Basrah Journal of Surgery

Editorial

LEADING ARTICLE
The physician is an active member of
the society. He interacts with it,
influences and takes care of it. His duty
is not only to cure patients, but also to
take the necessary procedures to reduce
errors and to lessen the harm resulting
from these errors on the health of the
patient. Such faults and errors may seem
travail, but they are serious however tiny
they are because they are related to the
divine and precious life of the human
being.

Despite important advances in surgical care and minimized surgical trauma, postoperative
complications are still of great concern. Nutritional depletion has been demonstrated to be a
major determinant in the development of postoperative complications. Nutritional status of
gastrointestinal surgical patients is an important issue, which need to be attended in particularly
during the perioperative period.
Fears of postoperative ileus and the integrity of the newly constructed anastomosis have led to
the adoption of starvation with administration of intravenous fluids until the return of normal
bowel sounds and passage of flatus. However, it has been shown that early postoperative
enteral feeding is both beneficial and well-tolerated.
Meta-analysis has shown that enteral feeding compared with parenteral nutrition is associated
with fewer complications, reduced costs and a shorter hospital stay. Therefore it should be the
preferred option whenever possible.
Evidence to support preoperative nutrition is limited, but malnourished individuals fed for 7-10
days preoperatively may have improved surgical outcome.
Prolong preoperative starvation is not essential, and the administration of preoperative
carbohydrates is safe without the fear of increasing the risk of aspiration.
Initially nutritional support was aimed at meeting the energy needs and providing proteins and
other essential micronutrients, while now it is more directed at modulation of the immune
functions, the so called immunonutrition.
Multimodal strategies including minimal invasive surgery, adequate postoperative analgesia,
nutritional care, and enforced mobilization resulted in reduction in postoperative complications
and length of hospital stay.

Open abdomen is a concept that the abdomen is left open after laparotomy especially when it
was done as emergency for traumatic abdomen or reopens the abdomen when signs of
increase intra-abdominal pressure (IAP) causing abdominal compartment syndrome (ACS).
This open abdomen must be covered temporarily till the signs of abdominal compartment
syndrome (ACS) disappears and intra-abdominal pressure (IAP) returns normal, then reclose
the abdomen by one of definitive procedure.
It was found that Vacuum-assisted wound closure (VAWC) is the best temporary procedure to
close the abdomen to get early or late fascial closure as the best definitive closure of open
abdomen.
Also It was found that the classification of open abdomen is so helpful in choosing the
procedure for temporary and definitive closure, this classification is new thing and dependable.

Thyroid surgeries are common operations with an extremely low mortality. It is associated with
specific morbidities which are dramatically decreased due to the rapid progression in operative
techniques which helped to make the thyroid surgery less feared and better understood than it
once was. Inferior thyroid artery is one of the vital structures that require special attention during
operative technique in order to avoid troublesome and in most cases a preventable
complications.
We conducted this study to assess the: Prevalence and significance of post-operative
hypoparathyroidism following thyroid surgery, with or without inferior thyroid artery ligation.
Incidence of recurrent laryngeal nerve injury with or without inferior thyroid artery ligation.
Intraoperative and post operative bleeding with or without inferior thyroid artery ligation.
A prospective observational study was done from June 2005 to June 2008, at Basrah General
Hospital. One hundred and eight patients underwent subtotal thyroidectomy. Majority of them
(90) patients were females. Patients were placed in two groups, Group I had inferior thyroid
artery ligation whereas in Group II, inferior thyroid artery was not ligated.
Analysis of data reveals that (50%) of patients in group I had hypocalcemia, (16.1%) recurrent
laryngeal nerve injury and (4.83%) hematoma, whereas in group II (47.82%) had hypocalcemia,
(8.7%) recurrent laryngeal nerve injury and (2.17%) hematoma.
Statistically, there is no significant difference regarding post-operative hypocalcaemia,
recurrent laryngeal nerve injury and hematoma formation between truncal ligation and nonligation
of inferior thyroid arteries.~ �C

A palpable thyroid nodule is a common clinical problem; the ultrasonography (US) and fine
needle aspiration biopsy (FNA) are its main diagnostic tools. This article aimed to study the
reliability and advantages of ultrasound as a diagnostic aid in predicting malignancy in thyroid
nodules and to reduce the number of unnecessary surgery. Two hundreds and thirty three
patients were examined by ultrasound, and then fine needle aspiration cytology under
ultrasound guidance (US-FNAC) was done for 210 of them. From those 210 patients we
obtained the histopathological proof of 58 patients who underwent surgery. We calculated the
sensitivity, specificity and accuracy of US-FNAC. There are certain sonographic criteria that
suggest malignancy these include microcalcification, irregular margins, and hypoechogenicity of
the nodule. The sensitivity, specificity, and accuracy of US-FNAC were 80%, 96%, and 94%
respectively. Although ultrasound can not reliably distinguish benign from malignant nodules,
but it can identify suspected nodules based on certain sono-graphic criteria.

This study aimed to evaluate the safety and efficacy of cystic artery cauterization in
laparoscopic cholecystectomy (Lap.Chole.) and to outline possible complications and limitations
that might arise from adoption of such approach.
Cauterization of the cystic artery was adopted as the principal mean of securing the cystic
artery in the course of standard lap.chole. The technique was applied on 46 cases of
laparoscopic cholecystectomy. Patients with adhesions in the triangle of Calot and/or very short
cystic arteries were excluded from the study. All patients were followed up for 2-3 weeks.
We didn't get any serious complication in form of: major bile duct injury, right hepatic artery
injury, post operative hematoma.
Mean operative time was 35 minutes. Out of the 46 patients who had cystic artery cauterization
we had the following complications: one patient developed intra-operative bleeding from the
cystic artery in the course of its skeletonization which was controlled by prompt clipping, another
patient developed rather severe bleeding from a torn cystic artery and we converted him to
open cholecystectomy.
Forty one patients were females (age range 18-48 years) and 5 were males (age range 33-49
years). Complications occurred exclusively in females.
Apart from conversion due to other causes, the incidence rate of conversion due to bleeding
from cystic artery during clipping and cauterization was 1.5%, 2% respectively.

Auricular reconstruction represents a meticulous reconstructive and aesthetic problem to the
plastic surgeon. One of the greatest challenges in facial plastic surgery is total ear
reconstruction. The ability to reconstruct a fully satisfactory complete external ear has for
centuries been an elusive goal. The most promising field of advances with the hope of
eventually clinical utility lies in the realm of bioengineering with cultured cartilage.
To date, no perfect material has been found to substitute for the sharply elastic cartilage
normally present in ear, the matter of total auricular reconstruction remain very complex,
Prosthetic restoration is not favored by most but does remain available option for many
patients. Tissue engineers have waited to create a precise three dimensional auricular
reconstruction neocartilage.
Ten patients were operated upon for auricular reconstruction in Basrah Alsader Teaching
Hospital. The operation had 2 stages: First stage, creation and implantation of framework
cartilage graft, which harvested from the 6th ,7th & 8th ribs. The second stage, was detachment of
the constructed auricles ear lobe transposition and post auricular sulcus was defined by
separating the constructed auricle from the head covering the under surface with a thick split
thickness skin graft.
The success rate was 90% with good and satisfactory result except in one case; there was
infection with loss of the cartilage.

To estimate the incidence, indications, risk factors and complications associated with emergency peripartum
hysterectomy, we analyzed retrospectively all cases of emergency peripartum hysterectomy performed
at Basrah Maternity and Children from 1st of January 2005 to 31st of December 2007. Emergency
peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment
less than 24 hours after delivery. There were 20 emergency peripartum hysterectomy among 51,121
deliveries for a rate of 0.3/1000. Fifteen women (75%) were delivered by caesarean delivery. Eighteen
women were multiparous and 2 were primiparous. Most frequent indications were placenta accrete (60%),
9 with praevia and 3 with out praevia), followed by uterine atony in (20%), uterine rupture in (10%),
extended cervical tear in (5%), and retroperitoneal haematoma in 5%.
Placenta accreta was the most common indication in multiparous women (66.6%, 12 of 18) while uterine
atony was the most common in primiparous.
Eleven out of 12 (91.7%) women with placenta accrete had a previous caesarean delivery. Three (25%)
had a previous one caesarean section and 8 (66.6%) women had .2 previous caesarean section. Fourteen
(70%) of hysterectomies were subtotal. Intraopeartive complications were (15%) and Postoperative
febrile morbidity was (60%).We concluded that placenta accreta has become the most common indication
for emergency peripartum hysterectomy. The number of caesarean deliveries increased the risk of
placenta accreta proportionally.

Orthopaedic surgeons often remove foreign bodies from the extremities. If the foreign body is
radio-opaque, it can be located using conventional radiographs or fluoroscopy. However if the
foreign body is a radiolucent object, it may not be detected by radiograph leading to serious
complications. The aim of this paper is to discuss the role of US in detection of non radioopaque
foreign body in addition to the presentation and nature of the foreign body.
Twenty patients with penetrating injuries to the extremities were treated from January-
December 2008 at Samawa General Hospital. They were 11 male and 9 female, their ages
ranged between 4 to 50 years (average 22.7). All patients were evaluated by detailed history,
clinical examination, radiography and US which were done at the department of radiology in
Samawa General Hospital.
The lower limb was affected in 14 cases (70%) while the upper limb in 6 cases (30%).
presenting symptoms were; pain (16 cases) followed by swelling (3 cases), limping and
discharging sinus (one case). No foreign bodies were detected by radiography in this study. On
the other hand, US detect and localize foreign body in each case. Fifteen patients had history of
failed previous interventions for removing foreign bodies.
In conclusion, Non radio-opaque foreign bodies are common in children and adults most often
presenting as penetrating injury to the extremities. Failure to remove it may lead to serious
complications and malpractice lawsuits. US has emerged as the study of choice for detection of
radiolucent foreign bodies.

This study aimed to evaluate the use of surgicel as the primary hemostasis method in
tonsillectomy. It is a cross-sectional prospective study included 211 patients who underwent
tonsillectomy alone or with conjugation with adenoidectomy over a period of 4 years in a tertiary
centre. The surgeon used cold steel dissection and surgicel as primary Hemostasis technique.
There was no post-tonsillectomy hemorrhage in this study, giving a 0% risk of post tonsillectomy
bleeding. It is concluded that the use of surgicel is a valid technique to achieve hemostasis in
tonsillectomy. Larger number of patients has to be operated on using this technique in order to
validate the comparison between our technique and techniques currently used.

Nutritional status of the women has been considered as an important prognostic indicator of
pregnancy outcome and risk of preterm birth. Few studies have evaluated the patterns of body
mass index in developing regions where malnutrition and poor weight gain as well as maternal
obesity have significant influences on the pregnancy outcome. This study aims to show the
effect of pregnancy body mass index on the incidence of preterm labour.
This is a prospective descriptive study of 200 women attended Basrah Maternity and Child
Hospital who were diagnosed with preterm labour were recruited in the study. Patients were
classified into categories that were based on their body mass index (BMI) according to the
national institute of health guidelines. Rate of spontaneous preterm birth were determined.
Women with body mass index <19 kg/m2 had 34.5% of spontaneous preterm labour, with BMI
19-24.9 kg/m2 had 28.5% of spontaneous preterm labour, while those with BMI 25-29.9 kg/m2
had 21% of spontaneous preterm labour, women with BMI 30-34.9 kg/m2 had 14% of
spontaneous preterm labour and with BMI >/35kg/m2 had 2%of spontaneous preterm labour.
Risk of spontaneous preterm labour tend to progressively decrease with increasing body mass
index.
Thinner women who have preterm delivery tend to deliver at earlier gestational age than women
who were obese 42.3% of non obese women deliver before 30 weeks of gestation compared to
25% of the obese, 44% of non obese deliver at gestational age 30-40 weeks compared to 28.25
of the obese.
In conclusion, high body mass index is associated with a lower rate of spontaneous preterm
birth.

This study demonstrates the effectiveness and safe outcome of the treatment of hydatid
disease by laparoscopic approach in selected cases. This is an experimental prospective study.
Fourteen cases of liver hydatid (11 men & 3 women), properly selected were subjected to
laparoscopic hydatid endocystectomy in the period from February to September 2004 at the
endosurgery Center. Sirte County.����

This prospective study includes 80 eyes of 78 patients with cataract, who had manual
phacoemulsification operated upon by the same surgeon at Basrah Hospitals between Feb,
2006 and Jul, 2007. They were 35 males and 43 females, 2 of them (females) have cataract in
both eyes. The age of patients range from 35-70 years, 23 eyes of 21 patients (28.7%) at age of
between 35-45 years, 20 eyes (25%) at age of between 46-55 years, 27 eyes (33.7%) at age of
between 56-65 years, 10 eyes (12.5%) at age . 66 years. The pre-operative visions for those
patients were ranged from 6/24 to projection of light (PL), depend on the type and extent of
cataract. There was selected with no significant corneal astigmatism in all of these patients.
Surgery was done on 21 eyes (26%) with posterior subcapsular cataract, 20 eyes (25%) with
nuclear cataract, 30 eyes (38%) with mature cataract and 9 eyes (11%) with hypermature
cataract. On the first postoperative day, according to Oxford Cataract Treatment and Evaluation
Team Grade (OCTET) classification the observation was: Grade 0 was reported in 46 eyes
(58%), Grade I developed in 25 eyes (31%), Grade II developed in 8 eyes (10%), and Grade III
developed in 1 eye (1%). On the 7th postoperative day, 54 eyes (67.5%) had Uncorrected
Visual Acuity (UCVA) of good outcome, 23 eyes (28.7%) had of borderline. On day 40
postoperative, 75 eyes (93.7%) achieved a best corrected visual acuity (BCVA) of good
outcome. The final refractive states in 73 eyes (91.2%) was emmetropic or within (-1) diopteric
sphere of the desired refractive target without a significant astigmatism.

The objective of the present study is to evaluate the clinicopathological characteristics
of labial mucocele. Eighteen cases of labial mucocele were studied, a special protocol
was designed and clinical & histopathological variables were recorded. Only one
mucocele occurred in the upper lip, the rest being in the lower lip. One was bilateral. Of
the mucoceles examined, 88% were of the extravasation type and 11% were retention. Of
the 16 classified as of the retention type, 12.5% were in the initial stage, 31.25% in the
resorption stage and 56.25% in the final stage. It is concluded that diagnosis can be
established from clinical details although a histopathological study is necessary to
confirm the diagnosis.

Tendency to heal with an abnormal
scar7.
The external ear is most prone to
unfavorable wound responses such as
keloids8. Earlobe keloids are common
response to ear piercing, especially in
females and darker skin individuals9.
Keloids on the ears present several
therapeutic challenges. They are
common after small skin excisions and
other procedures, including drainage of
auricular hematomas, repair of other
auricular traumas or as secondary
keloid formation after prior keloid
excision. Several treatment modalities
are used for keloid such as surgery
alone or surgery combined with other
measures with varying success rates.
Today there is no agreement about
which treatment modality will
significantly solve the problem10.
This paper report a case of a large
bilateral post burn ear keloid on the
helical rim which was successfully
treated with surgery and intra-lesional
injection of 5FU and Triamcinolon.

A 27 year old male, known case of Ewing's Sarcoma of the right lower third humerus since July
2002, he was treated by combined therapy. After 3 years, he presented with pain, pathological
fracture of the upper end of the right humerus and soft tissue mass around the right shoulder.
Forequarter Amputation was done to him in October 2005. The presentation and management
of this patient is discussed.

Introduction
Giovanni Di Guglielmo first described erythroleukemia, a leukemia composed of purely erythrocytic precursors in 1926, and the disorder is often still referred to as acute Di Guglielmo syndrome. It is classified
as an M6 subtype of acute myelogenous leukemia (AML) in the French-
American-British (FAB) classification system based on morphologic and
cytochemical criteria1a. Acute erythroleukemia accounts for 3-5% of
all de novo AMLs and 20-30% of secondary leukemias. It is very rare in
children. The incidence of erythroleukemia increases in people
older than 50 years2 Mazzella et al (2000) described 2 peaks, one in the
seventh decade of life and a second, smaller peak in the fourth decade of life.