was performed through the same stab of liposuction at the midaxillary line in the fifth or sixth intercostal spaces under general or local anesthesia; liposuction was first performed using the tumescent technique and then the glandular disc was released from its deep attachments and from subcutaneous and nipple attachments by scissors. Then, drains were inserted through the same liposuction excision opening and pressure bandage and garments were applied. Results One hundred and thirty-four (93.7%) patients showed satisfactory results after 6 months and 138 (96.5%) patients were satisfied with the results after 1 year in terms of proper symmetry and sound healing. One hundred and fifteen patients (80.4%) underwent surgery under general anesthesia and 28 patients (19.5%) underwent surgery under tumescent local anesthesia; the mean operative time was 55 min, the mean hospital stay was 9.6 h, and the average period off work was 5 days. Four patients (2.8%) showed unilateral hematoma formation, none of the patients showed saucer dish deformity, areola, nipple necrosis, or inversion, one patient (0.6%) developed a unilateral wound infection, two patients (1.4%) showed seroma formation, and two patients (1.4%) showed skin laxity. Conclusion The axillary liposuction excision technique was associated with very good esthetic results for both fibrous and fatty gynecomastia, with little complications.
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Influence of standardized histopathological workup on reporting of the resection margin status in pancreatic head cancer
Ahmed M El-Gendi, Saba El-Gendi
July-September 2014, 33(3):131-139
DOI:10.4103/1110-1121.141894  
Background Resection margin (RM) status in pancreatic head adenocarcinoma is assessed histologically, but pathological examination is not standardized. Our aim was to determine the influence of the 'standardized histopathological workup' of pancreaticoduodenectomy specimens on the reporting of the RM status using a 'surgical quality protocol'. Patients and methods Starting October 2009, 42 patients underwent pancreaticoduodenectomy using the 'surgical quality protocol' for pancreatic ductal adenocarcinoma and were examined using 'standardized histopathological workup'. We prospectively evaluated and validated its results for 50 months. We evaluated different sites of R1 at 0 and 1 mm resections according to the color code and determined the most frequent site of incomplete tumor resection. Results Patients included 14 women and 28 men. Their age ranged from 46 to 74 years, with a median of 60 years. Changing to 'standardized histopathological workup' from traditional pathological examination procedures resulted in an increase in the R1 rate from 14.3 to 64.3% in this prospective series. Fifteen percent of R1 resections showed multifocal margin involvement (i.e. more than one margin involved in a single specimen) for the 0 mm in contrast to 33% for the 1.0 mm margin. The uncinate margin represents the most frequent site with residual tumor mass by far (42% at 0 mm and 43% at 1 mm), followed by the posterior margin. When R1 resection was defined by a positive margin of 0 mm, 48% of the present patients achieved R1 resection. In contrast to when R1 resection was defined by the presence of tumor cells within 1.0 mm, 64% of the present patients achieved R1 resection. Conclusion Standardization of the histopathological examination of pancreaticoduodenectomy specimens influences the reporting of RM status. The RM involvement is significantly more frequent than commonly reported. Complete and meticulous surgical resection of the uncinate process en bloc with all the peripancreatic tissues between the artery and the pancreatic parenchyma must become the standard surgical approach in pancreatic head resection as it is the most frequent site for residual tumor by far.
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