Introduction. Recurrence rates for ventral hernia repairs are practically negligible because of advancements in surgical procedures. Pain and suffering, which significantly lowers patients’ quality of life, are currently the main concerns with ventral hernia repair rather than the possibility of recurrence. This study used “EuraHS-QoL” score for evaluating the quality of life of patients before and after ventral hernia repair. Methods. A prospective observational study involving patients with ventral hernias receiving surgery from May to December 2023. Using the EuraHS-QoL questionnaire, patients’ quality of life was evaluated both before and after surgery. Results. Of the 53 patients, 17 (32%) were men and 36 (68%) women, with a mean age of 49.71±10.9 years (range, 32–68 years). BMIs averaged 25.4±3.4 kg/m2, range (21.25 to 35.4 kg/m2). The majority of pain was from regular duties. By frequency, umbilical (22%), infraumbilical (43.3%), supraumbilical (5.7%), and numerous (19%) hernia sites exist. Three patients suffered surgery site infections and one had skin dehiscence. All patients showed overall improvement of QoL at the end of 90 days.

Background and Aims. Pan facial fractures are complex and often requiring complex airway management. Elective tracheostomy (ET) and submental endotracheal intubation (SEI) are the two major techniques for airway management. The aim of this article is to compare the management outcome between these techniques. Methods. This study was done in a tertiary care hospital from Jan 2019 to Dec 2019. Data were retrieved for all patients from hospital admission-discharge reports, operation room records, follow-up notes, and clinical photograph records which was recorded prospectively after ethical clearance. Total 38 patients were included in the study after the exclusion criteria into two groups: submental endotracheal intubation (SEI) and elective tracheostomy (ET). Demographic data, intraoperative time (IOT), length of hospital stay (LOHS), postoperative pain score at three and seven days, and Vancouver Scar Score (VSS) at 4 and 12 weeks was compared between the two groups. Results. SEI consisted of 23 patients (60%) while ET had 15 (40%) patients. The mean age was 32.77±8.24 years in the SEI and 29.36±7.32 years in the ET. The IOT in SEI was 15.36±1.53 min and 24.60±1.40 min in the ET which was statistically significant (p = 0.00001). The LOHS was 11±3.87 days in SEI and 25.2±3.88 days in ET (p = 0.0001). The mean VSS at 4 and 12 weeks for SEI were moderate and mild respectively and for the ET was moderate and mild respectively. Both were statistically significant with a p = 0.003 and p = 0.006. Conclusion. Submental intubation is a safe airway management technique in pan facial fracture. It provides the surgeon with an excellent operative field for achieving the proper dental occlusion. Both short- and long-term outcomes are better compared to the alternative airway method of elective tracheostomy.

Carcinoma gallbladder is a common hepatobiliary malignancy with aggressive biological behavior. Most common histopathological variant is adenocarcinoma (>90%). Squamous cell carcinoma is an uncommon variant of carcinoma gallbladder. Its clinical presentation is similar to those with adenocarcinoma. They grow very rapidly and has diffuse hepatic and local organ infiltrations. Early detection and radical surgical resection remain the cornerstone of the definitive management. We report a case of locally advanced carcinoma gallbladder of squamous cell variant. Patient presented with features of acute cholecystitis and had palpable gallbladder mass. Clinically and radiologically, she was diagnosed as a case of carcinoma gallbladder and underwent exploratory laparotomy, radical cholecystectomy with right hemicolectomy. Post operative histopathological examination confirmed squamous cell carcinoma of gallbladder.

Background. Nonthyroidal neck swellings are common and cause diagnostic challenges. This study highlights various diagnosis associated with non-thyroidal neck swellings and their management challenges. Objective. This pilot study highlights the various diagnosis associated with nonthyroidal neck swellings and their management challenges. The clinical spectrum of two most common aetiology of nonthyroidal neck swelling: tubercular cervical lymphadenopathy and lymphomas, are also compared. Methods. This prospective study was conducted in a tertiary care teaching hospital from 01 Jun 2018 to 31 Dec 2019. The first 100 nonthyroidal neck swellings presented to the surgical outpatient department were included and assessed clinically, radiologically and histopathologically. Comparison was carried out between the first two common diagnosis of tubercular cervical lymphadenitis and lymphoma. Continuous variables were analysed using Student’s t-test and categorical data were analysed using the Chi square test. A statistical p value <0.05 was taken as significant. Results. There were 73 lymph node swellings and 27 non-lymph node swellings in the study. The most common diagnosis was tubercular cervical lymphadenitis (n=38) and lymphoma (n=17). The mean volume of lymph nodes in the lymphoma group (38.72±22.12 cm3) was significantly bigger than in the tuberculosis group (9.44±5.99 cm3) P=0.00001. The mean age (33.81±11.8 years) of tubercular patients was significantly less than the lymphoma (52.38±25.3 years) with P=0.000167. The clinical diagnosis was nearly accurate in 85% of cases. However, in 15 cases clinical diagnosis was changed after fine needle aspiration cytology. Conclusions. Ultrasonography and fine needle aspiration cytology are very useful adjunct in arriving at a definite diagnosis of a lymph node swelling in neck. Tubercular cervical lymphadenopathy and lymphoma were two major diagnosis. Tubercular cervical lymphadenopathy is significantly different from lymphomas in terms of early age of presentation and smaller size at the time of presentation

Veinous thrombosis is a rare manifestation of leprosy (Hansen's disease). In this case report, we bring to notice this extremely rare presentation and challenges faced during management. A 26-year-old young healthy individual presented with painless cord-like swellings on both sides of the neck for 1 month. This was evaluated to be external jugular vein (EJV) thrombosis on ultrasonography Doppler. Trying to evaluate the cause of the thrombosis, there was no specific etiology found. On further detailed evaluation, it was found that he had hypopigmented skin patches. This led to the diagnosis of borderline tuberculoid leprosy downgrading to borderline lepromatous in type 1 lepra reaction. He responded to rifampicin, clofazimine, and dapsone with progressive resolution of skin lesions. Simultaneous treatment with apixaban caused complete resolution of EJV thrombosis. Further evaluation revealed heterozygous methylenetetrahydrofolate reductase mutation and beta-2-glycoprotein immunoglobulin M positivity. An extensive literature review suggested that intimal damage caused by lepra bacilli can lead to veinous thrombosis in Hansen's disease. However, the interplay of genetic procoagulant predispositions in phenotypic presentation is yet to be determined.

Internal hernia through foramen of Winslow (FoW) is rare condition as there are only 200 cases reported so far in the literature. Our patient a 78 years man presented with a clinical picture suggestive of small bowel obstruction for 5 days. Patient underwent emergency laparotomy following suspicion of internal hernia on imaging. On exploratory laparotomy there was grossly dilated bowel loops and a small segment of terminal ileum and omentum was found herniating through FoW in to the lesser sac. The bowel segment was reduced with gentle traction and herniated segment of omentum was excised due to questionable viability. Opening of FoW was unusually large and to prevent hernia recurrence it was closed partially. Postoperative period was uneventful. This unusual case presented to us diagnostic confusion and management challenge considering the previous history, multiple comorbidities and geriatric profile.

Introduction:Managing soft-tissue defects of hand is a challenging problem for any surgical team, even more in a field hospital setting of a conflict combat zone, where resources are scarce and such cases due to blunt trauma, gunshot wound and deep tissue infections are common.Case Report:We present four different cases, all middle aged males, who sustained injuries due to crush, low velocity gun shot, and defects post-debridement of acute onset infections following abrasions. The first patient was managed with doubled pedicled abdominal flap, the second patient was managed with external fixation for fracture, and cross finger flap for the defect. The third and fourth patients had similar presentations of acute onset deep soft tissue and bony infection, out of which one was managed with full thickness skin graft from anterior abdominal wall and the other with bi-pedicled abdominal flap. All the patients had good functional outcomes with no functional restrictions at follow-up of 12 weeks.Conclusion:All the cases were performed in a challenging situation of a highly active combat field zone, with limited resources and lack of availability of a trained hand surgeon. An early soft-tissue coverage, as soon as possible, was crucial in saving the hand function and guaranteeing a speedy return to function in view of lack of a professional hand surgery team and specialized microsurgery equipment.

Gossypiboma is a term used to describe retained surgical sponge after surgery. This is an avoidable clinical condition causing significant morbidity and mortality. The clinical presentation is variable and often a diagnostic enigma. The consequences of gossypiboma are undesirable, disappointing, and have medicolegal implications for the surgical team. We report three cases of gossypiboma with varying clinical spectrums. The first case had gastric outlet obstruction due to retained surgical sponge after open cholecystectomy. It had eroded both into the first part of the duodenum and transverse colon. Endoscopic and radiological evaluation helped to establish the diagnosis of duodenocolic fistula with gastric outlet obstruction. The second patient was treated for penetrating abdominal wound and presented with persistent fever with discharging sinus at the wound site. The third patient had undergone exploratory laparotomy for recurrent hydatid cyst of the liver and, in addition to recurrent hydatid cyst, a surgical sponge was also found. All these patients had retained surgical sponges but different clinical presentations. These patients underwent exploratory laparotomy and surgical removal of the retained surgical item (RSI) followed by a successful recovery. Gossypiboma should be considered as a differential diagnosis in all unexplained postoperative sepsis, intestinal obstruction, and intra-abdominal mass. Standard surgical safety measures in the operative room help to prevent the incidence of RSIs.

Background. Laparoscopic cholecystectomy has become the choice of treatment for symptomatic cholelithiasis and has replaced open cholecystectomy. Numerous studies and scoring system have been developed over the past 2–3 decades which predict the rate of conversion of laparoscopic to open cholecystectomy. Recently, few scoring systems have been developed which incorporates various intraoperative findings to predict this conversion. No studies are available in literature to assess gender-specific and body weight complications in laparoscopic cholecystectomy. The purpose of this study was to compare the outcome of laparoscopic cholecystectomy between male and female patients in terms of preoperative factors, intraoperative difficulties and rate of conversion to open cholecystectomy and common postoperative complications. Materials and methods. This non-randomized, prospective, observational study was conducted at a tertiary care hospital in Northern India from June 2019 to May 2021. Various preoperative data was collected from the patients like age, the American Society of Anesthesiologists (ASA) class, comorbidity, indication for surgery, preoperative ultrasonography findings and any previous surgery. Surgeries in all patients were started with laparoscopic cholecystectomy under general anaesthesia. The outcomes were measured in terms of time taken to complete surgery, whether laparoscopic cholecystectomy was converted to open cholecystectomy, common bile duct/cystic duct injury during surgery, common postoperative complications and average length of hospital stay in days. Results. A total of 300 patients were included in the study: 222 females and 78 males. Mean age of presentation in women was (46.45±11.55) years ranging from 21 to 71 years and in men (51.78±11.49) years ranging from 36 years to 76 years. This difference was statistically significant (p=0.001). The other significant preoperative differences between males and females were comorbidity (p=0.001) and previous surgeries (p=0.001). However, the ASA class under which the patients were operated was not significant (p=0.998). The various indications for surgery to include chronic cholecystitis, resolved acute cholecystitis, gallstone-induced pancreatitis and common bile duct stone had no statistical difference between men and women (p=0.072). Conclusions. This study concludes that intraoperative difficulties were more often in male patients as compared to females. The average operating time, conversion of laparoscopic to open cholecystectomy and postoperative hospital stay were significantly higher in men than in women.

Sir, A 17-year-old girl with no known comorbidities presented with mildly painful and gradually enlarging swelling over the left side of her face and temple for 2 years. Clinical examination revealed an ill-defined soft-tissue swelling over her left temple, measuring approximately 4 × 3cm in size. The swelling was non-tender, non-pulsatile, and compressible with no local rise in temperature. Her facial MRI [Figure 1a and b] revealed a discrete extra-calvarial left temporal hypervascular soft-tissue lesion in the subcutaneous planes with no skull base or intracranial extension. Corroborative digital subtraction angiography (DSA) revealed a high-flow vascular lesion with venous shunting, seen on the left external carotid artery (ECA) angiogram [Figure 1c and d]. Arterial feeders were from left maxillary and superficial temporal artery branches; venous drainage was into the pterygoid plexus and left internal jugular vein. No feeders from right ECA or bilateral ICA were present. Pre-operative selective embolization [Figure 2a and b] was performed by combined percutaneous glue and transarterial polyvinylalcohol (PVA) particle injection. After the tumor bed was optimally occluded with 50% glue percolation, the remaining feeders were embolized through a microcatheter in the left internal maxillary artery. Complete obliteration of the abnormal blush and venous shunting was seen with no inadvertent embolization [Figure 2c]. Complete near-bloodless excision of tumor [Figure 2d] was done with the uneventful early discharge of the patient. A biopsy of the lesion revealed an epidermal inclusion cyst and no features of arteriovenous malformation (AVM) or hemangioma.Figure 1: Cranial MRI coronal fat-suppressed T2 (a) and post-contrast T1 (b) showing heterogeneously hyper-intense and avidly enhancing soft-tissue lesion (straight arrows) in the left temporal subcutaneous region. Corroborative DSA in Antero-Posterior(c) & lateral (d) views showed a hypervascular lesion with arterial supply from the branches of the left internal maxillary (curved arrows) and superficial temporal (arrowheads) arteriesFigure 2: Embolization of the left temporal subcutaneous hypervascular lesion with percutaneous injection of glue (arrow in a) and endovascular injection of PVA particles (curved arrow in b) resulted in the optimal embolic cast (arrowheads in c) and complete obliteration of the abnormal tumor blush. Complete excision of the devascularized lesion (arrowheads in d) was performed with <10 ml blood lossEpidermal inclusion cysts are a proliferation of squamous epithelium in dermis or subdermis usually seen following trivial trauma. AVMs are congenital hamartomas consisting of an abnormal nidus of dysplastic vascular channels with feeding arteries, draining into the veins or venous plexuses with no intervening normal capillaries. Schobinger's classification system describes the clinical characteristics of superficial AVM.[1,2] Both the hypervascular tumors and facial AVMs may show ectatic feeding arteries and early-draining veins. Both may also show typical flow voids in T1- and T2-weighted MRI. DSA is the gold standard for diagnosing venous shunting and also is a prelude to therapeutic embolization, mapping the flow pattern in relation to the lesion.[3] Combined percutaneous glue and trans-arterial PVA–particle embolization is the optimal strategy for pre-op occlusion of the hypervascular lesion with simultaneous obliteration of prominent feeders and tumor bed.[4] Our case was unique to have venous shunting within the epidermal inclusion cyst, both of which might be the results of old trauma. To the best of our knowledge, successful combined embolization–excision of the co-existing inclusion cyst and AVM is hitherto unreported. Abbreviations DSA = Digital subtraction angiography AVM = Arteriovenous malformation Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Acute intestinal obstruction is a common surgical emergency. Most of the time, the cause lies in the gastrointestinal track. A 19 year old boy presented with clinical features of acute intestinal obstruction and radiological features suggestive of large bowel obstruction was taken up for surgery. During evaluation we found extravasation of urine inside pelvic cavity. Exploratory laparotomy showed intraperitoneal rent in dome of urinary bladder with dense adhesion of omentum kinking the transverse colon causing acute intestinal obstruction. We were surprised to see the resolution of obstruction with excision of omental band. The bladder was repaired and he was relieved of the problem. This article is a rare example of nongastrointestinal cause for intestinal obstruction. Most of these cases are seen by a general surgeon in an emergency setting. Hence this report is to enlighten the medical caregivers about the existence of this rare entity.

Background: Camp approach has been advocated as an effective means of motivating the target population to adopt vasectomy as a method of permanent sterilization. There is a high degree of acceptance of Non-scalpel Vasectomy (NSV) among physicians and laypersons. With this knowledge, we organized camps and found good results which we share in this article. Methods: Four NSV camps were organized in four different villages across India on a vehicle-mounted mobile operation theater. The meticulous and detailed planning, dissemination of information, careful execution, and post-procedure follow-up is enumerated. Results: A total of 76 individuals underwent the operation in these camps. The mean age of the participants was 35 ± 5.2 years (range, 27–44 years). The complication rate was negligible and there was no failure of vasectomy. There was a high level of satisfaction among those who underwent this procedure as seen by the increased number wanting to undergo the procedure from places where camps were located. Conclusion: NSV as a procedure is perceived as being simple and pain-free. Re-enforcing this fact and removing doubts, and conducting operations at the camp in an environment the client is familiar with achieved rewarding results.

Background. Hydronephrosis is the most common urinary tract pathology detected on antenatal screening by Ultrasound. The detection of fetal hydronephrosis by ultrasound pres­ents a treatment dilemma to the treating surgeon and parental anxiety. Objective. This study aims to examine the role of serial ultrasounds in antenatally detected fetal hydronephrosis to know the disease progression, and to assess indications and timing of surgery in these patients to preserve renal function. Methods. This is an observational study of 30 cases of foetal hydronephrosis conducted at a tertiary care paediatric surgery centre. A foetal renal pelvic Antero-posterior diameter (APD) >7 mm at 32 weeks of gestation is considered to indicate Foetal hydronephrosis. These patients are followed up for a period of two years from 2018 to 2020. Progression of disease and need for surgical intervention is noted. Results. The study comprised 30 cases of antenatal foetal hydronephrosis (42 renal units). Of 26 renal units with mild hydronephrosis, all are resolved in the post-natal period. Of 10 renal units with moderate hydronephrosis, 3 (30%) resolved and 7 (70%) worsened and required surgical intervention. Of 6 renal units with severe hydronephrosis, all required surgical intervention and underwent surgery between 12 to 18 months of age. Conclusions. These results suggest a grading system with antero-posterior diameter of renal pelvis distinguishes those cases with moderate and severe degrees of hydronephrosis that are at higher risk of surgery.

Background. Gastrointestinal stromal tumours (GIST) are non-epithelial mesenchymal solid neoplasm with varied presentation. The study reports the case of a retroperitoneal GIST in a 21‑year‑old male presented with an abdominal lump for six months. The lesion was initially thought to be a retroperitoneal sarcoma. Exploratory laparotomy revealed an abdominopelvic mass covering the entire right side of abdomen and pelvis. The tumour was adherent to the terminal ileum and ascending colon. There were dense adhesions between the retroperitoneum with involvement of the middle third of the right ureter. The tumour was resected with right hemicolectomy with ileotransverse anastomosis. Post-operative histopathology revealed it as high-grade spindle cell type GIST. The patient is presently on post-operative chemotherapy with Imatinib mesylate. Objective. Atypical presentations of GIST are seldom discussed but frequently encountered in clinical practice. This article depicts different challenges the surgeon has to face while diagnosing such atypical entity. Methods. Case report of atypical GIST presenting as retroperitoneal lump. Results. The patient underwent surgical resection and is presently on post-operative chemotherapy with good overall outcome for a one year follow up. Conclusions. GISTs presenting as retroperitoneal lumps are very rare, they should be considered in their differential diagnosis of an atypical retroperitoneal mass.

Congenital diaphragmatic hernia is a life-threatening anomaly with the high mortality rate in infancy. Very rarely they remain silent and manifest in the adult life. Once they manifest, the symptoms vary and are not easy to diagnose. The entity also has associated problems in the form of hypoplastic lungs and loss of domain of the abdomen. In such cases, the diagnosis is most often based on clinical suspicion and radiological confirmation. The treatment options are open abdominothoracic procedures or laparoscopic procedures. Once hernia is reduced, the defect is closed and should be reinforced with prosthetic mesh. Here we present a case of congenital diaphragmatic hernia in a teenager presenting with cardiac symptoms. The challenges faced in managing the case are discussed.

Blastomycosis is a chronic systemic pyogranulomatous infection caused by the fungus Blastomyces dermatitidis, endemic to North America (Mazi et al. in Infect Dis Clin North Am 35(2):515–530, 2021). This is a dimorphic fungus, which exists as a non-pathogenic mycelial form in nature and converts to pathogenic yeast at body temperature. Although it primarily affects lungs, extrapulmonary involvement is reported in 20–30