Background Circumcision is the most common surgical procedure performed for a male newborn. This trial aimed to compare between three commonly used techniques for male circumcision in our institute. Patients and methods From January 2014 to January 2015, 150 babies were randomized into three groups according to the circumcision technique: babies circumcised using the bone-cutter forceps with thermal cautery (group I), Gomco clamp (group II), and the Plastibell device (group III). Intraoperative details, postoperative pain and complications, cosmetic outcome, and parent satisfaction were recorded. Results Operative time was significantly shorter for group I (P<0.001). Postoperative dressing was needed in 50% of infants in group II compared with 12% in group I. Analgesic consumption was significantly lower in group I (P<0.001). No significant differences were found between the three groups as regards the peer assessment score for the final cosmetic outcome. Parent satisfaction was significantly higher in groups I and II (P=0.023). Infection was reported only in the Plastibell device group, and 10% had device-related complications. Conclusion The thermal cautery with bone-cutter technique proved superiority in hemostasis, operative time, and parent satisfaction, with less pain in the postoperative period. All three techniques had comparable final cosmetic outcome.

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Objective The aim of this study was to evaluate the outcome of laparoscopic drainage (LD) of pelvic and paracolic abscesses not amenable to percutaneous or transrectal computed tomography-guided or ultrasound-guided drainage. Patients and methods Forty patients presented with a picture of acute abdomen. Radiological diagnosis defined 32 primary intra-abdominal abscesses and eight postoperative (PO) abscesses. After laparoscopic exploration, the abscess cavity was entered, and septa were cut down, drained, and irrigated using normal saline. The source of infection was managed if possible and then drains were inserted. Results Thirty-six patients underwent successful LD within a mean operative time of 94.3 min. Four patients required conversion to laparotomy for a conversion rate of 10%. Pain scores showed a gradual significant decrease. The mean duration of peritoneal drainage was 3.7±0.9 days and the mean PO hospital stay was 5.6±1.7 days. Three (8.3%) patients developed PO infection; two patients had a surgical wound infection at the umbilical port site and one patient developed recollection that required second-look LD of pelvic recollection. Two patients were died because of flare-up of an already present medical problem. Conclusion LD was a feasible, safe, and effective minimally invasive procedure for primary or secondary pelvic abscesses, with a conversion rate of 10%. No surgery-related mortality was encountered.

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Background and aim of the work Around 10–18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment can be provided as open cholecystectomy plus open CBD exploration, laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE), or precholecystectomy or postcholecystectomy endoscopic retrograde cholangio-pancreatography (ERCP) in two stages for CBD clearance. The aim of this study is to compare the CBD clearance rate by each procedure in a well-equipped tertiary center. Patients and methods A total of 250 patients with choledocholithiasis were included from the General Surgery Department, Sohag and Assiut University Hospitals, and managed randomly by either conventional surgery, endoscopic, or laparoscopic procedures. Results The ages of our patients ranged from 20 to 60 years (mean=40 years), with a slight female predominance (1.6 : 1); most of them presented with calcular obstruction (54.3%). However, there were also other presentations such as colic, cholangitis, or accidental discovery in 14.3, 10, and 21.5%, respectively. Patients were categorized randomly into three groups: group I included 100 patients (40%) who were treated by open choledocholithotomy and T-tube insertion; the operative time was 90 (60–180) min, with the success rate of the attempted procedures reaching 100%, and CBD clearance of stones was achieved in 95% of cases (five cases of missed stones). Hospital stay was 8 (5–12) days, with no mortality, and morbidity rate reached 15% in the form of wound infection, bile leak, and missed stone. The patient could return to work after 2 weeks (12–20 days). Group II included 100 patients (40%) treated by endoscopic sphincterotomy; basket extraction was performed in 45%, balloon in 25%, the combined maneuver in 15%, and mechanical lithotripsy in 13%, with failure of the technique in two cases (2%); the duration of the procedure was about 30 (20–45) min, with a success rate of attempted procedures of 98%, and CBD clearance of stones was achieved by 100%, with no mortality; the morbidity rate was 9% in the form of cholangitis (3%) and mild pancreatitis with hyperamylasemia (6%). The period of hospital stay was 1 (1–2) days and the patient returned to work after 3 (2–5) days. Group III included 50 patients (20%) treated by laparoscopic approaches: transcystic approaches in five cases and transcholedochotomy approaches in 45 cases. Choledochoscopic exploration was performed in almost all cases (45 cases) to detect, extract the stones, and test CBD clearance, and there was conversion to open techniques in one case. The time needed for this procedure was 123 (70–292) min, with CBD clearance of stones in 96% (two cases of missed stone), with no mortality, and a morbidity rate of about 10% in the form of mild hyperamylasemia, fever, and missed stone. The period of hospital stay was 3.2 (2–4) days, with return to work after 7 (5–10) days. Conclusion Both ERCP/LC and LCBDE were highly effective in CBD clearance, and equal in terms of the overall cost and patient acceptance. However, the overall duration of hospitalization was shorter for LCBDE with elimination of the potential risks of ERCP-associated pancreatitis, further procedures, and anesthesia risks. It is feasible, cost-effective, and ultimately should be available for most patients in each specialized center.

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Purpose The aim of this study was to evaluate the surgical outcome of circumareolar concentric skin excision for (grades 2b and 3) gynecomastia and its impact on the quality of life of these patients before and after surgery. Patients and methods Thirty male patients with bilateral gynecomastia (grades 2b and 3) were included in this study during the period from January 2012 to December 2014 at Benha University Hospital; all patients were operated upon by performing circumareolar doughnut skin excision for their Simon’s (grades 2b and 3) gynecomastia. Results There was an acceptable improvement in the shape and contour of the breast with significant patient’s satisfaction. No major offending operative or postoperative complications have been reported. Conclusion Although there are some possible complications associated with surgery, our case series demonstrates that with shrewd planning and careful patient selection, outcomes of operative correction can be favorable and yield high levels of satisfaction for both the patient and the surgeon.

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Introduction Indirect inguinal hernia has incidence of 0.8–4.4%. In female children, the hernia sac contains an ovary in approximately 20–25% of cases, and some also contain a fallopian tube. Different forms of injury to ovaries and fallopian tubes were reported in female children who had herniotomy. Patients and methods Prospective study to evaluate incidence and surgical importance of sliding ovary and fallopian tube in congenital inguinal hernia in female children at Menoufia university hospitals between March 2012 and August 2015 included 118 female children with 31 cases with bilateral hernia with total of 149 hernias. Results Hernias were bilateral in 31 (26.2%) children, 52 hernias were on the right side (44.1%), and 35(29.7%) were on the left. 18 cases (15.2%) presented with irreducible hernia; 15 of them were sliding hernia and the other 3 reduced spontaneously with induction of anesthesia. Overall sliding hernias with ovary and or fallopian tube were 52 of the 149 hernias (34.8%). Conclusion Sliding ovary and fallopian tube is not uncommon finding and it is found in nearly one third of congenital inguinal hernia in female children, so from a clinical point of view, it is of utmost importance to keep in mind this fact while dealing with hernia sac. Hernia sac should be opened in all cases to exclude the presence of sliding ovary and tube; and if present the sliding ovary and tube should be carefully dissected and reduced before ligation of the sac in order to avoid their injuries.

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Background Edema occurs because of trauma to tissues from an injury or a surgical procedure and is bothersome to both patients and treating physicians. The presence of edema is an initial component of the inflammatory response to tissue trauma. Chymotrypsin possesses potent anti-inflammatory properties that accelerate the reabsorption of inflammatory edemas as well as postoperative and post-traumatic hematomas and edemas. This study is a pioneer research to evaluate the efficacy and safety of α-chemotrypsin injection in postoperative and post-traumatic edema. Patients and methods A total of 529 patients with postoperative and postfracture edemas were recruited from three centers in Egypt (Orthopedic, Gynecology, and Surgery). Edema grades during visit 1 (V1) and visit 2 (V2) were evaluated and given scores from 1 to 4; their mean values were obtained and compared using the paired t-test for the overall sample, for each center, and by nature of edema (postoperative and post-traumatic). Results Of the 529 patients, 523 (98.9%) cases improved, six (1.1%) cases did not change, and the condition of no patient worsened. The mean edema grade score in V1 in the overall sample was 2.75, which decreased to 1.53 in V2 (P<0.001), with a percent change of −61%. There was a statistically significant difference in edema grade between V1 and V2. No adverse events or serious adverse events were reported during the study. Conclusion α-Chymotrypsin ampoules from Amoun are effective in lowering the edema grade and in managing patients with postoperative edema and postfracture edema as well.

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Context Pilonidal sinus PNS is a common condition. Although many methods for treatment are available, there is no consensus on the optimal treatment. Aim The aim of this study was to compare the results of a modified sinotomy method with those of lay-open, limited excision, and primary closure with and without a drain in the management of a PNS. Settings and design This is a prospective randomized comparative study. Patients and material Fifty-eight patients undergoing surgery for primary PNS were enrolled. The patients were randomized into three groups: group A (17 patients) underwent modified sinotomy; group B (22 patients) underwent lay-open, limited excision, and primary closure with a drain; and group C (19 patients) underwent the same procedure as group B but without a drain. Each patient was followed up for 24 months. Statistical analysis Continuous variables were expressed as mean±SD. Categorical variables were expressed as frequencies and percentage. Results Significantly short operative time was recorded in the modified sinotomy group. Postoperative wound complications occurred in 5.9% of patients in group A, in 31.8% of patients in B, and in 21.1% of patients in group C. Significantly short time was recorded between the completion of the procedure and the patient being able to walk, sit, and sit on a toilet comfortably, as well as be able to return to work, in group A; however, the healing duration was significantly longer. Visual analogue scale score showed significantly less pain in group A. Complete wound healing occurred in all patients in groups B and C, but one patient in group A developed failure of healing. Recurrence rate was a slightly higher in group B but with no statistical significance. Conclusion The modified sinotomy technique for treatment of PNS is superior to excision with primary closure either with or without a drain with respect to operative time, hospital stay, comfort in walking, sitting, and sitting on the toilet, return to work, and visual analogue scale scores for pain, although the healing time is longer.

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Background Although meshplasty has been established as the gold standard for ventral hernia repair, there is debate on the mesh-placement site. This study tried to compare onlay mesh placement with sublay meshplasty in terms of outcome. Patients and methods This is a prospective cross-armed study including 65 patients suffering from ventral hernias who were electively admitted to Sohag University Hospital between October 2013 and November 2014. Patients were randomly allocated to two groups: group A included 32 patients who underwent onlay meshplasty and group B included 33 patients who underwent sublay meshplasty. Patients were evaluated with respect to the outcome of both techniques and statistically analyzed after 2 years of follow-up. Results Regarding the operative and postoperative outcomes, the operative time was longer in group B, which was highly significant (P≤0.001). Postoperative wound pain was less in group B, which was significant (P=0.018). Regarding early postoperative complications, postoperative superficial infection (P=0.050) and hematoma formation (P=0.033) were significantly less in group B. Seroma formation was also significantly less in group B (P=0.050). The mean duration of postoperative hospital stay was shorter in group B and this was highly significant (P<0.001). During follow-up, recurrence was seen in group A, which was statistically significant (P=0.015). Conclusion Sublay meshplasty, when feasible, is superior to onlay mesh placement for open ventral hernia repair.

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Background Clinical scores were designed to improve the diagnostic accuracy (DA) of acute appendicitis. However, their results vary when applied in different populations. This study aimed to compare the validity of the Modified Alvarado Score (MAS) with the Raja Isteri Pengiran Anak Saleha (RIPASA) score for diagnosing acute appendicitis in adult Saudi population. Materials and methods This study followed a prospective study design. It was carried out in Aseer Central Hospital, Abha, Saudi Arabia, during the period from November 2014 to May 2015. The study included 60 (aged >13 years) patients who were admitted in the Emergency Department and were clinically diagnosed as having acute appendicitis. Both the MAS and the RIPASA score were applied. A cutoff value for positive MAS was more than or equal to 7, and it was of at least 7.5 for positive RIPASA score. Surgical team members were blinded to the results of both scores. Operative findings describing the appendix, postoperative complications, hospital stay, and final diagnosis by histopathology were recorded. Results The study included 60 patients. There were 17 (28.3%) male and 43 (71.7%) female patients, with a mean age of 23.3±9.7 years. Negative appendectomy rate was 13.3%. The mean duration of hospital stay was 2.39±1.67 days. The MAS showed poor sensitivity (59.6%), poor DA (63.3%), and good specificity (87.5%). Compared with the MAS, the RIPASA score showed better sensitivity (96.2%) and DA (85.0%) when applied to our patients. Conclusion Neither the RIPASA score nor the MAS seems ideal for the accurate diagnosis of acute appendicitis when applied to patients in the southern region of Saudi Arabia.

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Context Open appendectomy is the standard procedure for complicated appendicitis and is associated with an increased incidence of postoperative complications. Recently, laparoscopic approach for complicated appendicitis has been gaining ground against the open approach. Some studies still favor the open approach while others advocate the laparoscopic approach. Aim The present study aimed to compare the laparoscopic approach with the open approach in the management of patients with complicated appendicitis, and their postoperative complications. Settings and design This was a prospective, randomized, comparative study. Patients and methods Eighty-eight patients were included in the study and were divided into the laparoscopic group (33 patients) and the open group (55 patients). Each group was further divided into five subgroups according to the operative findings. All patients were monitored for early and late postoperative complications and followed up in the outpatient clinic for 6 months. The operative time, rate of conversion, drain application, early and late complications, frequency of analgesia, time to start oral feeding, length of hospital stay, and time of returning to normal daily activity were all recorded. Statistical analysis Continuous variables were expressed as mean and SD. Categorical variables were expressed as frequencies and percentage. Results The open group showed less operative time. Patients in the laparoscopic group needed less analgesia, with early return of the bowel habits and early start of oral feeding. They also had shorter hospital stay and early return to the normal activities. The laparoscopic group had less postoperative complication in comparison with the open group. Conclusion The laparoscopic appendectomy was found to be better in comparison with the open approach as it involved less postoperative pain, shorter hospital stay, and fewer postoperative complications in addition to the possibility of exploring the whole abdomen.

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Background/purpose Hypospadias is a congenital penile defect in which the urethra opens into the ventral part of the penis, scrotum, or perineum. Hypospadias surgery is performed in children where losses of even minimal amounts of blood are of concern. The two commonly used methods to achieve hemostasis are vasoconstrictive agents and the bipolar and application of a penile tourniquet. The aim of this study is to compare the outcome of using vasoconstrictors and bipolar diathermy without tourniquet versus the use of tourniquet and bipolar diathermy to obtain hemostasis during hypospadias repair in children. Patients and methods This prospective study was carried out at 4 different pediatric surgery units, during the period from April 2012 to September 2014. The study included 60 uncircumcised boys with mid penile, distal penile or coronal hypospadias with ages ranging between 6 months and three years. Recurrent hypospadias, proximal penile hypospadias and patient had sickle cell disease or sickle cell trait was excluded from this study. Standardized proformas were used to allot patients to two treatment groups. Group A, included 30 patients in whom the tourniquet, rolled rubber glove, was applied around the base of the penis during operations to control bleeding. Group B, included 30 cases, in whom the operation was performed without tourniquet and hemostasis was obtained by preoperative infiltration of the incision site with adrenaline and bipolar cautery throughout the procedure. Results The operative time ranged from 66–85 minutes (mean 76.66 ± 21.50) in group A, while in group B it was 79–95 minutes (mean 88.50 ± 29.40). The difference between the two groups was statistically significant. Early Postoperative hematomas occurred in 13.3% of group A and 6.6% of group B patients respectively. The rate of fistula formation was higher in group B patients than group A (10% and 6.6% respectively). One patient developed urethral stricture in group A and two cases in group B. Metal stenosis was higher in group A than group B, (6.6% and 3.3% respectively). However, there was no significant statistical difference between both groups as regard the post-operative complications. Conclusion Use of tourniquets as hemostatic technique is a good option in hypospadias surgery. It facilitates the surgical technique and gives clear field to the surgeon so reduces the operating time.

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Background Patients with complete occlusive lesions of the infrainguinal, and more frequently infragenicular, arteries have comorbid diseases that favor the endovascular option for treatment. In those patients the retrograde transtibial approach is suggested when the antegrade approach fails. This study aimed to describe the feasibility and complications of this approach. Patients and methods The retrograde transtibial approach was used, after a failed trial with the antegrade approach, in 29 patients suffering from severe chronic lower-limb ischemia. Success in accessing the tibial arteries, crossing the lesion, effectively dilating the occluded lesions, patency up to 6 months, and complication rate were measured. Results In all patients one of the tibial arteries was successfully accessed and the lesion was crossed. Postdilatation contrast study confirmed successful dilatation, which was maintained for 6 months, with no significant complications. Conclusion The retrograde transtibial approach is a feasible and safe alternative in treating infrainguinal arterial lesions when the antegrade approach fails or cannot be used.

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Intussusception is a rare cause of intestinal obstruction in adults and is usually secondary to malignant neoplasms as the pathologic leading point. We present a case of ileocolic intussusception in an adult caused by a large pedunculated cecal lipoma and mobile cecum. The patient was a 45-year-old woman with 3 weeks’ history of colicky abdominal pain, hematochezia, and alternating bowel habits. Computed tomography of the abdomen revealed ileocolic intussusception with 7×5 cm low-density mass in the cecum. Right hemicolectomy was performed, and histopathological examination of the specimen confirmed the diagnosis of a subserosal cecal lipoma.

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Ileal pouch anal anastomosis is a commonly performed procedure. The operation can be completed in one stage, two stages, or three stages depending on the general condition of the patient and the local condition of the bowel. The J pouch is the most commonly performed pouch design. After construction, the pouch mesentery can be short, necessitating ligation and division of the superior mesenteric pedicel to allow the pouch reach the anal canal at ease. In this case, the ileocolic pedicle should be intact to give alternative blood supply to the newly constructed pouch. The ileocolic pedicle can be inadvertently injured during dissection to take down the ileostomy in the second stage of a three-stage operation. This can risk the pouch integrity in case the superior mesenteric pedicle needs to be divided. We are describing a method to avoid such inadvertent ileocolic vessel injury. After adopting this method, we did not have a single incident of ileocolic vessel injury in the second stage of a three-stage ileal pouch anal anastomosis.

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Background Total thyroidectomy for controlled toxic goiter is usually associated with more bleeding because of high vascularity of the toxic gland. Several new instruments were developed as hemostatic tools (harmonic scalpel; LigaSure) during total thyroidectomy as an alternative to conventional hemostatic methods. This study aimed to compare the use of Harmonic Focus Scalpel to conventional hemostatic technique (classic suture ligation with standard bipolar diathermy forceps) in patients with controlled toxic goiter undergoing total thyroidectomy regarding operative time, intraoperative complications, postoperative complications, postoperative hospital stay, and return to normal daily activities. Patients and methods The present study included 50 patients with a diagnosis of controlled toxic goiter who underwent total thyroidectomy at the Department of Surgery, Medical Research Institute Hospital, Alexandria University. Candidates were randomized into two groups: group A, in which patients underwent total thyroidectomy using Harmonic Focus Scalpel, and group B, in which patients underwent total thyroidectomy using classic suture ligation and standard reusable bipolar diathermy. Results There was no significant difference between both groups regarding preoperative data (age, sex, comorbidities, and type of thyrotoxicosis). The operative time was significantly shorter in group A patients compared with group B patients (P<0.001). Both groups were comparable to each other with regard to intraoperative blood loss, postoperative transient and permanent vocal cord paresis, transient and permanent hypocalcemia, postoperative hematomas and bleeding requiring surgery, hospital stay, timing of drain removal, and return to normal daily activities. Conclusion Harmonic Focus Scalpel can be used safely and effectively as a hemostatic tool instead of conventional hemostatic techniques in total thyroidectomy for controlled toxic goiter.

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