Abstract Background: Acute appendicitis is a common surgical emergency with a lifetime incidence of 7–8%. Diagnosis remains challenging due to overlapping clinical features with other abdominal and pelvic conditions, leading to delayed treatment or negative appendectomy. Clinical scoring systems such as the Alvarado and RIPASA scores have been developed to improve diagnostic accuracy. However, comparative validation in the Indian population remains limited. Aims and Objectives: To compare the diagnostic accuracy of the Alvarado and RIPASA scoring systems in predicting acute appendicitis in an Indian population, using histopathology as the gold standard. Materials and Methods: A prospective study was conducted from June 2022 to January 2024 at two tertiary care hospitals in New Delhi. A total of 121 patients aged 1–70 years with suspected acute appendicitis who underwent appendectomy were included. Both Alvarado and RIPASA scores were calculated at presentation. Cut-off values of ≥7 (Alvarado) and ≥7.5 (RIPASA) were used. Histopathological examination confirmed the diagnosis. Diagnostic performance was evaluated using Receiver Operating Characteristic (ROC) curve analysis to determine sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy. Results: Of 121 patients, 110 (90%) had histopathologically confirmed appendicitis. The mean Alvarado score was 6.5 ± 1.9, and the mean RIPASA score was 9.9 ± 1.9. ROC analysis showed good predictive ability for Alvarado (AUC = 0.789, P = 0.002) and excellent predictive ability for RIPASA (AUC = 0.991, P < 0.001). The Alvarado score demonstrated sensitivity 58.2%, specificity 81.8%, and overall accuracy 60.3%, whereas the RIPASA score showed sensitivity 97.3%, specificity 90.9%, and overall accuracy 96.7%. Conclusion: The RIPASA score demonstrated superior diagnostic accuracy compared to the Alvarado score and may serve as a more reliable clinical tool for diagnosing acute appendicitis in the Indian population.

Background:The Indian Armed Forces is an extremely fit fighting force. However, due to some factors like injuries or lack of physical activities, a very small percentage of serving population, who fall under the morbidly obese category, is offered bariatric surgery if diet changes and exercises fail to achieve satisfactory weight reduction. In the absence of a study to look into this cohort who have undergone bariatric surgery, a need is felt to estimate the effects of bariatric surgery on body mass index (BMI), co-morbidities and employability of these patients. Methods:This is a retrospective study of patients, who underwent bariatric surgery over a ten-year period at a service hospital with super specialty services and followed-up for a period of minimum of a year after the surgery. Results:The study included a total of 35 patients. Their mean body weight and BMI reduced significantly as compared to the pre-operative status. Though there was a significant improvement in the control of diabetes mellitus (p < 0.001) and obstructive sleep apnoea (p = 0.002); hypertension, though fared better, failed to achieve a statistical significant value (p = 0.074) after the surgery. Twenty-eight (80 %) of patients returned back to their active duties. Conclusion:Bariatric surgery stands as a valid option for management of obese patients with good clinical outcomes and no major morbidity and mortality was observed in the 30-day post-operative period.

Background and Aim: Conventional surgery for caustic/thermal strictures (CS/TS) entails considerable trauma, which may be mitigated by minimal access surgery (MAS). Experience with its use in CS/TS is both heterogeneous and limited, hence, warrants a comprehensive review. Methods: Medical literature/indexing databases were systematically searched for pertinent articles published in English, from 1990 to 2021, and analysed. Results: Fifty relevant articles, pertaining to over 200 patients, were found. They showed that MAS is feasible in CS/TS management. It reduces the access damage in chest and abdomen whilst facilitating resection or bypass of the affected gut segment through different combination of operations, sequence of steps, conduits and routes. The procedures range from completely minimal access to hybrid ones, with reduced complications and faster recovery. Hybrid procedures prove as expeditious as open ones. Conclusions: MAS proves efficacious in restoring alimentary continuity in corrosive/thermal strictures of the foregut.

A complex renal mass arousing suspicion of malignancy warrants exploration. Echinococcal etiology without any other organ involvement is a rarity. Experience with such a singular case managed laparoscopically is presented and discussed.

Dear Editor in Chief, Indian Journal of Surgery, I read with great enthusiasm the editorial, “HeforShe: Why doing the Right Thing Matters” by Mallika Tewari [1]. This well-crafted article has been an invitation for introspection for all of us and initiatives are required at each level, starting from our homes, the society at large, and the government. I could not buy into her statement in the third paragraph on page 1343 that “Surgery per se remains a male-dominated specialty.” While I do know, understand, accept, and acknowledge that general surgery and the majority of its subspecialties are male-predominant (obvious to notice), I don’t think they are male-dominated (commanding, controlling, or prevailing over others)! While the lesser number of lady surgeons are a fact in the demanding general surgery practice, the reasons are manifold. As the author points out, lady doctors voluntarily avoid demanding branches with emergencies and odd-hour calls and opt instead for “cooler” ones that lead to early settlement so that they could have a home-work balance, the burden of which essentially rests on the woman, especially in a country like India. These differences are prominent in developed nations too. Yutzie et al. in 2005 in a post-residency survey found that most men (64%) listed general surgery as their primary work type, whereas women most commonly reported breast surgery (38%, p < 0.001) [2]. Gallivan et al. in in 2021 found that women accounted for 20.2% of total editorial board positions, 11% of editor-in-chief positions, 32% of deputy editors, and 19.1% of general editorial board positions of international general surgery journals [3]. But the same logic does not seem to act when lady doctors choose obstetrics as their career! This offshoot of surgery is even more challenging and demanding, and requires the surgeons’ attention round the clock, with endangering of two lives, both the mother and to be born! In 2001, Pearse et al. from a survey of ACOG Fellows indicated that, as a group, lady obstetricians are approximately 85% as productive as male obstetricians in the specialty [4]. Do our patients have a role to play in selecting a surgeon based on gender? Though studies do not come from India, even in many developed nations, patients may prefer the same gender surgeon, when it comes to diseases related to “socially sensitive organ systems.” In 2016, Asnat Groutz et al. in Israel found in a women patient survey that about a third of women prefer a woman breast surgeon for their breast examination, sheer due to embarrassment. In contrast, when it comes to breast operations, the professional skills of the surgeons became the predominant consideration [5]. Halpern found that while the number of lady surgeons performing vasectomies increased, a gender gap still persisted in the proportion of vasectomies performed by ladies from 2004 to 2013 [6]. To summarize, though personal preferences exist today both from the surgeons’ and the patients’ sides, we must ideally have gender neutrality in our surgical workforce, as we strive to achieve in other professions too. This gender-neutral society is ideal, where a professional will not be selected, judged, or paid based on gender, but on the professional capabilities!

Delayed gastric emptying (DGE) is the most common complications after Whipple pancreaticoduodenectomy (WPD). Braun enteroenterostomy (BEE) is a useful technique to divert bile from the stomach. We recently started doing binding pancreaticogastrostomy (BPG) for pancreatic reconstruction after WPD, and the most frequent complication was DGE. The aim was to study the effect of Braun enteroenterostomy on delayed gastric emptying in binding pancreaticogastrostomy following Whipple pancreaticoduodenectomy. The study included all patients who underwent BEE in BPG following WPD from February 2014 till May 2016 at a tertiary care center. Braun enteroenterostomy was constructed approximately 25 cm distal to the gastrojejunostomy by a side-to-side hand-sewn or stapled anastomosis. Delayed gastric emptying was defined as per International Study Group of Pancreatic Surgery (ISGPS) definition. All patient data including patient demographics, type of procedure performed, complications, mortality, hospital stay, postoperative interventions, or re-operations were documented. There were 13 (30.95%) patients with DGE A and 4 (9.52%) patients with DGE B, and no patients had DGE C. Hence, there were only 4 patients (9.52%) with clinically significant DGE. Addition of Braun enteroenterostomy reduces delayed gastric emptying after Whipple pancreaticoduodenectomy with binding pancreaticogastrostomy.

The urogenital tract is a rare source of pneumoperitoneum in peritonitis. Spontaneous rupture of the urinary bladder (SRUB) as a cause is rarer. Preceding severe acute respiratory syndrome coronavirus-2 (SARS‐CoV‐2) infection predisposing to such eventuality is unprecedented. Experience with such a singular case is presented and discussed.

BACKGROUND:Thrombosis of hepatic artery anastomosis (HAT) after liver transplantation is a catastrophic and dreaded complication. Early identification of HAT can salvage the situation. To monitor the anastomosis, conventional daily transcutaneous Doppler is performed. However, it has disadvantages of being noncontinuous, operator-dependent and technically difficult. Implantable Doppler probes wrapped around the anastomosed vessel giving continuous signal may be an important tool; however, very few studies are performed to study its efficacy after intra-abdominal vascular anastomosis, and its role is not clearly established.METHODS:Patients who underwent deceased donor liver transplant surgery were part of the study. On hepatic arterial anastomosis, implantable Doppler probe was fixed for monitoring. Conventional daily transcutaneous Doppler was also performed and the results were compared.RESULTS:A total of 40 hepatic arterial anastomoses were studied. The incidence of HAT was 10.53%. For the implantable Doppler probe monitoring, sensitivity and negative predictive value was 100%, whereas specificity was 94.44% and positive predictive value was 66.66% with an overall accuracy of 95%. A mean of 10 h of lead time was gained by implantable Doppler probe monitoring.CONCLUSION:Our study showed that there was high sensitivity and negative predictive value of implantable Doppler probe monitoring system, which makes it ideal for post-operative vascular anastomoses surveillance monitoring; however, abnormal positive finding on implantable Doppler probe monitoring needs to be confirmed by conventional transcutaneous Doppler. The implantable Doppler probe monitoring, because of its round the clock and continuous nature gives us a good lead time in identifying vascular complication, which translates into graft salvage and reduction in morbidity and mortality.

Background: Despite the availability of modern cross-sectional diagnostic staging modalities, preoperative assessment of operability in intra-abdominal malignancy is often inadequate, especially in patients being considered for potential curative resection, resulting in many unnecessary laparotomies. Staging laparoscopy (SL) is usually undertaken in tertiary care centers, but the same has not been widely studied in India. The aim of the present study was to find out the possibility of diagnosing inoperability on SL and to study whether SL can prevent unnecessary laparotomy in cases of clinically diagnosed potentially resectable abdominal malignancies. Methods: This prospective diagnostics study was conducted in consecutive patients with gastrointestinal malignancies. All eligible patients were subjected to a thorough SL to look for inoperability before a therapeutic laparotomy. Statistical analysis of SL as a diagnostic modality was performed and the results were noted. Results: A total of 88 such patients were studied. The SL demonstrated inoperability in 24 out of the 88 (27.3%) patients. However, it failed to predict inoperability in 11 (12.5%) patients, yielding a sensitivity of 68.57% and specificity of 100%. The positive predictive value (PPV) of SL was 100%, whereas the negative predictive value (NPV) was 82.81% with efficacy of 87.5%. Conclusions: The specificity, PPV, NPV, and accuracy of SL to rule out inoperability in clinically diagnosed potentially resectable intra-abdominal gastrointestinal malignancies are noteworthy. The sensitivity of SL for the same purpose, though relatively low, may be augmented with practices such as liberal use of frozen section biopsy and intraoperative ultrasound. However, SL still fails to demonstrate unresectability due to locoregional advancement and aortocaval lymph node mets.

Gastro-oesophageal reflux disease (GERD) is, now, common in Indians. Anti-reflux surgery is gaining popularity as its definitive treatment option. However, studies from India on anti-reflux surgery are scarce. This study audits a low volume centre’s experience with laparoscopic Nissen’s fundoplication (LNF) in the management of GERD. Patients undergoing LNF between June 2014 and September 2019 were studied. Subjective and objective assessments of GERD were made using validated symptom indices and endoscopy, respectively, during both pre-operative evaluation and post-operative follow-up, to assess outcomes. Twenty-four-hour pH monitoring was selectively used in equivocal cases. Short and floppy LNF was constructed without using oesophageal bougie. Fifty-nine patients (39 males:20 females) with a mean age of 52.5 ± 16.2 years underwent LNF. The severity of typical symptoms improved significantly (p < 0.05) within 15 days following surgery. Clinical improvement, in the severity of atypical symptoms too, was observed but was not found statistically significant. There were no major perioperative complications or mortality. Three patients needed endoscopic dilatation at 3 months for persistent dysphagia. No failures or recurrences were observed during the follow-up. Structured subjective and objective assessment by the operating team has revealed that LNF proves efficacious in the management of GERD even in a low volume centre.

BACKGROUND:Opinion is divided on the optimal technique of skin closure after stoma reversal as most conventional techniques compromise either on speed/neatness of wound apposition or on the incidence of surgical site infection (SSI). Evidence suggests that purse-string skin closure (PSSC) may achieve both objectives. This study aims to compare conventional primary closure (PC) with PSSC to determine the efficacious technique for stoma wound closure.METHODS:Patients undergoing stoma reversal between April 2015 and September 2017 were prospectively studied. Patients were divided into two groups based on the technique of skin closure (PC or PSSC). The following parameters were assessed: SSI, hospital stay, additional outpatient visit, wound healing time and patient satisfaction based on a standardised questionnaire.RESULTS:Forty one patients underwent stoma reversal (20 PSSC vs 21 PC). Wound infection, need for wound care, length of hospital stay, healing time and scar size were significantly less, whereas average patient wound satisfaction scores were significantly more in the PSSC group.CONCLUSION:Purse-string skin closure (PSSC) proves efficacious and hence merits adoption as the technique of choice for closure of stoma wounds.

Background: Numerous incisions are described for abdominal operations. However, opinion is divided regarding the correct choice of incision for major upper abdominal surgeries. Material & methods: Experience of 3 surgical centres with the use of modified Makuuchi incision, for major upper abdominal surgeries, from Mar 2014- Dec 2018, was audited. Results: 144 patients [76 Males: 68 Females] with an average age of 48.25 years underwent surgery using modified Makuuchi incision. ’J’ and ‘L’ incisions were used in 96 and 48 patients, respectively. Further extension of the incision was necessary in 2 patients. Adequate exposure and enhanced surgical ergonomics was observed in all cases. Surgical site infection was seen in 19 patients [13.2%]. Incisional hernias was observed in 6 patients [4.2%], on an average follow up of 27.78 months. Conclusions: Modified Makuuchi incision proves efficacious for major upper abdominal surgeries.

Hydatid cyst is a common health-related entity in the developing world but is rarely seen as an isolated lesion in pancreas. It is mostly seen as a part of multisystem infection. It masquerades as cystic neoplasms clinically and radiologically, making its diagnosis a challenge. A high index of suspicion is required for timely diagnosis of such cases. We present one such rare case where a 50-year-old female patient was diagnosed as a case of serous cystadenoma on radiology. The patient underwent distal pancreatectomy with splenectomy for the same and on histopathology the lesion was diagnosed to be hydatid cyst of pancreas.

Background: Laparoscopic cholecystectomy (LC), the gold standard of treatment of gallstone disease, is a widely performed surgery, but it can become a challenge to complete at times. Aim of present study was to find out the possible preoperative features in a gallstone disease patient that predispose him to having a difficult LC. Methods: All cases of gallstone disease undergoing LC at a tertiary care hospital were studied over one year. Patients with jaundice, abnormal liver function tests, concomitant common bile duct stones, ongoing acute cholecystitis or concurrent gallstone pancreatitis were excluded. Various preoperative clinical, laboratory and ultrasound parameters were studied to see their correlation with different aspects of difficult LC.Results: 166 patients were studied with age ranging from 10-80 years, maximum incidence (36.14%) being in the age group 35-50 years. The time taken for LC increased significantly with increasing age. 70.48% were females but gender status did not affect the difficulty. Pain in the preceding 15 days of surgery increased the operating time as did the association of diabetes mellitus. Increasing body mass index (BMI) also increased the surgery time as well as the conversion rate (7.69% in patients with BMI >30Kg/m2). Clinically palpable gallbladder increased the surgery duration, difficulty and conversion rate. TLC >11000/mm3, contracted gallbladder, wall thickness ≥4mm made LC longer, while multiple stones increased surgeon’s difficulty and impacted stone in gallbladder neck increased the conversion rate.Conclusions: Certain factors that increase the difficulty of LC can be identified preoperatively and this knowledge should be used when planning LC.