Journal of Society of Surgeons of Nepal <p>Journal of Society of Surgeons of Nepal is the official, peer reviewed journal of the Society of Surgeons of Nepal.</p> Society of Surgeons of Nepal en-US Journal of Society of Surgeons of Nepal 1815-3984 Sick Surgeon: Problem and the panacea! <p>Gautam Buddha has rightly said ‘To keep the body in good health is a duty... otherwise we shall not be able to keep our mind strong and clear’. We need clear minds as a clinician and more so as surgeon to plan the course of treatment and to physically execute it. However, apart from clear minds a surgeon should also be physically capable to withstand strenuous activities for long periods of time. Daily exertion for prolog periods for surgeons leads to poor quality of life especially in our subcontinent where health institutions and the government do not prioritize the health of clinicians.</p> Bikal Ghimire ##submission.copyrightStatement## 2018-12-31 2018-12-31 21 2 1 3 10.3126/jssn.v21i2.24353 Hematoma block for fracture reduction <p><strong>Introduction</strong>: Distal radius fractures are one of the commonest fractures and more commonly involve children and elderly. Analgesia during reduction are determined by safety, simplicity, effectiveness and costs. The objective of this study is to evaluate the effectiveness of the Hematoma Block (HB) for reduction in distal forearm fractures in a developing country like Nepal.</p> <p><strong>Methods: </strong>The study design was double blind randomized control trial performed at tertiary care hospital from July 2016 to August 2017. The patients having radiologically confirmed distal forearm fractures less than 96 hours old in 46 males and 54 females included after obtaining informed consent. 50 patients receiving Brachial Plexus Block (BPB group), and 50 patients receiving HB group during reduction of distal forearm fractures were initially allotted in two arms of randomized group. Pain measured by Visual Analogue Scale (VAS) was recorded before, during, and after reduction.</p> <p><strong>Results: </strong>The study showed that HB with (mean ± SD) a VAS score of 2.08 ± 0.85 was as effective as BPB with a VAS of 1.7 ± 0.64 in terms of producing analgesia ( p=0.013), with the advantage of no motor paralysis and a significantly higher reduction rate, odds 3.45, 95% CI 1.52 – 7.85, p = 0.0013. 1/50 patients in brachial plexus block had bronchospasm needing intubation and ICU care where as 1/50 patient with hematoma block and infection which needed incision drainage and external fixation for complete healing.</p> <p><strong>Conclusions: </strong>“The Hematoma Block” is to be encouraged in our set up for the reduction of the distal forearm fractures. The technique may be used in those fractures like isolated ulna fractures, minially displaced tibial fractures, fracture fibula where local anesthesia can be easily infiltrated percutaneously The study may be beneficial in managing such fractures and hence, it will help change in therapeutic policies comparing other modalities.</p> Suraj Bajracharya Tamanna Bajracharya Shriraj Shrestha ##submission.copyrightStatement## 2018-12-31 2018-12-31 21 2 4 11 10.3126/jssn.v21i2.24354 Prediction of Infectious Complications after Percutaneous Nephrolithotomy <p><strong>Introduction: </strong>Post-operative infection is one of the most common and potentially life-threatening complications following percutaneous nephrolithotomy, ranging from Systemic inflammatory response syndrome (SIRS) to severe sepsis. It is reported to be the most common peri-operative cause of death. Despite taking utmost precautions, we come across major complications such as haemorrhage and urosepsis after percutaneous nephrolithotomy. This study aims to find the risk factors for infectious complications after percutaneous nephrolithotomy.</p> <p><strong>Methods: </strong>This was an observational, cross-sectional, analytical study carried out in the Department of Surgery of Lumbini Medical College and Teaching Hospital over a period of six months. Pre- operative and intra-operative parameters of ninety-seven patients who underwent percutaneous nephrolithotomy were analysed to see the association between perioperative and intraoperative factors in development of post-operative infectious complications.</p> <p><strong>Results: </strong>Post-operatively, SIRS was observed in 28.9% of the patients and 6.2% developed post operative sepsis. Stone burden, types of stone, abnormal urinalysis and mean operative time were associated with post-operative SIRS while stone burden, abnormal urinalysis, positive urine culture and operation time were statistically associated with post-operative sepsis. In univariate analysis only mean operation time and mean stone burden were statistically associated in development of post operative SIRS and sepsis.</p> <p><strong>Conclusion:</strong> In the present study mean operation time and mean stone burden were found to be the predictive factors for post-operative infectious complications after percutaneous nephrolithotomy.</p> Raj Kumar Chhetri Suman Baral Neeraj Thapa ##submission.copyrightStatement## 2018-12-31 2018-12-31 21 2 12 18 10.3126/jssn.v21i2.24355 Clinical practice of mininally invasive gynaecological surgeries <p><strong>Introduction</strong>: Endoscopic gynaecological surgery which is a routine practice in outer world since last 40 years, is still at earlier phase in Nepal. This study was done to know the clinical practice of minimally invasive gynaecological surgeries in Minimally Invasive Diagnostic and Therapeutic (MIDAT) hospital.</p> <p><strong>Methods</strong>: A hospital based descriptive study was conducted in gynaecological department of MIDAT hospital over 16 months period from 1<sup>st</sup> Bhadra 2071 to 30<sup>th</sup> Poush 2072 (17<sup>th</sup> August 2014 to 14<sup>th</sup> January 2016) among 115 women who underwent minimally invasive gynaecological surgeries (MIGS). Patient demographics, types of surgeries, indications of laparoscopy and hysteroscopy, reason for laparoscopic conversion, complications of surgeries and hospital stay were analyzed.</p> <p><strong>Results</strong>: There were total 115 minimally invasive gynaecological surgeries done in MIDAT hospital during study period. Laparoscopic gynaecological surgeries and hysteroscopy were performed in 86 (75%) and in 29 (25%) women respectively. Among laparoscopy, laparoscopic hysterectomy {31 (36%)} was the more common operation. During laparoscopy, conversion to open was done in nine (10.5%) patients. Complications of MIGS were seen in three (3.5%) women.</p> <p><strong>Conclusions</strong>: MIGS has acceptable morbidity, smooth post operative recovery and shorter hospital stay. In recent time, MIGS is gradually becoming popular in Nepal. &nbsp;&nbsp;</p> Binaya Raj Bhandari Ranjana Shrestha Binita Pradhan ##submission.copyrightStatement## 2018-12-31 2018-12-31 21 2 19 23 10.3126/jssn.v21i2.24356 Comparison of the use of neutrophil: lymphocyte count ratio (NLCR) to total leukocyte count in diagnosing appendicitis in adults with right iliac fossa pain <p><strong>Introduction: </strong>Diagnosis of acute appendicitis (AA) is purely based on history, examination and few laboratory investigations. However, it is often a perplexing diagnostic problem during the early stages of the disease. Failure to make an early diagnosis is a primary reason for morbidity and mortality. Elevated leukocyte count is one of the indicators of appendiceal inflammation in patients with right iliac fossa pain and most of the patients with acute appendicitis present with leucocytosis. Recently, it has been seen that the neutrophil: lymphocyte count ratio (NLCR) is a more sensitive marker than leukocytosis in patients with acute appendicitis.</p> <p><strong>Method: </strong>This is a prospective observational study conducted over a period of one year in the department of surgery at the Tribhuvan University Teaching Hospital, from September 2013 to August 2014. The clinical diagnosis of Acute appendicitis was made by history and clinical examinations and laboratory investigations. Total leukocyte count (TLC) and NLCR of patients diagnosed as AA were measured and recorded in the pro forma. Histological diagnosis was taken as the final diagnosis.</p> <p><strong>Results: </strong>A total of 106 patients were included in the study. Two third of the patients were male. Right iliac fossa tenderness was the most common sign. Ultrasound was able to diagnose acute appendicitis in 40.65% of the cases. NLCR&gt; 3.5 was observed in 90.56% of patients with acute appendicitis, whereas 78.3% of patients had leukocytosis only. High NLCR (5.60) is associated with complicated AA.</p> <p><strong>Conclusion: </strong>NLCR is a more sensitive laboratory parameter than TLC in patients with RIF pain to diagnose acute appendicitis. A high NLCR ratio has a high likelihood of a complicated AA. &nbsp;</p> Rabindra K.C. Abhishek Bhattarai Rakshya Joshi Ashok Kharel Ishwar Iohani ##submission.copyrightStatement## 2018-12-31 2018-12-31 21 2 24 27 10.3126/jssn.v21i2.24357 Outcome of Snodgrass Repair in Distal Hypospadias – An Institutional Experience <p><strong>Introduction: </strong>Hypospadias is a common congenital anomaly in which the urethral opening is on the ventral surface of the penis, often associated with ventral curvature of penis (chordee). Many techniques have been descried in the literature for the repair of hypospadias with variable results. This study aimed at outcome following Snodgrass repair in distal hypospadias by a single Urologist.</p> <p><strong>Methods: </strong>This was a retrospective study conducted at Department of Urology, Birat Medical College from December 2017 to January 2019 during which 16 patients with distal hypospadias underwent primary repair using Snodgrass technique.</p> <p><strong>Results: </strong>Mean age was 5.12 years and duration of operation was 136.25 minutes. About 56.25% of cases were subcoronal and 43.25% were coronal. Chordee of &lt;30 degree was present in 25% of cases. Complications occurred in 25% cases of which half (12.5%) were urethrocutaneous fistula and rest were meatal stenosis (6.25%) and hematoma (6.25%).</p> <p><strong>Conclusion: </strong>The outcome of Snodgrass repair in distal hypospadias is satisfactory with acceptable complications and urethrocutaneous fistula is the commonest complication. &nbsp;</p> Deepak K. Thakur ##submission.copyrightStatement## 2018-12-31 2018-12-31 21 2 28 31 10.3126/jssn.v21i2.24358 Treatment of advanced rectal cancers: Cylindrical abdominoperineal excision of rectum <p><strong>Introduction</strong>: Treatment for patients with locally advanced low lying rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. They require multimodality treatment, including preoperative chemo-radiation and extended surgical resection. Cylindrical abdominoperineal excision of rectum (C-APER) along with possible composite pelvic organ resection is a surgical method to remove an adequate circumferential margin.</p> <p><strong>Method</strong>: Patients with the diagnosis of advanced rectal cancers over a period of 9 months are included in this study. Therapeutic approach of C-APER is taken for these patients with focus on multimodality treatment protocols to downstage the tumours and extended resections to enable complete removal of all tumour tissue with clear surgical margins. Consecutive review of cases of advanced rectal cancer to their immediate surgical outcome were done.</p> <p><strong>Results</strong>: Five patients with compromised CRM in MRI of rectum, 4 were treated with Neoadjuvant FOLFOX 6 regimen chemotherapy 3 cycles and Short course Radiotherapy. All underwent surgery 6-8 weeks after treatment. The pelvic floor was repaired with biological mesh in 1 and synthetic mesh in 4. The pathological stage of disease remained T3 and above despite neoadjuvant treatment in majority of patients but none of them had positive CRM. The wound complication rates were high in the perineum with serous discharge in almost every patient and one patient needing long term vacuum assisted dressing in the community.</p> <p><strong>Conclusion</strong>: The surgery is technically feasible with acceptable morbidity in short term with possible long term outcome of reduced loco-regional failure. &nbsp;</p> Nirmal Lamichhane Kenneth G. Walker ##submission.copyrightStatement## 2018-12-31 2018-12-31 21 2 32 37 10.3126/jssn.v21i2.24359 Median Arcuate Ligament Syndrome: A Case Report <p>Median arcuate ligament (MAL) syndrome results from extrinsic compression of the celiac axis and or celiac ganglion by the MAL and diaphragmatic crura. A seventy five years lady presented with post prandial epigastric pain for 6 months. She had undergone considerable investigations for other diagnoses before an abdominal computed tomography (CT) revealed median arcuate ligament impinging celiac artery at its origin. She successfully underwent laparotomy and release of median arcuate ligament. &nbsp;</p> Akash Chitrakar Nirajan Subedi Ramesh Singh Bhandari ##submission.copyrightStatement## 2018-12-31 2018-12-31 21 2 38 39 10.3126/jssn.v21i2.24360