Basrah Journal of Surgery

LASER (Light Amplification by Stimulated Emission of Radiation), is a mechanism of emitting
electromagnetic radiation typically light as a process of stimulated emission.
Common light sources(electric light bulb)��Emit photons in all directions, usually over a wide
spectrum of wavelengths. Host light sources are incoherent
LASER��Emit photons in a narrow, well defined beam of light. The light is often nearmonochromatic,
consistency of single narrow wavelength. It is highly coherent and is often
polarized.
LASER was introduced to practice in 16 May 19601,2. Laser introduce into medicine at early
197011.
LASER in Medicine: various types of laser are used in medicine for diagnosis, treatment and
therapy.
The medical areas that employ laser include: Angioplasty, Dentistry, Dermatology, Lithotripsy,
Mammography, Ophthalmology, Surgery, Urology, Cancer laser (PDT: Photodynamic therapy)3.

Laparoscopic cholecyctectomy became gold standard for treatment of symptomatic gall stone
disease. Analysis of the first hundred patients who underwent laparoscopic cholecystectomy to
study the learning curve and complications. The highest number of patients underwent
completed laparoscopic cholecystectomy 54 (90%) and the lowest conversion rate 10% (6/60)
with high percentage 22% of patients with complicated gall stone disease during year of 2004.
Biliary injury 2%, occurred mainly in the early years. Total conversion rate was 21%. These
results were improved with~1

This is a Prospective study to evaluate the effects of whether to use antibiotics or not in the treatment of non-perforated acute appendicitis in children.
One hundred & two children with acute appendicitis were operated upon by emergency open appendicectomy in AL-Sadir Teaching Hospital, Basrah Child & Maternity hospital and AL-shefa'a General Hospital. In thirty six patients, the appendix was perforated or gangrenous and was excluded from the study. Regarding the remaining 66 patients, 50 patients received antibiotics whether pre-operatively or post-operatively and 16 patients did not receive antibiotics. Both groups were followed postoperatively for development of: fever, wound infection and intra-abdominal abscess for 3 weeks.
Post operative fever was observed in 11(22%) of those who received antibiotics compared to only 3(18.75%) of those who did not receive antibiotics. One (2%) of those who received antibiotics compared to zero of those who did not receive antibiotics developed wound infection.
None of either groups developed intra-abdominal abscess. Thirty four (68%) of those who received antibiotics and 12(75 %) of those who did not receive antibiotics went home within 3 days of admission. where is 16(32 %) of those who received antibiotics and 4(25 %) of those who did not receive antibiotics stayed in the hospital for a period of 4 days.
In conclusion, No administration of antimicrobials to children with non-perforated acute appendicitis did not in anyway increases morbidity but in contrary it reduced hospital cost by way of less medication and shorter hospital stay. Add to this the less inconvenience to the family.

Laparoscopic cholecystectomy has become the gold standard in the treatment of symptomatic
cholelithiasis. Several preoperative variables have been identified as risk factors that are helpful
in predicting the probability of conversion to laparotomy for safe and successful removal of the
gallbladder.
This study aimed to look for the various sonographic findings and to make a predictive index for
patients who are candidates for laparoscopic cholecystectomy, operative difficulties and
conversion to open cholecystectomy.
This is a prospective study conducted in the Department of Surgery of Al-Mawani General
Hospital, Al-Mousawi Private Hospital in Basrah, Iraq, between May 2005 and October 2008.
Abdominal Sonography performed in 105 consecutive patients before laparoscopic
cholecystectomy (the sonographic signs are: gallbladder wall thickness, pericholecystic fluid,
sonographic Murphy's sign, shrunken gallbladder, number and size of gallstones). Patients
excluded are those with history of jaundice, abnormal liver function test, upper abdominal
surgery, co-morbid illnesses, extreme obesity, dilated intrahepatic or extrahepatic biliary ducts or
those with CBD stones.
The surgeon re-evaluates the results of ultrasound with the results obtained during surgery.
One hundred and five patients included in the study, 103 patients with gallstones, the other 2
patients having polyps. Ultrasound was accurate 100% in detecting gallstones and polyps, 99
patients (94.3%) have their cholecystectomies via the laparoscope, 75 patient (75.8%) from
them show easy procedure, while 24 patients (24.2%) suffered from difficulties.
Six patients (5.7%) needed conversion to open cholecystectomy to complete the operation
safely.
In conclusion, there are many sonographic signs that we can be depend on them to give us an
idea about the possibility of conversion to open cholecystectomy, the most specific one is
pericholecystic fluid. Secondly gallbladder wall thickness more than 3mm, thirdly, sonographic
Murphy's sign, fourthly, shrunken gallbladder, fifthly single gall stone. The other signs are of less
specificity like size and multiplicity of gall stones.

This comparative prospective study was conducted to assess surgical outcome and postoperative
complications in 70 children with 115 idiopathic clubfeet treated at Basrah General
Hospital. Children up to age of 5 years were included. There were 49 males and 21 females.
Male to female ratio was 2.3:1. The deformity was bilateral in 61.4% and unilateral in 38.6% of
cases. The indications for surgery were failure of early conservative treatment and late patient
presentation beyond 6 months of age. Patients were placed into two groups; group A in whom a
standard posteromedial soft tissue release through single incision including 58 feet (19
moderate, 28 severe, and 11 very severe), whereas in group B, combined posteromedial and
lateral releases through two separate incisions in 57 feet (19 moderate, 28 severe, and 10 very
severe). Analysis of data reveals that combined release is superior to single release in the rates
of operative wound breakdown and more important in term of correction of initial preoperative
clubfoot deformity for which the surgery was performed. Postoperative skin necrosis occurred in
8.8% of combined release feet compared to 17.2% in single posteromedial release feet. With
combined release 87.7% of feet obtained satisfactory deformity correction outcome in contrast
to only 63.8% in single release feet. The most common single residual deformity reported in this
study following surgical correction whether by single posteromedial release (13.8%) or by
combined release (12.3%) was forefoot adduction. The risk of wound infection was
approximately the same for both procedures 8.6% in single release, and 8.8% in combined
release.
The study showed that the proportion of satisfactory deformity correction results decreases as
the patient age at operation increases, particularly if single posteromedial release alone was
performed. With single release a 100% satisfactory deformity correction outcome will be
obtained only if surgery was performed during the first 6 months of life, beyond which this rate
had dropped to 63.6% when operation was delayed to the age of 7-12 months, and to 25% at
1-3 years of age. After 3 years of age single posteromedial release alone did not yield any
satisfactory results. On the other hand a100% satisfactory results were obtained in all feet
treated with combined release during the whole period of the first 3 years of life, after which the
rate of satisfactory results decreased to 50%. The study highly recommends the use of
combined posteromedial and lateral release through two separate incisions when operating on
clubfeet above the age of 6 months. This is a very valuable procedure with high success rate
both in correcting the initial deformity and minimizing the rates of surgical wound breakdown.

Mastalgia is one of the most common breast symptoms. The aim of this study is to describe the
clinical, pathological, ultrasonographic and mammographic features of this common symptom in
Sulaimania, Iraq.
A prospective study done over a period of 1 year, between 1st Sept 2007 and 30th Aug 2008,
during that period, 132 cases of mastalgia were seen in a private general surgical office in
Sulaimania. Data were collected about history, physical examination, ultrasonographic,
mammographic, fine needle aspiration cytology and open surgical biopsy findings.
Mastalgia was divided into cyclical mastalgia and non cyclical mastalgia and their underlying
causes and their response to different lines of treatment were recorded.
Out of 132 patients, 58 patients (43.94%) had cyclical mastalgia, and 74 patients (56.06%) had
noncyclical mastalgia. Their age ranged 17-67 years. Duration of pain was from 7 days - 2
years. Fear of breast cancer was present in 34.09% of the patients. Normal findings were found
in 58.33% of ultrasonographies and negative findings in 78.57 % of mammographies done. In
the majority of patients with mastalgia (58.33%) no cause could be found and the most common
finding was fibrocystic changes (19.69%). The incidence of breast cancer in our patients was
low (0.75%). Most patients with mastalgia (84.69%) improved with reassurance.
Conclusion: Most of the patients with mastalgia were young and middle aged, housewives,
married, multiparous and practiced breast feeding. The incidence of breast cancer was low. In
the majority of them no cause could be found. Most patients improved with reassurance.

Closure of the wound after surgery is a routine procedure and one of the first things that a
surgeon in training should learn. A surgeon will successfully closes a thousand of wounds
during his career, but the problem of wound infection remains challenging.
This study was conducted to compare between two methods of skin closure which are
subcuticular alone and combined subcuticular with interrupted suturing regarding; wound
infection, cosmesis &speed of wound closure.
Between December 2006 and October 2009, two hundred and two patients were admitted in
Basrah General Hospital, department of surgery. They underwent elective abdominal operation
and were randomized into two groups, group A (abdominal skin closure by subcuticular suturing
only) and group B (combined subcuticular with interrupted suturing). There were 102 cases in
the subcuticular group, 50 cases of them were males and 52 cases were females, while in
group B there were 100 cases,42 cases of them were males and 58 cases were females. Mean
age was 38.9 (range 4-66) for group A and 41.6 (range 8-67) for group B. The mean BMI was
25.2 (range 17.4-34.8) for group A and 26.4 (range 18.7-39) for group B.
Results: Wound infection: The total number of early wound infection for the six �weeks follow �
up period was 12 cases (11.7%) for the subcuticular (group A),and 4 cases (4%) for the
combined (group B)_(P=0.036). Cosmoses: There was no significant difference in cosmetic
result in both groups. Speed of wound closure: Combined (group B) closure was accomplished
at significantly faster rate (mean 35.6 sec/cm) than subcuticular (group A) closure (mean
46.8sec/cm) (p=0.001). Conclusion: From this study we conclude that the choice of technique
for wound closure did not affect the final cosmetic outcome of the wound but the incidence of
postoperative wound infection significantly reduced by combined subcuticular and interrupted
suturing. The closure of wound is rapid in combined group than in subcuticular group alone.

Deep partial or full thickness burn if untreated, neglected, infected or managed conservatively can develop
sever deformity & scar contracture in the joint with significant reduction in patient activities.
In this study, the patients who underwent excision and grafting had significantly shorter hospital stay, lower
hospital charges and fewer infectious complications.
One hundred cases of burn injury admitted to the department of Plastic Surgery in Al-Sadder teaching
hospital for the period between January 2009 to January 2010. They were referred because of late
complications of burn injury. They were 60 males and 40 females. Patients burned with dry heat are most
likely to get complication according to this series, 67% of the patients with complication are injured by dry
heat, far less are scalding which forms 18%.
The types of reconstructive operations depend on severity of the deformity, site of the deformity and patient
preference. About 35% of the patients needed excision and grafting, but also some needed surgical
interference ranging from simple grafting to more lengthy procedure as tissue expander.
First degree burn can be treated conservatively, 2nd&3rd degree are treated by early surgical excision &
grafting within 24 hours when the general condition is stable. This will decrease the duration of wound
healing, decrease time of patient morbidity & hospitalization, early return to their jobs.

Chronic rhinosinusitis (CRS) is a common problem worldwide that results in significant impairment of quality
of life. Endoscopic surgery aims at maintaining physiological function and anatomical structure.
This study aimed to assess the outcome after functional endoscopic sinus surgery (FESS) for chronic
rhinosinusitis with or without nasal polyps using symptom scoring and endoscopic assessment.
Thirty patients having chronic rhinosinusitis CRS with or without nasal polyps underwent endoscopic sinus
surgery in Otolaryngology dept. / Sulaimaniya Teaching Hospital from May 2008 to April 2009 after failure of
medical treatment to resolve the condition for more than 12 weeks. Preoperative symptoms and radiologic
findings were scored as well as the extent of surgery. Post operative endoscopic findings and symptoms
outcome were evaluated.
The common presenting symptoms in order of frequency were nasal obstruction, facial pressure or pain,
purulent nasal or post nasal secretions, headache, hyposmia, Fatigue, cough, and halitosis. All symptom's
scores significantly reduced (t-test P value < 0.000), with exception of cough (t- test P value = 0.023).
Halitosis showed no significant change (t-test P value = 0.103). Patients who had the lowest radiological
scores underwent the least extensive surgery.
In conclusion, most CRS symptoms can be expected to improve significantly after ESS and correlates with
postoperative endoscopic examination of the nasal cavities. Lund-Mackay radiologic scoring can be used as
a predictor of symptom outcome although it correlates weakly with the severity of symptoms preoperatively.

This study aimed to evaluate the clinical impact of coronal image of the spine at initial presentation for
magnetic resonance imaging of the spine. Images were evaluated by two experienced radiologists, the
added value of the additional sequence was assessed. Correlation was made with surgery or clinical followup
at 3 months. We concluded that the coronal image of the spine is of great value in detecting extraspinal
lesion in magnetic resonance imaging of the spine.

Acute appendicitis is one of the commonest surgical emergencies. The diagnosis is still
doubtful in a number of cases. Neutrophil/Lymphocyte ratio (N/L R) is a simple, applicable
hematological test which carried out to find if there is any relationship between this ratio and
acute appendicitis and to see could the ratio be used as a diagnostic tool rather than white
blood cell count (WBC) alone.
This study was carried out on 70 patients aged (9-45) years who was admitted to hospital with
suspicion of acute appendicitis, latter on, they underwent appendectomy. Preoperative blood
sample was collected from each patient for WBC and differentials leukocyte count.
Postoperatively appendectomy specimens were taken to histopathological examination, which
shows 52 cases of inflamed appendix and 18 normal appendices.
When the (N/L R) and (WBC) were correlated with results of histopathology, it was found that
there is a relationship between acute appendicitis and (N/L R), especially if we use the ratio at
cut off point which was>2.6(p value<0.05=0.0001), The sensitivity was 80.76% while the
specificity was 72.22% and accuracy was 78.57%, while the results showed that the (WBC)
alone had a limited role in diagnosis of acute appendicitis (p value >0.05=0.219).
In conclusion, there is a strong relationship between (N/L R) and acute appendicitis.

This study aimed to know the effect of serum calcium(Ca), inorganic phosphate(P), uric acid
(UA), copper(Cu), zinc(Zn) and magnesium(Mg) on osteoarthritic (OA) patients who are having
pure OA of knee & those having diffuse OA (knee and spine), and to clarify the relationship of
those parameters with severity of symptoms and radiological findings.
This is a prospective case control study conducted at Basrah province through of a period of 9
months from October 2001 to June 2002, during which 100 patients with different types of OA
were admitted to the Orthopedics Clinic of Basrah General Hospital. Their age ranged from 40
to 68 years olds (24 males and 76 females), were allocated into 3 groups (mild, moderate and
sever OA) according to their symptoms and radiological findings. On the other hand 80
apparently heath subjects (23 males and 57 females). Their ages ranged from 40-70 years old
were participated as a control group.
Venous blood samples were collected from each subjects and patients participated in this study
for measurements Ca, P, UA ,Cu, Zn and Mg by using standard methods.
Among two age groups and in female patients serum Ca level was highly significantly lowered
(p > 0.01) in patients with moderate OA of knee as compared with mild OA patients.
Serum uric acid was significantly increased(p> 0.05) in patients having mild OA of knee as
compared with mild OA of (knee and spine) at age group . 55 years, the same results was
observed in male patients as compared to the females group. Serum Cu and P levels were nonsignificantly
altered (p< 0.05) in two types of OA among different age and sex groups. Serum
Zn levels was significantly lowered (P<0.05) in patients with moderate and mild OA of knee and
in sever and moderate OA of knee and combined for serum Mg levels among different age and
sex groups.
On the basis of this study, it can be concluded that incidence of moderate OA were high and
represent 58% of total numbers of patient studied who were at higher risk of significantly
decrease in the concentration of calcium, zinc and magnesium.

Worldwide, prostate cancer incidence and mortality vary significantly between countries and
regions and are highest in African American men. In the USA, prostate cancer is the most
common visceral malignant neoplasm in men and the second leading cause of cancer-related
deaths. Bilateral orchidectomy with or without hormonal therapy are the main treatment options
for patients with advanced prostate carcinoma.
The objective of this study is to compare the efficacy of orchidectomy alone and orchidectomy
plus flutamide in treating patients with advanced carcinoma of prostate.
The study was conducted from June 2006 to March 2010. Thirty six patients were included in
the study. The inclusion criteria were histologically documented carcinoma prostate along with
distant metastasis (stage D2). Following orchidectomy, the patients were stratified into two
groups. Group I had patients treated with orchidectomy alone (17 patients) and Group II those
treated with orchidectomy plus flutamide therapy (19 patients). Follow up of patients was done
for the next two years following initiation of therapy.
The maximum percentage change in PSA was found in the first three months after
orchidectomy. The mean percentage change at two years, in the two groups was 65% and 62%
respectively. Based on the evaluation of response, there was no significant difference in
response rate between the two treatment groups.
In conclusion, addition of antiandrogen like flutamide to orchidectomy has not given any
significant benefit to effect the PSA changes as well the survival in advanced carcinoma of
prostate. Hence, routine use of additional antiandrogen to orchidectomy is not advisable.

ABO blood grouping is currently considered as one of the essential immunological tests done
before many clinical interventions; on the top of them are clinical blood transfusion procedures.
In a period of 14 months, 620 blood samples were collected from normal individuals including
294 males & 326 females after demographic study of each one. Samples were tested for ABO
grouping using the standardized methods.
Results were analyzed statistically using the SPSS analytical system. Results showed that
blood group O was the most prevalent type among the whole Basrah Governorate, in all its
districts & among both sexes, while the blood groups B & A came next, where as B group was a
little bit higher in the whole sample of the Governorate & among females while the A was a little
bit higher among males. The AB blood group was the least of the four among all. There was
little variation in the distribution of the four blood groups among the different regions of Basrah
Governorate but with conservation of the above mentioned graduation. Those results were
comparable to the results registered in some neighboring countries, but differ more or less from
other far countries.

Trace elements copper (Cu) and zinc (Zn) have a role in many biochemical reaction as micro
source, their metabolism are profoundly altered in neoplastic diseases and since breast cancer
rank the first of female cancers, this study aims to evaluate the diagnostic significance of
copper/zinc ratio in 70 patients with breast tumor and compared to the grade and
histopathological examination. result had been shown that there is significant difference in level
of zinc and copper and copper/ zinc ratio between benign and malignant tumor and this
difference persist to be present between different grade of malignant breast tumor and it had
been found that copper/zinc ratio have diagnostic significance of 78.5% in discriminating
between benign and malignant tissue and this had been increased to about 95.1 % in
differentiating between grade of malignant breast neoplasm. So we conclude that copper/zinc
ratio is higher in malignant breast tissue and could be a better indicator of grade of cancer.

Sacrococcygeal pilonidal sinus (PNS) is a common disease. There are different lines of
treatment but the best surgical technique is still controversial. The aim of this study is to show
the effectiveness of treatment of sacrococcygeal PNS with excision and primary midline closure
as day case surgery. This is the first study on sacrococcygeal PNS to be done in Sulaymania
governorate, Iraq.
A prospective study was done over a period of 3 years, between 1st Jan 2003 and 31st Dec
2005 in a private general surgical office, in Sulaymania city, Iraq, where 78 cases of chronic
symptomatic, uncomplicated, nonrecurrent sacrococcygeal PNS were seen. From these 78
patients 6 patients refused operation and they were excluded from the study. Data collected
from the remaining 72 patients were age, gender, presenting complaint and its duration,
operative findings, duration of the operation, time of wound healing, any hospitalization if
required, time to return to work, postoperative complications, postoperative pain, wound
hematoma, wound infection, wound disruption, recurrence of the sinus, cost of the operation,
patient satisfaction about the treatment and follow up compliance of the patients. They were
treated with excision and primary midline closure technique. From the total no of 72 patients, 7
patients were unable to complete the follow up period and they were excluded from the study,
and we continued the study of the outcome data of the remaining 65 patients.
Of those 65 patients treated excision and primary midline closure, 1 patient (1.53%) developed
wound disruption, 4 patients (6.14%) developed surgical site infection (SSI) and only 3 patients
(4.61%) had reccurence of the sinus.
It is concluded that excision and primary midline closure technique is simple, convenient,
economic and successful treatment as day case surgery for chronic, sympotomatic,
uncomplicated and non recurrent sacrococcygeal PNS.K

Wandering spleen is a clinical rarity, torsion of a wandering spleen is a rare cause of an acute
abdomen. The etiology of wandering spleen is not precisely understood and this clinical
condition presents a diagnostic challenge for clinicians. Available treatment options include
splenectomy. This is the first reported cases of such an anomaly in our hospital.

Delirium is a common complication after surgery, especially among critically ill patients. The
etiology is multifactorial and the condition is frequently identified after major complicated
surgery. It is associated with prolonged hospital stay and increased morbidity and mortality.
This paper present a complex case which required intensive treatment and support as a result
of several complications including delirium. The case also serves a good example in discussing
the different aspects of the condition.

CASE REPORT