Background Parotidectomy was first introduced into the world literature by Berard in 1823 who removed a parotid tumor of 8 years' duration. Since then the procedure has been modified and applied to a variety of benign and malignant conditions affecting the gland; superficial parotidectomy, subtotal parotidectomy, and total parotidectomy are now the options available to the head and neck surgeon. The primary goal of parotid surgery is the complete removal of tumors while preserving facial nerve function. Despite efforts to preserve the anatomic and functional integrity of the facial nerve, facial nerve paralysis continues to be a daunting complication of parotidectomy. Purpose The aim of the study was to evaluate our experience in parotid surgery, aiming to lower the incidence of facial nerve palsy and study postoperative complications. Patients and methods This prospective study was conducted on 30 patients from July 2012 to June 2013 with parotid swelling persistent over 1 year; patients were submitted to careful history taking, complete clinical examination, and examination of facial nerve integrity before surgery. Over a period of 1 year these 30 patients with parotid swelling underwent parotidectomy by means of an antegrade technique of whom 26 underwent superficial conservative parotidectomy (nine men and 17 women) and four underwent total conservative parotidectomy (two men and two women). Results Most patients (26) underwent superficial conservative parotidectomy. Four patients underwent total conservative parotidectomy with excision of the superficial lobe, dissection of facial nerve branches, and excision of the deep lobe of the gland from between the branches of the facial nerve. In our study population (30) 10 patients had temporary facial nerve paralysis (33.3%) of whom five were HB II (16.7%), three were House-brackmann Scale HB III (10%), and two were HB IV (6.6%). Conclusion In our study, we adopted certain precautions to lower the incidence of temporary facial nerve paresis. One of these precautions is vertical retraction to reduce the risk of traction injury. Once the nerve trunk was identified we did not use diathermy at all; hemostasis was performed with surgical ligatures (5/0 polygalactin).

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A 65-year-old woman was admitted with a complaint of a constant dull aching pain in the epigastrium for 4 days, with subsequent worsening and generalization of the pain. Clinically the abdomen was tender all over with board-like rigidity. Chest radiography revealed pneumoperitoneum and a decision was made to explore the patient. During laparotomy we found mild peritoneal collection with no perforation in the anterior surface of the stomach, duodenum, or the entire gastrointestinal tract. After opening the gastrocolic omentum, we found a large perforation of the posterior wall of the stomach. After direct repair with an omental patch, the patient recovered and was discharged after 14 days, with only wound infection. Posterior perforation of a gastric ulcer is a very rare condition.

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Background Milligan Morgan (MM) hemorrhoidectomy is associated with significant postoperative pain and late return to daily activities. Doppler-guided hemorrhoid artery ligation with recto-anal repair (DG-HAL with RAR) is a minimal-invasive surgical treatment for hemorrhoids that has been used as an alternative method in order to reduce these inconveniences. Objective The aim of this study was to compare the results of the two procedures in the management of grade IV hemorrhoids. Methods This prospective, randomized, clinical study was carried out between June 2011 and June 2015. It included 126 patients with grade IV hemorrhoids, who were divided into two equal groups: group A, in which 63 patients were operated for DG-HAL with RAR; and group B, in which 63 patients were operated for MM hemorrhoidectomy. Patients were evaluated preoperatively and postoperatively at 1 week, 1 month, 6 months, and 1 year. The follow-up period was 1 year. Results The mean age was higher in group A patients (P = 0.003). The operative time was significantly longer in group A (P > 0.001). The first defecation occurred sooner in group A (P = 0.006) than in group B. The mean hospital stay was significantly shorter in group A (P > 0.001). Moreover, the return to work was achieved significantly earlier in group A (P > 0.001). The postoperative pain score (visual analog scale) was significantly less in group A patients, especially during defecation (P > 0.001). The postoperative consumption of class II and III analgesics was significantly less in group A than in group B (P > 0.005). After 1 year of follow-up, there were no significant differences between the two groups as regards postoperative complications, recurrent prolapse, anorectal function, and fecal continence. Conclusion DG-HAL with RAR is an effective minimal-invasive procedure with results comparable to MM hemorrhoidectomy for the treatment of grade IV hemorrhoids with fewer complications, less postoperative pain, shorter hospital stay, and earlier return to work.

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Background Peptic ulcer perforation is an emergency and requires urgent surgical treatment. In spite of rare incidence of elective surgery for duodenal ulcer, frequency of emergency operations is on the rise. Objective This study is aimed at comparing success rate between Graham’s omentopexy (GO) and modified-Graham’s omentopexy (MGO) as an emergency management technique for duodenal perforation. Patients and methods A prospective study was carried out for 2 years with 80 patients. GO was done in 40 patients and 40 patients underwent MGO between March 2015 and March 2017 in the Department of Surgery in Aswan University. Data regarding age, sex, time elapsed between onset of symptoms and hospital admission, comorbid diseases, morbidity, and mortality were recorded. Results MGO was associated with longer operative time, but the incidence of reperforation is less than GO. Mean hospital stay in GO group is higher than MGO group. Conclusion Graham’s patch repair is as effective as modified-Graham’s patch repair in terms of morbidity and mortality. There is no statistically significant difference in undergoing either procedure for repair.

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Background: The thyroglossal duct cyst (TDC) results from a failure of complete obliteration of thyroglossal duct. It represents the most common type of developmental cyst seen in the neck region. Objective: Evaluate our experience in the management of primary and recurrent thyroglossal cyst and fistula and to determine the role of pre- and postoperative infection as an important factor associated with thyroglossal duct recurrence after surgery. Methods: During the period from January 2013- April 2014, in General and Pediatric Surgery Department, 50 patients with thyroglossal duct cyst (35 patients) and fistulae (15 patients) were diagnosed and treated. All records were reviewed for age and sex, diagnostic methods, surgical management and postoperative infection and recurrences. Results: The recurrence rate was high in cases with infection occurred preoperative or postoperative. Conclusion: Infection very important leading factor for recurrence of thyroglossal cyst.

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Purpose There is no doubt that cholecystectomy relieves presurgical symptoms of gallbladder (GB) disease. The persistence of symptoms following cholecystectomy is termed as postocolecystectomy syndrome, the incidence of which ranges from 10 to 30%. The present study was conducted to evaluate patients who had a residual GB stone/cystic duct stump stone after cholecystectomy, and to study the surgical outcomes. Patients and methods This retrospective study was conducted on 21 cases with residual GB/cystic duct stump stone. The diagnosis was guided by ultrasound and magnetic resonance cholangiopancreatography. All the cases were managed by using completion cholecystectomy − either open or laparoscopic. All preoperative, operative, and postoperative data were collected. Results Preoperative endoscopic retrograde cholangiopancreatography and papillotomy were required in nine cases that presented with obstructive jaundice. Laparoscopic completion cholecystecomy was feasible in 14 cases. The conversion rate was 1/14 cases. The mean operative time was 127±31.3?min and the mean blood loss was 165±74.5?ml. Intraoperative minor biliary injury occurred in one case. The mean hospital stay was 3.1±1.8 days (1–9 days). All patients were reported to be symptom-free at the follow-up after surgery. Conclusion Residual GB/cystic duct stump stone is a preventable and correctable cause of postocolecystectomy syndrome. Completion cholecystectomy is a proven treatment of choice to relieve symptoms and avoid complications, and, furthermore, it can be carried out laparoscopically.

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Background Cervical lymphadenopathy is usually defined as cervical lymph nodal tissue measuring more than 1 cm in diameter, and can be caused by benign local or generalized infection, but occasionally, it might herald the presence of a more serious disorder such as malignancy. Cervical lymphadenopathy can be soft, firm, or stony hard according to the disease process by which they involved. Clinical examination, radiological studies, and biopsies can lead to a definitive diagnosis. Aim This work aimed to study in detail the results of cervical lymphadenopathy that was removed surgically, and its value in detecting pulmonary diseases (i.e. to analyze the pathological spectrum of variant benign or malignant diseases affecting the cervical lymph node). Patients and methods This was a prospective and retrospective study of 32 patients who presented with respiratory symptoms discovered during a physical examination to have cervical lymphadenopathy, were admitted, and were treated surgically at Al-Shaheed Ghazi El-Hareri Hospital of the Medical City Teaching Complex during the period from 1 July 2014 to 30 June 2015. Proper assessment of history and clinical examination, in addition to radiological studies and biopsy analysis, were performed to analyze the causes of cervical lymphadenopathy. Results Twenty-one of our patients were males; the remaining 11 patients were females. The youngest patient was a 10-year-old male and the oldest patient was a 50-year-old male. Fever was the most common presenting feature in 26 patients. All patients were referred for neck ultrasound to detect the size of the enlarged nodes; 23 patients had a lymph node diameter of more than 1 cm. Chest radiography was performed for all patients; it was found that 22 patients had central lesions (closed to the hilum). Computed tomography-chest showed pleural effusion in 18 patients, lung masses in 16 patients, and mediastinal masses in nine patients. Conclusion Cervical lymph node involvement has a major impact on the prognosis and treatment decision in patients with pulmonary malignancy.

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Background Abdominal wall reconstruction after huge incisional hernias considered one of challenges that face surgeons, component separations, either anterior component separation (ACS) or posterior component separation (PCS) with transversus abdominus release (TAR), are novel and less expensive solutions for this problem. Aim This prospective randomized trial compares the results of ACS procedure versus PCS with TAR in repair of incisional hernias. Patients and methods This study included 40 patients who underwent surgical repair for midline incisional hernias with defects larger than 5 cm in width between March 2016 and October 2017 at Ain Shams University Hospitals. Patients were randomly assigned to surgical procedures. Patients in group Ι (n=20) underwent ACS, and patients in group II (n=20) underwent PCS with TAR. Results In group Ι (ACS), wound morbidity significantly exceeded that in group II (PCS with TAR) such that 10 (50%) patients in group I developed surgical wound infection compared with four (20%) patients in group II. Regarding wound dehiscence, seven patients in group I had this sequel, whereas two patients in group II had wound dehiscence. Hernia recurrence occurred in seven (35%) patients in group I, but only one (5%) patient in group II developed this. Conclusion PCS with TAR provides equivalent myofascial advancement with significantly less wound morbidity and recurrence rate when compared with ACS.

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Background Laparoscopic sleeve gastrectomy (LSG) is considered as one of the most popular bariatric procedures worldwide. Although LSG appears simple, there is still no standard procedure across different surgical teams. The most debatable issue in sleeve gastrectomy is the gastric pouch size; by changing the size of the bougie, we can create different volumes of the stomach tube. Aim The aim was to compare the outcome following LSG results when using 32 versus 40-Fr bougie as regards the effects of each on the clinical outcome: weight loss of the patients and possible complications. Patients and methods Our study is a prospective, comparative study of 60 patients, who underwent LSG between ‘March 2015 and March 2016’ with a 1-year follow-up. The patients were classified into two groups: group A (n=30) who underwent LSG using a bougie size of 32 Fr and group B (n=30) who underwent LSG using a bougie size of 40 Fr. We recorded the operative time, hospital stay, and intraoperative and postoperative complications. Results A total of 60 patients [17 (28.3%) men and 43 (71.7%) women] underwent LSG. Patients had a mean age of 35±10 years (range: 18–58 years). The mean;Deg;BM;Deg;I was 46.66±4.30 kg/m² (range: 34.6–57.5 kg/m²); the duration of hospital stay in group A was 56±28.07 h, with group B being 36.4±10.68. As regards the weight loss both groups had the same excess weight loss over 1 year; postoperative persistent vomiting was in favor of group A with four (13.3%) patients, two of them required intervention either by endoscopy or conversion to bypass, in comparison to one patient in group B who was managed conservatively. Conclusion The use of bougie size 32 Fr did not result in significant excess weight loss differences than bougie size 40 Fr; however, more complications were observed.

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Background It has been clinically observed that posthaemorrhoidectomy pain is the most feared symptom by the patient, often leading to avoiding surgery altogether. Opioids and NSAIDs are used to control posthaemorrhoidectomy pain, but they have short duration of action and well-known side effects and may be expensive. These factors justify the need to search for new treatments to decrease posthaemorrhoidectomy pain. Patients and methods A total of 90 patients who had undergone surgery for third-degree and fourth-degree haemorrhoids were included in this prospective, randomized, controlled and double-blinded study. The patients were randomly assigned to two groups. Group A received topical sucralfate in petrolatum base and group B received plain petrolatum base. Patients were evaluated at days 1, 7 and 14 for the severity of pain (using the visual analogue pain scale) and for the amount of analgesia used. On day 28 patients were evaluated for wound healing. Results Patients in the sucralfate group suffered significantly less pain and required less analgesics (narcotic and nonsteroidal) on days 1, 7 and 14 postoperatively (P < 0.001). Also, the rate of wound healing was significantly better in the sucralfate group (37/45) than in the control group (28/45) (P < 0.05). Conclusion Topical sucralfate ointment significantly decreases pain at days 1, 7 and 14 after haemorrhoidectomy and significantly accelerates wound healing.

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Objective The aim of this study was to evaluate and compare clinical safety and efficacy after Bascom's cleft lift and rhomboid flap (Limberg) procedures for the treatment of primary sacrococcygeal pilonidal sinus (SCPS). Patients and methods This study included 100 adult patients with primary (nonrecurrent) SCPS who were randomized to Bascom's cleft lift procedure (n = 50) or to rhomboid flap procedure (rhomboid-shaped excision and Limberg flap) (n = 50). Through the follow-up period, which ranged from 6 to 12 months, with an average of 9.1 ± 1.7 months, patients were evaluated for wound-related complications and recurrence of symptoms after complete wound healing. Results There were insignificant differences in the baseline characteristics between both groups. Compared with Bascom's cleft lift procedure, the rhomboid flap procedure involved a longer duration of operation (61.14 ± 16.36 vs. 40.78 ± 11.96 min; P < 0.001). A significant clinical outcome was achieved after the rhomboid flap procedure in terms of less duration to pain relief (12.42 ± 1.59 vs. 17.86 ± 3.10; P < 0.001) and less healing time (17.42 ± 4.68 vs. 20.06 ± 5.94; P < 0.05). The incidences of postoperative wound-related complications and recurrence were 6 and 2%, respectively, after the Bascom's cleft lift procedure and 4 and 2%, respectively, after the rhomboid flap procedure, with insignificant differences. Conclusion Although Bascom's cleft lift operation involves a shorter duration of operation, the rhomboid-shaped excision with the Limberg flap procedure was superior in terms of early wound healing, with similar incidences of wound-related complications and recurrence after treatment of primary SCPS.

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Introduction Pilonidal sinus disease is a chronic, recurrent disorder of the sacrococcygeal region, which commonly occurs in young adults following puberty. The male population is affected more frequently compared with the female population. A large number of surgical techniques (with varying complexity) have been described in the literature for the treatment of this disease. Such diversity suggests that no single technique has emerged as the preferred method in preventing recurrence of this condition. Objectives The aim of this study was to compare karydakis lateral flap technique with open technique in the treatment of noncomplicated pilonidal sinus. Patients and methods A total of 70 patients with uncomplicated pilonidal sinus, attending Minoufiya University Hospital and other private hospitals, were included in this study. They were divided into two groups: the karydakis group and the open procedure group. Results A total of 57 male and 13 female patients were included in this study. The mean operative time in the karydakis and the open group was 45 ± 7.27 and 23.4 ± 4 min, respectively. There was a significantly lower rate of wound infection in the karydakis group. Two patients (5.7%) showed recurrence in the karydakis group, whereas eight patients (22.8%) had recurrence in the open group. There was no significant difference between the two groups as regards scar pain and numbness (P > 0.05), but there was a significantly lower recurrence rate in the karydakis group (P = 0.022). The healing time and duration of work-off was significantly shorter in the karydakis group (P < 0.001). Conclusion Karydakis technique showed shorter hospital stay, earlier healing, shorter duration of work-off, and lower rate of complications compared with the open technique.

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Introduction Many surgeons treat pilonidal sinus (PNS) by wide excision, leaving a lay open or a primary sutured midline wound. Others use more sophisticated techniques such as skin flap reconstruction. Objectives The aim of the study was to determine the method of excising PNS minimally under local anesthesia and study its subsequent effects on wound closure and the healing process. Patients and methods This prospective study was carried out on 30 consecutive patients with primary nonrecurrent sacrococcygeal PNS. All patients were treated surgically with minimal excision and primary closure under local anesthesia. Parameters of follow-up included wound seroma, infection, or disruption, in addition to pain, difficulty in mobilization, time off work, and recurrence. Results The mean operative time was 38 min. Hospital stay ranged from 2 to 4 h. Healing time was 14-20 days. Three cases presented with wound seroma. One patient had a wound infection. One patient had significant wound infection and wound disruption; this patient had a recurrence after 6 months, which was treated with wide excision and rhomboid flap reconstruction. Conclusion Minimal excision and primary closure for uncomplicated cases of PNS under local anesthesia is a safe and easy operative procedure with shorter operative time, short duration of hospital stay, less postoperative time off work, low complication rates, and low chances of recurrence.

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Objective The aim of the study was to determine the best technique for surgical treatment of chronic anal fissure in female patients. Study designs The study was designed as a prospective randomized study. Place and duration of study The study was conducted in Surgical Unit, Al Kuwait University Hospital and Al Huribi Hospital (Sana'a, Yemen) from January 2007 to December 2010. Patients and methods A total of 205 female patients undergoing surgery were divided into two groups. In group A, there were 100 patients who were treated by closed lateral internal anal sphincterotomy, and in group B there were 105 patients who were managed by open lateral internal anal sphincterotomy method. Patients were followed up for 6 months following surgery to observe for pain, bleeding, infection, incontinence, and recurrence. The exclusion criteria were patients who had in addition hemorrhoids or any other anorectal diseases. Results There was acceptable difference in postoperative acute complications between the two methods of internal anal sphincterotomy. However, in group A, six patients (6%) were complicated with very low anal fistula postoperatively, whereas the recurrence rate was 6 versus 1.9% in group A versus group B, respectively (P = 0.015). Conclusion Lateral internal sphincterotomy either with open or closed method is the treatment of choice for chronic anal fissure in female patients and can be performed effectively and safely with acceptable rate of complications; however, the open method is considered to have less morbidity and rate of recurrence.

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Background/aim The use of splenectomy for thalassemia major is restricted over concerns of its long-term outcome. The aim of this study was to assess the long-term outcomes of splenectomy for patients with β-thalassemia major. Patients and methods This study included 70 patients with β-thalassemia major. Patients were classified into two groups: 35 patients underwent splenectomy (S group) and 35 patients did not undergo splenectomy (NS group). Patients were assessed by review of medical records, assessment of medical history, and a clinical examination. In addition to complete blood count, liver function tests and serum ferritin were performed. Assessment of lymphocyte populations was carried out by flow cytometry. These investigations were performed at least 2 years after splenectomy in the S group. Results The mean age of the patients who underwent splenectomy was 6.68 ± 2.54 years and the mean postoperative follow-up period was 6.26 ± 3.03 years. Splenectomy improves anemia, but does not reduce iron burden; more patients were found to be on regular iron chelation after splenectomy. Hematocrit and red blood cell indices were significantly increased after splenectomy. Platelet count increased significantly in the S group (644.700 ± 299.400/mm ³ ). There were no significant differences in T-lymphocyte populations between both groups. IgM memory B lymphocytes were lower in the S group compared with the NS group. No overwhelming postsplenectomy infection was reported in this series. Postsplenectomy portal vein thrombosis was reported in one (2.9%) case. Conclusion With long-term follow-up after splenectomy for treatment of thalassemia major, thrombocytosis and the risk of thromboembolic persist. Splenectomy improves anemia, but does not reduce iron burden or the requirement for blood transfusion. Proper preoperative vaccination can reduce the risk of overwhelming postsplenectomy infection.

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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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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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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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Introduction Appendectomy is one of the commonest operations performed annually. Despite the advancement in the laboratory tests and radiological tests, still the rate of negative appendectomies is 15-30%. This study was designed to assess the diagnostic value of quantitative C-reactive protein (CRP) and white blood cell count (WCC) in patients suspected to have acute appendicitis. Patients and methods Our study is a prospective study that was conducted between December 2012 and March 2013 after approval of the ethical committee. Inclusion criteria

1. Patients with clinically diagnosed acute appendicitis without generalized peritonitis.

Exclusion criteria

1. Patients with generalized peritonitis

All patients were subjected to the following

1. Clinical examination
2. Routine bloods immediately after decision to admit including full blood count and CRP.
3. Urine test
4. Pregnancy test for all females
5. Ultra sound scan to rule out other causes of abdominal pain

All the patients were operated upon via open approach and the appendix was sent for histopathological analysis and the results were compared with C-Reactive protein (CRP) and the WBC (White blood cell count) and the results were compared using t-tests. Results Our study recruited 100 patients, 60 males (60%) and 40 females (40%), in the age range 20-55 years. The histopathological analysis showed acute appendicitis in 85 patients (85%), the operative notes showed 60 patients with noncomplicated appendicitis, 25 patients with complicated appendicitis; the WCC alone has a sensitivity of 85%, specificity of 75%, CRP alone has a sensitivity of 93.3% and specificity of 86.6%, WCC alone had positive predictive value of 44% and it improves to 70% when both parameters are combined together, whereas the negative predictive value of the WCC was 100%. In patients with normal appendix the mean CRP level was 10.6 mg/l, the median level was 10.6 mg/l, and the mean WCC was 8 Χ 10 ⁹ cells/l, the median WCC 7 Χ 10 ⁹ cells/l, whereas in patients with noncomplicated acute appendicitis (n = 60) the mean CRP was 40 mg/l, the median was 20 mg/l; in patients with complicated appendicitis (n = 25) the mean CRP was 90 mg/l and the median was CRP 60 mg/l. Conclusion We suggest that patients experiencing lower abdominal pain, with normal CRP values and normal WCC are unlikely to have acute appendicitis and need further investigations before embarking onto surgery.

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Background Umbilical herniorrhaphy in cirrhotic patients with ascites is not usually done due to high postoperative morbidity and mortality rates. However, recent reports recommending elective surgery in these patients with perioperative preparation will result in good and safe outcome to avoid emergent repair later on. The aim of this study was to evaluate the outcome of umbilical herniorrhaphy in patients with liver cirrhosis and ascites regarding postoperative morbidity and mortality. Patients and methods A retrospective study was done on 102 patients with umbilical hernia and ascites in the period between March 2014 and April 2017 who had undergone surgical repair either electively or emergently at Tanta University Hospital. Patient characteristics, morbidity, and mortality are recorded. Results Seventy-two men and 30 women with a mean age of 51.3 years were analyzed. Eighteen (17.6%) patients were of Child–Pugh–Turcotte (CPT) class A, 54 (53%) patients were of class B, and 30 (29.4%) patients were of class C. The patients had a model for end-stage liver disease score of 16.23. Fifty-seven patients underwent elective operations while 45 patients underwent emergency surgery of whom 24 patients had incarceration, 12 cases had rupture of the hernia sac, and nine cases had skin ulceration or necrosis. Primary repair was done in 60 (58.8%) patients and meshes were used in 42 (41.2%) patients. The morbidity and mortality rates were 37.2% (n=38) and 3.9% (n=4), respectively. Conclusion Elective repair of umbilical hernia can be performed easily and safely in cirrhotic patients with ascites with good perioperative preparation with better results than emergent repair.

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Background Burst abdomen represents one of the most frustrating and difficult postoperative complications encountered by surgeons who perform a significant volume of surgery. Burst abdomen occurs because of various preoperative, operative and postoperative factors, which can be prevented to some extent by being aware of them. The choice of incision for laparotomy depends on the area that needs to be exposed, the elective or emergency nature of the operation, and personal preference. Type of incision may, however, have an influence on the occurrence of postoperative wound complications, which is discussed in our study. There is little consensus in the literature as to whether a particular incision confers any advantage. Objective The purpose of this study was to provide an evidence-based consensus regarding the patients who underwent laparotomy for various intra-abdominal conditions included in our inclusion criteria and who developed burst abdomen in relation to the type of abdominal incision (vertical vs. transverse), as well as to know the rates of incidence, morbidity and mortality due to burst abdomen, and study other variables within the scope of postoperative complications. Other variables within the postoperative complications spectrum were also studied alongside the main one, burst abdomen. Patients and methods This is a prospective, randomized study (by card picking under supervision of the ward nurse) that compared the postoperative complications (mainly burst abdomen) after two main types of abdominal incisions, vertical and transverse, within a period of 12 months from October, 2015 to October, 2016. The study was conducted at the Emergency Unit, General Surgery Department, Kasr Al Ainy University Hospital, Faculty of Medicine, Cairo University. Sixty patients underwent open abdominal operations (exploration) after following distinctive inclusion and exclusion criteria. Thirty patients underwent vertical and thirty patients underwent transverse incisions. The main outcome measures were early complications such as burst abdomen, pulmonary complications and hospital stay. Results The transverse incision offers as good an access to most intra-abdominal structures as a vertical incision. The incidence of burst abdomen is higher in the vertical incision (midline) group, with 71.4% of the total patients suffering a burst abdomen. Respiratory complications occurred significantly in cases of burst abdomen (P<0.001). Hence, hospital stay was longer in cases of burst abdomen (P<0.001), which added to the economic burden. Conclusion Transverse incisions in abdominal surgery are based on better anatomical and physiological principles. It should be preferred, as the early postoperative period is associated with fewer complications (burst abdomen and pulmonary morbidity). A midline incision is still the incision of choice in conditions that require rapid intra-abdominal entry (such as trauma with suspected intra-abdominal haemorrhage).

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Introduction Gynecomastia has a negative impact on male self-esteem and social health. In the absence of a medically treatable condition, surgery is the only effective treatment. Treatment includes either liposuction, excision of male breast gland, or both. Excision of the breast tissue is usually performed through a circumareolar incision, which could be a site of infection, unsightly scar, nipple, areola inversion, or necrosis. Aim This study aimed to evaluate the outcome of liposuction excision of gynecomastia through a small axillary approach. Patients and methods One hundred and forty-three patients with gynecomastia, through the period from March 2010 to March 2014, in Minoufiya university hospital and other private hospitals were included in this study; their mean age was 24.3 years. After clinical and laboratory evaluation, liposuction and excision of glandular tissue was performed through the same stab of liposuction at the midaxillary line in the fifth or sixth intercostal spaces under general or local anesthesia; liposuction was first performed using the tumescent technique and then the glandular disc was released from its deep attachments and from subcutaneous and nipple attachments by scissors. Then, drains were inserted through the same liposuction excision opening and pressure bandage and garments were applied. Results One hundred and thirty-four (93.7%) patients showed satisfactory results after 6 months and 138 (96.5%) patients were satisfied with the results after 1 year in terms of proper symmetry and sound healing. One hundred and fifteen patients (80.4%) underwent surgery under general anesthesia and 28 patients (19.5%) underwent surgery under tumescent local anesthesia; the mean operative time was 55 min, the mean hospital stay was 9.6 h, and the average period off work was 5 days. Four patients (2.8%) showed unilateral hematoma formation, none of the patients showed saucer dish deformity, areola, nipple necrosis, or inversion, one patient (0.6%) developed a unilateral wound infection, two patients (1.4%) showed seroma formation, and two patients (1.4%) showed skin laxity. Conclusion The axillary liposuction excision technique was associated with very good esthetic results for both fibrous and fatty gynecomastia, with little complications.

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Background Posthemorrhoidectomy pain represents an annoying problem for the surgeon and the patient; although it can be controlled with an analgesic ladder, its management remains in question. Purposes The current study investigated the efficacy of topical tannic acid powder in reducing postoperative pain, in promoting wound healing after open diathermy hemorrhoidectomy, and in the prevention of secondary hemorrhage. Patients and methods A prospective, randomized trial was conducted on 97 patients suffering from grade 3 or 4 internal or external hemorrhoidal disease to compare posthemorrhoidectomy pain and wound healing with the use of topical tannic acid applied to the surgical site compared with placebo. Postoperative follow-up was for 3 months. Results Postoperative pain in patients given topical tannic acid improved during the first 2 days (VAS: 1.2 ± 0.4 vs. 8.2 ± 0.6; P < 0.05) and on day 7 (VAS: 3.6 ± 0.6 vs. 6.3 ± 0.5; P < 0.05); wound healing also improved significantly [mean postoperative edema score: 3.0 vs. 7.0, P < 0.05; and mean overall wound healing score: 4.0 vs. 6.0, P < 0.05)], although there was no difference as regards primary and secondary healing (P > 0.05). In addition, secondary hemorrhage in the topical tannic acid group was significantly less (mean score, 2.0 vs. 12.0; P < 0.05). Conclusion Topical tannic acid application plays an important role in diminishing postoperative pain, in improving wound healing after open diathermy hemorrhoidectomy, and in preventing secondary hemorrhage.

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Objective The present study aims to describe and evaluate a modified major duct excision (MDE) technique as regards its role in minimizing postoperative complications. Patients and methods We included female patients who underwent total duct excision due to the following indications: suspicious nipple discharge, periductal mastitis, and nipple retraction with a history of periductal mastitis. The modified MDE was performed under general anesthesia. All the patients were discharged home on the same day of the procedure and they were followed up for 6 months. In the follow-up, the patients were assessed for any complications to the wound, any retraction or necrosis to the nipple, the nipple sensation compared with the other one, or the nearby skin in bilateral cases. Results In this study, a total of 29 operations were performed on the 25 patients. No seroma or hematomas were observed. On follow-up of the patients, two patients suffered from infection of the wound, three cases developed breakdown that healed by daily dressing, one case presented with nipple necrosis most probably occurred as a result of excessive dissection with diathermy, while the remaining 31 patients recovered by primary intention with no recurrent discharge. Loss of nipple sensation occurred in four patients, impaired sensation occurred in six patients, and normal sensation in the rest of the patients was observed at 6 months of follow-up. Conclusion The modified MDE technique is a safe alternative to the classic technique with low rate of postoperative complications.

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Background Laparoscopic sleeve gastrectomy (LSG) is a safe and effective surgical treatment modality for morbid obesity. Variations in surgical technique could affect the results. The optimal size of the bougie remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies. Patients and methods Between March 2011 and January 2014, 102 morbidly obese patients underwent LSG. These patients were divided into two groups: group 1 (50 patients) and group 2 (52 patients). In group 1, 32-Fr bougies (orogastric calibration tube) were used, and in group 2 40-Fr bougies were used. Patients completed at least 6 months of follow-up visits. Results The excess body weight loss percentage in group 1 was 53.6 ± 10.96% at 6 months and 69.4 ± 15.6% at 1 year postoperatively, whereas in group 2 it was 52.7 ± 11.27% at 6 months and 66.4 ± 13.4% at 1 year postoperatively, with no statistically significant difference between the two groups. There were neither intraoperative complications nor postoperative mortalities. The overall complication rate was 14.7% (15 patients) with no statistically significant difference between the two groups (14% in group 1 vs. 15.4% in group 2). The postoperative hospital stay was 2.3 days in group 1 versus 2.2 days in group 2. There was 58.8% complete resolution of diabetes mellitus, 60% resolution of hypertension, and 87.5% resolution of sleep apnea 6 months after sleeve gastrectomy with no statistically significant difference between the two groups. Conclusion LSG is a safe and effective treatment method for morbid obesity. Bougie size does not affect the short-term outcomes.

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