Basrah Journal of Surgery

The patient's complaint should be considered seriously as the father of medicine
Hippocrates says; Listen to the patient, he is the one concerned, listen to the
patient; he is telling you the diagnosis. This is very true, provided that the patient is
capable of expressing his symptoms and suffering.

The intervertebral disc is an avascular tissue, and penetration of antibiotics occurs by passive
diffusion. Cefotaxime penetration has not been well studied. The aim is to investigate the
penetration of cefotaxime into the intervertebral disc removed from patients undergoing
discectomy.
Twenty-six patients undergoing discectomy were recruited for this study. They were given one
gram of cefotaxime intravenously as a prophylactic antibiotic. Cefotaxime was extracted from
nucleus pulposus and serum and analyzed using an HPLC method with cefuroxime axetil as
internal standard.
Cefotaxime penetrated into all the 26 samples of nucleus pulposus resulting in a mean
concentration of 0.66±0.13 µg/gm. The mean serum concentration at time of disc removal was
13.61±3.54 µg/ml. The concentration in 16 samples were below the minimum inhibitory
concentration against Staph. aureus with an average of 0.27±0.03 µg/g. There is a statistically
significant correlation between time after intravenous cefotaxime administration and its
concentration in the nucleus pulposus. The greater increase is in the third hour after
administration. Factors like age, body weight, gender, number of associated diseases and
surgical history did not seem to affect nucleus pulposus cefotaxime concentration.
In conclusion, cefotaxime can penetrate into the nucleus pulposus but its concentration is
relatively low. This concentration has a strong positive correlation with time after cefotaxime
intravenous administration. Cefotaxime, therefore, needs to be given at least two hours before
disc removal, with re-dosing immediately before operation to maintain high serum concentration.

LOCAL EXPERIENCE OF TOTAL KNEE REPLACEMENT IN BASRAH Thamer A Hamdan@, Khalil I Sadek# & Mohammed AbedYasir* @FRCS, FICS, FACS, FRCP, American Board of Neurological & Orthopedic Surgery, Professor of Orthopedic Surgery. # FICMS, Orthopedic specialist, Basrah Teaching Hospital. * CABHS Orthopedic specialist, Al-Sadr Teaching Hospital, Basrah, IRAQ. Abstract Total knee arthroplasty (TKA) represents a major advance in the treatment of degenerative joint disease providing excellent restoration of joint function and pain relief. This is a prospective study undertaken in the Department of Orthopedic Surgery in Basrah Teaching Hospital, from October 2009 to June 2011. Thirty-three patients who underwent primary total knee arthroplasty were included (25 females 75.7% and 8 males 24.2%). The diagnosis was osteoarthritis in 20 knees and rheumatoid arthritis in 13 knees. The operation included primary cemented TKA (25 cruciate-retaining and 8 cruciate-substituting), by anterior approach. The knee function was evaluated by knee society score system. Preoperative functional knee scores were uniformly poor and improved postoperatively with excellent results in 18 knees (54.54%), good in 9 knees (27.27%), fair in 5 knees (15.15%), and poor in 1 knee (3%). Thus, excellent and good results were achieved in 81.8% of the cases (27 of 33 knees). For knee scores, 2 knees (6%) were fair preoperatively and another 31 knees (93.9%) were poor. Post TKA results were excellent in 28 knees (84.84%), good in 5 knees (15.15%), fair in (0%) and poor in (0%). Excellent and good results were achieved in 100% of cases. The most common complications were superficial infection and deep venous thrombosis In conclusion, this study showed good outcome for total knee replacement surgery in our region. Excellent relief of pain, range of motion, and restoration of function. Keywords: Total Knee Replacement, Osteoarthritis, Rheumatoid arthritis, Basrah, Surgery.



 

Abstract Strut graft is an important, commonly used method to increase nasal tip projection and rotation. This study discuss its benefit by prospective analysis of a group of patients in which strut graft was used and compare it with a control group using digitalized photographs. The aim of this study is to evaluate the benefit of columellar strut graft and its effect on nasal projection and rotation using digital images. Thirty two patients were treated with external rhinoplasty. Using their photographs, we analyzed the projection and rotation of the nose before and after operation. The patients were classified into two groups: group A included 18 patients who have strut and group B included 14 patients without strut. The analysis of the photos of the two groups was done with a computer program. By using Goode method, nasal tip projection decreases from 0.63 to 0.62 for patients using the strut, while in patients without strut nasal tip projection decreases from 0.64 to 0.61. Nasal tip rotation slightly increased in patients with strut graft from 99 to 99.5 degrees, while in those without the graft, nasal tip rotation markedly increased from 95 to 103 degrees. In conclusion, external rhinoplasty decreases nasal tip projection and the use of strut graft is unnecessary in increasing nasal tip projection but it helps in preserving the projection and slightly increasing nasal tip rotation. Keywords: Rhinoplasty, Graft, Strut, Columella, Nasal, Projection, Rotation

Abstract Unexpected difficult endotracheal intubation remains the main concern of anesthesiologists. This study aimed to compare validity and role of 7 bedside techniques of assessment used in predicting difficult intubation. This prospective study included 80 patients scheduled for surgery. Before induction of anesthesia, bedside tests for predicting difficult intubation were done, these tests are: Prayer sign, Thyromental distance, Mallampati test, The inter incisor distance, Palm print test, Upper lip bite test, and Wilson scoring system. During induction of anesthesia, laryngoscopic view was evaluated. Values for each test were calculated and compared. The results showed that, the highest sensitivity (62.5%) was for Mallampati and thyromental distance but despite that, they differed in their specificity and predictive values. Upper lip bite was 12.5% sensitive but had one of the highest specificity alongside with Mallampati test. Thyromental distance was 34.7% specific. Mallampati classes of more than class I was strongly associated with difficult intubation. The mouth gap of more than 4 cm was marginally associated with difficult intubation. The predictor Wilson showed a significant association with difficult intubation if the score exceeded 3.5. The upper lip bite of more than class I was slightly associated with difficult intubation. In conclusion, Mallampati classification and thyromental distance are superior to other available tests to predict difficult intubation, performing these two tests alone is relatively adequate to predict intubation difficulty. Keywords: Difficult endotracheal intubation, The inter incisor distance, Wilson scoring system, Mallampati test, Palm print test, Prayer sign, Upper lip bite test, and Thyromental distance.

Abstract Many blood conservation strategies were developed in the past decades to reduce risk of bleeding and the need for blood products among patients undergoing cardiac surgeries. This study was conducted to define the benefit of reinfusion of preoperative collected autologous blood in reduction of the risk of bleeding and the need for blood and blood products in comparison with tranexamic acid. This single centre single-blinded, randomized study was conducted in Erbil cardiac centre during the period from 1st of November 2018 to 30th of April 2019. A total of 150 patients were divided into three groups with 50 patients for each. The 1st group received nothing, the 2nd group received initially infusion of 200mg/hr of tranexamic acid until reaching 1.5gm/hr, and the 3rd group received one pint of preoperative auto-transfused whole blood. Data on risk of bleeding and the need for blood and blood products were collected using special questionnaire prepared for the reason of this study and were analyzed using appropriate statistical tests. Patients receiving autologous blood showed lower chest tube drainage than the other study groups with a p value of

PROMINENT EAR CORRECTION BY TWO PARALLEL INTERRUPTED FULL THICKNESS CARTILAGE INCISION LINES Mohammed Breesam Hatif@, Arwa Kasim* and Jabir R Hameed# @ MB,ChB, FICMS, Consultant Plastic & Reconstructive Surgeon, Al-Wasity Plastic and Reconstructive Surgery Teaching Hospital, Baghdad. * MB,ChB, FICMS, Plastic & Reconstructive Surgeon, Al-Karama General Teaching Hospital in Baghdad. # MB,ChB, FICMS, Consultant Plastic and Reconstructive Surgeon, Al-Sadir Teaching Hospital, Basrah, IRAQ. Abstract Prominent ear is the most common congenital ear deformity affecting 5% of children in western world and has profound psychological effects on the bearer. The most common causes of protruded external ear are: an under developed or flat antihelix, an over developed deep concha, or combination of both of these features. The aim of this study is to evaluate clinical outcome of otoplasty in prominent ears by two parallel interrupted full thickness cartilage incisions. from February 2015 to November 2018, a prospective study accomplished on 40 patients (74 ears), they were 32 males and 8 females. The condition was bilateral in 34 patients and unilateral in 6 patients. Surgery was done by a modification of combined methods of Mustarde and Furnas with partial resection of conchal cartilage . The preoperative helical rim, temporo-mastoid surface distance was 28-40 millimeters (mean 34.6 mm) and 10-15 mm postoperatively (mean 12.1 mm). The preoperative cephalo-auricular angle was 50-90 degrees (mean 75.4 degrees), and was kept at 20-25 degrees (mean 22.5 degrees) postoperatively. Good esthetic and satisfaction results were noted by the patients, their families, and the surgical staff. No complication had occurred and no one needed surgical revision. In conclusion, the procedure was found to be simple, easily applied with good esthetic and satisfaction results.

TRANSLIMBAL INTRAOCULAR ENDOILLUMINATION DURING CATARACT SURGERY Fareed Warid* and Maha Elshafei@ * MB,ChB, CABO, FRCS-Ed, Consultant Ophthalmologist, Department of Ophthalmology, College of Medicine, Basrah University, Basrah, IRAQ. @MD, FRCSI, Senior Consultant Ophthalmologist, Department of Ophthalmology, Hamad Medical Corporation, Doha, Qatar. Abstract The aim of this study is to describe a technique for intraoperative examination of macula and posterior capsule during phacoemulsification surgery in eyes with dense cataract. This work was done in Ophthalmology Department, Hamad Medical Corporation, Doha-Qatar on 36 patients (42 Eyes) with dense cataract and obscured fundus view. No data were recorded for macular status, and preoperative macular assessment was not conclusive by Ophthalmoscopy, B-Scan Ultrasound, and Optical Coherence Tomography (OCT). All patients were consented for cataract surgery plus additional vitreoretinal surgical procedure if indicated. Fundus examination done during phacoemulsification by translimbal insertion of endo-light probe after Irrigation/Aspiration step prior to lens implantation, capsular-bag expanded by viscoelastic to accommodate probe insert. Posterior capsule status checked by Endolight using microscope lens system only, macula checked by endolight with a vitreoretinal viewing lens system. Forty-two eyes (25 right and 17 left), (27 males, 15 females) in 39 patients were studied. The mean age was 59 years (47-78 years). Fourteen patients (18 eyes) were diabetics. Preoperative Visual Acuity of ≤6/60 was recorded in all patients. Cataract Density was graded by fundus visualization and in all cases, only shadow of optic disc and/or major vessels could be seen. Concurrent intravitreal injections was done in eight eyes (19%): seven of them were having Diabetic Macular Edema, and one has hemorrhagic Choroidal Neovascular Membrane (CNVM) due to age related macular degeneration. No complication was recorded in relation to Endoillumination. Posterior Capsule visualization was improved significantly and intracapsular lens implantation was done in all cases In conclusion, translimbal endo-illumination technique improved view to both Macula and posterior capsule during phacoemulsification with subsequent early surgical decision according to endolight findings. No extra incision required. 

Abdulkareem Jabbar Ghadban Al-Ebadi Consultant General & Laparoscopic Surgeon, MB,ChB, CABS, FACS, SAGES, Al-Sadr Teaching Hospital, Basrah, Iraq. Abstract Bile leakage is a very dangerous condition after laparoscopic cholecystectomy and may lead to fatal complications and serious care should be taken to diagnose the cause as early as possible because it may be sign of bile duct injury which is a major concern to the surgeons as if it is not diagnosed early, it will lead to dangerous complications such as biliary peritonitis, hepatic failure and even death. Early diagnosis is important to decrease morbidity and mortality. This study aimed to determine the incidence of bile leakage, its types of management and the outcome in patients with gall stone who are submitted to laparoscopic cholecystectomy. This prospective study was done in Basrah Al-Sadr Teaching Hospital in a two-year period from October 2013 to October 2015 on 560 patients, they were 378 females and 182 males. All of them have symptomatic gall stones and underwent laparoscopic cholecystectomy. All converted cases to open cholecystectomy were excluded. From the total number of 560 patients, nine patients developed bile leak in early post-operative period, 6 of them have drains and the other three have no drain and they were presented with signs and symptoms of intra-abdominal collection. The causes of leak were: common bile duct (CBD) injury in 2 cases, accessory duct in 3 patients, leak from the gall bladder bed in 3 cases and one case iatrogenic from intra-hepatic drain. All the patients were treated conservatively except the two patients with CBD injury who were treated; one with the aid endoscopic retrograde cholangio-pancreatography (ERCP) and the other by re-exploration. In conclusion, bile leak is a serious complication after laparoscopic cholecystectomy, although it is not common but it is important to identify the site of leak and should be treated urgently especially by drainage to avoid more severe results which may lead to increased morbidity and mortality

Jabir Raheem Hameed* and Ahmed Mohammed kohil@ *MB, ChB, FICMS, Consultant Plastic and Reconstructive Surgeon, Al-Sadr Teaching Hospital, Basrah. @MB, ChB, Candidate of CABMS Plastic and Reconstructive Surgery, Al-Sadr Teaching Hospital, Basrah, IRAQ. Abstract Keloid scar is one of the most challenging problems for physicians and surgeons. The current treatment of keloids is based on many ways and modalities which includes medical therapy, combined surgical excision with other modalities, physical treatment etc. The optimal curative treatment remains undefined. This study aimed to evaluate the effectiveness of the surgical excision combined with local infiltration of verapamil to treat patients with keloid. This prospective study involved 20 patients with keloid scars at different parts of the body. These keloid scars were surgically excised with local infiltration of Verapamil. This study was carried out at Al-Shaheed Ghazii Al-Harriri Hospital, Al-Wasity Hospital in Baghdad and Al-Sadr Teaching Hospital in Basrah Between January 2017 and May 2018. The age of the patients ranged between 11 to 44 years. Fourteen of them were females and 6 were males. After one year follow-up period, 11 patients had good results, 5 patients had moderate results and 4 patients had poor results. Patient’s satisfaction in those who had good results was excellent. No serious complications were recorded, only one patient got local wound dehiscence. In conclusion, surgical excision of keloid scar combined with post-surgical verapamil infiltration showed promising results in the management of keloid scar and reduction of its recurrence rate.

THE EFFECT OF LIMITED VERSUS EXTENDED AXILLARY LYMPH NODES DISSECTION IN THE DEVELOPMENT OF POST-MASTECTOMY MORBIDITY Ahmed N Abdulnabi MB,ChB, CABS, Specialist of General Surgery, AL-Fayhaa Teaching Hospital, Basrah, IRAQ. Abstract Breast cancer is a common malignancy in female, modified radical mastectomy is widely used for the management of this tumour. Axillary lymph nodes dissection is accompanied by frequent postoperative morbidity including wound infection, paresthesia, seroma and upper limb lymphedema. This is a comparative study that was conducted to evaluate the frequency of postoperative morbidity in a limited and extended axillary lymph nodes dissection. One hundred and fifty patients were treated by modified radical mastectomy for invasive ductal carcinoma of the breast between January 2008 and October 2015 in Al-Fayhaa Teaching Hospital. This sample was divided into two groups; the first fifty patients were managed with limited N1 axillary dissection while the other one hundred patients with extended N2 axillary dissection. The postoperative morbidity in the form of wound infection, paresthesia, seroma formation and upper limb lymphedema were analyzed in respect to the N1 or N2 axillary lymph nodes dissection. The highest occurrence was in the age group between 36 and 45 years. Wound infection develops in 16% of patients in the first group and 12% in the second group. Seroma occurred in 20% in the first group and 23% in the second group. Paresthesia was obviously higher in the second group (19%) when compared with 4% in the first group. Lymphedema occurred more in the second group (26%), and less in the first group (4%). In conclusion, limited axillary lymph nodes dissection during modified radical mastectomy for patients with no or few axillary lymph nodes involvement is associated with low postoperative morbidity. Key words: Mastectomy,Axillary lymph nodes,Morbidity, Limited dissection, Extended dissection

MULTINODULAR GOITER AND RISK OF MALIGNANCY, SURGERY OR FOLLOW UP ? Ali Yousif Alwajeeh@ & Abutalib Bader Al Luaibi* @MB,ChB, CABS, Consultant General Surgeon. MB,ChB, FIBMS, General Surgeon, Almawanee Teaching Hospital, Basrah, IRAQ. Abstract Nodular goiter is one of the most common presentation of thyroid gland diseases. The risk of development of thyroid cancer is relatively rare (1%) of all types of tumors, however, it is the most common endocrine malignancy, and usually presented as multinodular goiter. Fine needle aspiration cytology (FNAC) considered as the golden tool in the diagnosis of thyroid nodule though, it still has false negative rate which is variable depending on the experience and the technique being used. This means that even if the FNAC done prior to surgery shows negative finding, this doesn't exclude the presence of carcinoma, especially in multinodular goiter where it is possible not to sample the involved area. In this prospective study which was done in Almawanee Teaching Hospital between 2012-2018, 69 patients with Multinodular goiter where considered for the risk of harboring an incidental malignancy. The results of patients with multinodular goiter of benign origin was 57 patients (82.86%) while multinodular goiter which has an incidental malignancy was 12 patients (17.14%). Conclusion: due to relatively high risk of malignancy in multinodular goiter especially with noncompliance for follow-up from patients and risk of missing incidental malignancy by FNAC in multinodular goiter, it is preferable to do total or near total thyroidectomy. Key words: Goiter, Malignancy, FNAC, Surgery, Incidence

EVALUTION OF BILATERAL V-Y ROTATION ADVANCEMENT FLAPS FOR TREATMENT OF FINGERTIP AMPUTATION Jabir Raheem Hameed* and Roaa Hamed Mahmood@*MB, ChB, FICMS, Consultant Plastic and Reconstructive Surgeon, Al-Sadr Teaching Hospital, Basrah. @MB, ChB, Candidate of CABHS, Plastic and Reconstructive Surgery, Al-Sadr Teaching Hospital, Basrah, IRAQ. Abstract Fingertip amputation is the most common injury of the upper limb. The goals of treating it are; covering the defect, achieve sensibility, preserving the length of the finger by using durable coverage, obtaining the satisfactory aesthetic appearance and allow the patient for faster return to work. This study aimed to evaluate the use of bilateral V-Y rotation advancement flaps for the management of fingertip amputations with exposed bones and to assess the functional and aesthetic outcome. Between January 2017 and August 2018, bilateral V-Y rotation advancement flaps was performed on eleven male patients, average age 32 years, whose fingertip amputation with variable planes and zones. Patients were followed-up for at least 6-12 months. Twenty two flaps were made on 11 fingers, there was no partial or total flap loss. Patients had neither cold intolerance nor scar hypersensitivity, no obvious hook nail deformity apart of one patient. Because flap have neurovascular bundle inside it, so no change in sensation or perfusion occur postoperatively. In conclusion, the V-Y rotation advancement flap is simple, single stage operation that is optimum for surgical reconstruction of any fingertip injury. It provides a good contour, finger pulp coverage and acceptable appearance. Keywords: Fingertip. Amputation, Pulpa, V-Y flap, Reconstruction.

MANAGEMENT OF CRISES DURING ANESTHESIA AND SURGERY. PART XVI: HARMS LINKED TO DRUGS ADMINISTERED DURING ANESTHESIASalam N Asfar@ & Jasim M Salman# @MB,ChB, MSc, Professor of Anesthesiology, College of Medicine, University of Basrah. #MB,ChB, DA, FICMS, Assist. Prof. & Consultant Anesthesiologist, College of Medicine, University of Basrah, Basrah, IRAQ. Unpleasant drug incidents are common during medical action. In anesthetic practice, the probability of errors is greater because of more tension and rapidity. Morbidity and even mortality are more expected in the course of anesthesia. Apart from many hazards that patients are exposed to such as; Biological hazards, Mechanical hazards, Chemical hazards, Physical hazards, and Personal Hazards1, it seems that danger of drug problems are more.