نشریه جراحی ایران
سال نوزدهم شماره 3 (پاییز 1390)

Introduction & The paradigm shift of minimal invasiveness in surgery, necessitates the use of methods and tools with minimal derangement of natural homostasis. For many years, N2O, inspite of being more neutral than, was not in use due to the reports that questioned its safety. Recently, there has been some doubts about the claims of its unsafety, and this has paved the way for its clinical trial. This study is about to provide more trustful evidences for judging between N2O and CO2. This clinical trial was done on patients who were candidates for laparoscopic cholecystectomy. Carbon dioxide or nitrous oxide was randomly used for the patients. The measured variables before and during the procedure were: Heart rate, mean arterial blood pressure, end-tidal CO2, minute ventilation, and O2 saturation and post operation pain. Pain, as perceived by patients, was measured after the procedure by visual analogue scale. Shoulder pain and ability to move in the bed and out of bed was recorded as proxy data for pain. Vomiting and use of analgesics and antiemetics were also recorded and compared. The two groups of 32 patients in each arm of the trial were comparable to each other. While hemodynamic parameters were statistically identical, end-tidal CO2 was greater in patients of CO2 group. (32 versus 27 mmHg, P < 0.001, 95% CI [2.00-7.27]). No differences were detected in pain perception and nausea/vomiting rate between two groups. Intra operative and postoperative use of analgesics and antiemetics were not statistically different between the two groups. No adverse events in either group were encountered. The use of N2O does not disturb respiratory system, contrary to the case of CO2.Its effect on the postoperative pain and vomiting and homodynamic variables had been reported to be different from that of CO2. But in our study, they were not different.

Introduction & Bowel mechanical preparation is a routine procedure before colorectal surgeries. Anorectal procedures are most prevalent procedures in general surgery. To reduce risk of infection and better performance, all authors insist on bowel preparation before anorectal surgeries. The aim of this study is the comparison of the mechanical bowel preparation with polyethylenglycol (PEG), saline enema or no prep before anorectal surgery (hemorrhoid and fistula). In a randomized clinical trial 150 cases of candidates for elective hemorrhoid or fistula in general surgery ward of hospital enrolled came under study: 50cases in PEG group (1), 50 cases in saline enema (2) and 50 cases with no prep or control (3). After surgery surgeon's satisfaction, pain after first defecation and post operative complications were evaluated and analyzed by SPSS 16, ANOVA and chi-square test. The mean of age, gender and procedure type were not different significantly between groups. Surgeon's satisfaction was 26% in group 1, 28% in group 2 and 0% in group 3; difference was significant (P-value.

Introduction & The purpose of this study was to compare the effect of two methods of tendon retrieval in the outcome of the repair of retracted flexor tendons in zone II flexor tendon laceration. In a randomized controlled trial, the Hemi Kessler core suture tendon retrieval was compared with the innovative method of retrieval by long loop of nylon suture without Pulling out the tendons from their sheath. Between September 2009 and July 2010 a total of 253 patients (307 fingers) with flexor tendon injury in zone II referred to the hand surgery ward in 15 Khordad hospital for whom if tendon was retracted to the palm and could not be brought into view by massage at the time of operation, joint flexion and other simple methods were included in our study. A small transverse incision was made over distal palmar crease and both flexor tendons were visualized and flexor tendons were randomly retrieved by two methods. In 36 patients (38 fingers) of control group tendon retrieval was done by Hemi Kessler core suture method and in 34 patients (37 fingers) of study group tendon retrieval was done by the use of long loop of nylon and nelaton chateter, without Pulling out the tendons from the sheath. The TAM (Total Active Motion) of the repaired fingers in both groups were calculated and scoring was done according to ASSH system. In all of our patients the contralateral finger was normal and accessible for comparison. The average follow up time was 368 days (ranging from 274 to 450 days). The average TAM was 208.1o in study group and 201.5o in control group. There was no statistically significant difference in the end results of both groups which was evaluated according to TAM (ASSH) system (P = o.408). The outcome of two groups were compared, according to the ASSH scoring of excellent, good, fair and poor. The results in the study group were: 2 excellent (5.2 %), 27 good (73%), 7 fair (18.9%) and 1 poor (2.7%). Results in the control group were 3 excellent (7.9%), 24 good (63.2%), 10 fair (26.3%) and 1 poor (2.6%). There was no statistically significant different between the two groups) P = 0.827(. Despite the fact that there was no significant differences in the results, we suggest retrieving of proximal tendon stump of retracted severed flexor tendons in zone II, without bringing them out of the sheath, thereby avoiding excessive trauma to the tendon and preserving its blood supply and tendon sheath integrity.

Introduction & Although one of the most influential modality for decreasing wound infections is utilizing prophylactic antibiotic before surgery, inappropriate use of antibiotics before operation is a major concern and can increase the prevalence of antibiotic resistant strains and adverse reactions, and negatively affect hospital budget. The aim of this study is to assess the appropriateness of surgical antibiotic prophylaxis among patients admitted in the surgical wards of a teaching hospital relative to the international guidelines and standards. In this descriptive cross-sectional study, surgical antibiotic prophylaxis of 172 surgeries was evaluated prospectively but discontinuously. During 2 years in six surgical wards of a teaching hospital. Information including demographic data of patients, wound classification, type of surgery, indication, selection of the prophylactic antibiotics, time, interval, duration and route of antibiotic administration were collected through a questionnaire; the sources of data were patient’s records and charts, physicians and nurses. Then the results of prescribed prophylactic antibiotics were compared with the international guidelines on antibiotic prophylaxis in surgery. All data were coded, entered, and analyzed using SPSS 13. For descriptive statistics, data were summarized using tables, measures of dispersion and central value, and frequency and percentages were calculated and presented. Among 172 operations, the overall adequacy of indication of prophylactic antibiotic (PA) was 71.5%. Of the 108 patients with indication, the timing of PA was appropriate in 95 (88%) patients; the choice of antibiotic was adequate in 44 patients (40.7%); the dosage and interval of PA were appropriate in 34 (31.5%) and 26 patients (24%), respectively, and the duration of antibiotic prophylaxis was appropriate in 5 cases (4.6%). The route of drug administration in all patients, except one, was intravenous. Considering all variables (indication, selection of the prophylactic antibiotic, time, interval, duration and route of antibiotic administration), the overall appropriateness of PA was 4.6% (5 cases) according to guidelines. Considering all variables (indication, selection of the prophylactic antibiotic, time, interval, duration and route of antibiotic administration), pre-operation antibiotic prophylaxis had little concordance with standard guidelines, especially regarding prolonged duration of antibiotic use, though after excluding the variable of duration of antibiotic administration, the prophylactic antibiotic was prescribed appropriately in one-fourth of patients. For appropriate use of antibiotic before operations, interventions including developing local hospital guidelines, implementing educational programs, and monitoring antibiotic prophylaxis should be considered.

Introduction & The standard management of inguinal hernia in children is surgical repair. It is the most common surgical procedure in children. Although the conventional open techniques still remain the cornerstone of inguinal hernia repair, but the advantages of laparoscopic procedure makes it a valuable alternative. Patients who underwent inguinal hernia repair by one surgeon were randomly categorized into two groups of open and laparoscopic repair. Each group involved 45 patients. Patients were evaluated one day, one week, and 3 months after the surgery. Surgical site infection, post-operative chronic pain and hydrocele, testicular swelling, scar size, and operation duration were surveyed for both groups. The data was analyzed with t-test and chi-square test. Ninety patients (73 males and 17 females) which were divided in two groups of 45, were evaluated. The mean age of patients in open and laparoscopic groups was 4.74±4.1 and 5.02±3.89 years respectively. Fifty (61%) patients had right, 26 (29%) left, and 9 (10%) bilateral inguinal hernia. Testicular swelling prevalence and scar size were significantly higher in open group (P=0.000). No evidence of infection or hydrocele was found in these two groups. The surgical procedure duration was significantly longer in laparoscopic repair (P=0.000). It is concluded that laparoscopic procedure could be an appropriate alternative for open ‎techniques in the cases of bilateral inguinal hernia as well as girls (due to better ‎aesthetic results).

Introduction & Primary hyperparathyroidism (PHPI) is a common disease mostly seen in women. Symptomatic PHPT is the predominant form of the disease in many parts of the developing world. In the countries with a screening system, it is usually seen and treated without presenting any symptom. In this study it is tried to define the frequency of different clinical symptoms in these group of patients in compare with other countries. A retrospective descriptive study of records of the patients, who had surgical operation from 1990 to 2010 at Taleghani Hospital, was done. All relevant information (age, sex, clinical presentation and diagnostic imaging procedures) were collected in this survey. Then the data were analyzed by SPSS. 82% of patients were female with the mean age of 47.4 years. None of the patients were without clinical symptoms. Bone disease (62%) and renal disease (45%) were most common manifestation of PHPT. Pathological review of cases revealed adenoma (77%), hyperplasia (12%), double adenoma (4%) and carcinoma (6.7%). PHPT in Iran is a symptomatic disease with predominant features of renal and bone disorders at a much younger age in compare with other countries. In recent decades, the age of becoming afflicted by this disease has increased in Tehran, but it is still lower than that of the west.

Benign multicystic abdominal mesothelioma is a rare tumor that occurs mainly in women in their reproductive age. To date 130 cases have been reported. It is characterized by the formation of multilocular cysts with thin-walled that frequently appears as large, intraabdominal masses. When tumor appears in the abdominal cavity, it attaches to intra-peritoneal organs like intestine and omentum, spleen, liver or progress toward retroperitoneal organs such as pancreas. Differentiation from other cystic lesions could be only with histologic study and surgery is mandatory for diagnosis and treatment. In this study we report a case of 52-year-old woman with 20×15cm abdominal mass that undergone surgery. Histopathological examination revealed a multicystic mesothelioma with retroperitoneal progression.