International Surgery Journal

Distribution of the methylenetetrahydrofolate reductase A1298C polymorphism among patients undergoing endovascular treatment for lower-extremity arterial disease

2026-02-28T23:58:05+0530

Background: The methylenetetrahydrofolate reductase (MTHFR) A1298C polymorphism reduces enzyme activity, leading to impaired homocysteine (Hcy) metabolism and moderate hyperhomocysteinemia. Elevated Hcy promotes endothelial dysfunction and accelerates atherosclerosis, increasing the risk of cardiovascular disease. Peripheral arterial disease may progress to critical limb ischemia, often requiring endovascular revascularization such as angioplasty with stenting.

Methods: This retrospective study consisted of 69 patients divided into 58 males and 11 females. The inclusion criteria for this study consist of patients diagnosed with chronic arterial insufficiency according to the Fontaine classification, patients with informed consent, patients who underwent lower-extremity revascularization, patients with surgical indication of atherosclerotic lesions and the exclusion criteria included patients without arterial chronic sufficiency, patients without obtained informed consent, patients with more than one intervention.

Results: Out 69 patients, 16 patients were found with hemodynamically significant atherosclerotic lesions in the aortofermoral segment, 37 in the femorotibial segment and 16 in both segments. The distribution of MTHFR A1298C polymorphisms with AA genotype was 37 patients (53.6%) with AC genotype was 21 patients (30.4%) and with CC genotype was 11 patients (16.0%).

Conclusions: This study revealed the most predominant revascularization procedure was angioplasty combined with stenting, accounting for 55.1% of all interventions. The most prevalent allele of the MTHFR A1298C genetic polymorphism was normal AA genotype in patients with lower-extremity arterial disease who underwent isolated endovascular or hybrid interventions on the main arteries were detected in 37 (53.6%) patients.

Negative appendectomy rate in the era of computed tomography

2026-04-12T14:36:16+0530

Background: Acute appendicitis remains a diagnostic challenge. Historically, a negative appendectomy rate (NAR) of up to 20% was considered acceptable to avoid missed diagnoses. With increasing use of computed tomography (CT), the impact of routine preoperative imaging on NAR warrants further evaluation. This study assessed the negative appendectomy rate among patients undergoing preoperative CT and evaluated its diagnostic contribution.

Methods: A retrospective study was conducted including all adult patients who underwent emergency open or laparoscopic appendectomy between January 2023 and April 2025 at King Fahad Hospital Hofuf, Kingdom of Saudi Arabia. Demographic data, preoperative CT findings, inflammatory markers, operative findings, and histopathological results were reviewed. Statistical analysis was performed using statistical package for the social sciences (SPSS) version 24.

Results: A total of 386 patients were included (62.2% male), with a mean age of 29 years. All patients underwent preoperative CT imaging. A normal appendix was identified intraoperatively in five patients (1.4%). Histopathological examination revealed catarrhal appendicitis in 66%, suppurative appendicitis in 18.7%, perforated or phlegmonous appendicitis in 13%, gangrenous appendicitis in 0.6%, and normal appendix in 1.4%. One case of appendiceal carcinoid tumor was identified. Normal leukocyte counts were present in 16.6% of patients.

Conclusions: Routine preoperative CT imaging was associated with a very low negative appendectomy rate. These findings support the role of CT in reducing unnecessary appendectomies.

Chemotherapy response rate in seminoma and non-seminoma testicular cancer cases

2026-04-16T20:22:25+0530

Background: Testicular cancer is a malignancy in the form of a solid tumor that occurs in men, with a global prevalence that has been steadily increasing. The most commonly found types are seminoma and non-seminoma, particularly among individuals aged 20-34 years. In recent decades, 9,560 new cases of testicular cancer were recorded in the United States in 2019. In Indonesia, based on data from January 1995 to December 2004, the majority of testicular cancer cases were also seminoma and non-seminoma types, with patient ages ranging from 18 to 72 years.

Methods: Data analysis was performed using SPSS software version 29.0, employing univariate and bivariate analyses. Univariate analysis was used to describe the characteristics of the study samples. Ratio-scale data were described using the mean as a measure of central tendency and standard deviation (SD) as a measure of dispersion. Categorical data were described in percentages (%) and numbers (n), and presented in tables. Differences in chemotherapy response outcomes among testicular cancer patients, which are categorical data, were analyzed using bivariate analysis. Comparative tests were conducted to assess differences in the success rates of chemotherapy responses in testicular cancer patients. Both tests were considered statistically significant if they had a p<0.05.

Results: Complete chemotherapy response in seminoma and non-seminoma testicular cancer was nearly similar at 66.7% and 68.8%, respectively; partial chemotherapy responses in seminoma and non-seminoma were 13.3% and 18.8%; however, progressive chemotherapy responses tended to be higher in seminoma (20.0%) than in non-seminoma (12.5%).

Conclusions: The success rate of chemotherapy response in testicular cancer cases was mostly complete (67.7%), while partial and progressive responses were 16.1% each, and there was no difference in chemotherapy response between seminoma and non-seminoma tumors.

Correlation of magnetic resonance imaging findings with clinical staging in carcinoma of the cervix

2026-05-04T12:37:30+0530

Background: Cervical carcinoma remains a significant health burden in developing countries, with accurate staging being critical for optimal management. Clinical International Federation of Gynecology and Obstetrics (FIGO) staging has limitations in assessing tumor extent and nodal involvement, whereas magnetic resonance imaging (MRI) offers improved visualization of local and regional disease. This study aimed to evaluate the correlation of MRI findings with clinical staging and assess its diagnostic accuracy in cervical carcinoma.

Methods: This hospital-based retrospective observational study was conducted in the Department of Radiology and Imaging, Combined Military Hospital (CMH), Dhaka, from October 2024 to September 2025. A total of 100 consecutive patients with histologically confirmed cervical carcinoma attending the Gynecology Oncology Department were included. Demographic, clinical, and MRI data were collected using a structured case record form.

Results: The majority of patients were aged 40-49 years (32%), married (85%), and postmenopausal (63%). Clinical FIGO staging showed stage IIIB (28%) and IIB (27%) as most frequent. MRI-based staging identified stage IIIB (31%) and IIB (25%) as most common. Concordance between clinical and MRI staging was 68%, with MRI assigning a higher stage in 65.6% of discordant cases. MRI demonstrated high diagnostic accuracy: parametrial involvement (sensitivity 91%, specificity 85%), pelvic sidewall invasion (94%, 96%), bladder/rectal involvement (87%, 98%), and tumor size >4 cm (92%, 90%).

Conclusions: MRI shows high concordance with clinical staging and superior detection of advanced disease, supporting its routine use for preoperative staging and treatment planning in cervical carcinoma.

Effectiveness of retrograde intrarenal surgery for upper ureteric and renal stones: a retrospective cohort study

2026-05-14T16:33:54+0530

Background: Retrograde intrarenal surgery (RIRS) has become an increasingly preferred minimally invasive procedure for the management of upper ureteric and renal stones due to its favorable safety profile and high stone clearance rate. This study aimed to evaluate the effectiveness and perioperative outcomes of RIRS in patients with upper urinary tract calculi.

Methods: This retrospective cohort study was conducted at the Department of Urology, Enam Medical College and Hospital, from July 2018 to January 2026. A total of 382 adult patients with upper ureteric or renal stones who underwent RIRS with holmium laser lithotripsy were included. Demographic characteristics, stone-related variables, intraoperative findings and postoperative outcomes were retrieved from hospital records and analyzed descriptively.

Results: The mean age of the patients was 46.2±14.8 years and the mean BMI was 26.3±4.6 kg/m². Multiple-site stones were the most common (36.1%), followed by renal pelvic stones (30.8%). Preoperative DJ stenting was performed in 36.9% of patients. General anesthesia was used in 91.8% of procedures and the combined dusting and popcorning technique was the most frequently applied stone management method (56.8%). The stone-free rate (SFR) at 4 weeks was 92.5%. Mean laser activation and operative times were 37.5 and 69.3 minutes, respectively. The average postoperative hospital stay was 2.5 days, while 7.5% of patients required additional intervention.

Conclusions: RIRS is an effective and safe minimally invasive treatment option for upper ureteric and renal stones, providing high SFRs with acceptable perioperative outcomes.

Presumptive androgen deprivation therapy in prostate cancer emergencies: an ambispective study of clinical presentation, diagnostic delays and early outcomes in Nigerian hospitals

2026-05-14T18:23:10+0530

Background: Advanced prostate cancer frequently presents with life-threatening complications in low-income settings where delays in histological confirmation often impede timely treatment. In such contexts, presumptive androgen deprivation therapy (pADT) may be initiated based on strong clinical suspicion. However, evidence on its clinical application and early outcomes remains limited. This study evaluated emergency presentation patterns, diagnostic delays, and short-term outcomes following pADT in men with suspected advanced prostate cancer in South-East Nigeria.

Methods: Between December 2021 and December 2025, 45 men presenting with prostate cancer-related emergencies prior to histological confirmation were enrolled and followed for four weeks after pADT initiation. Data collected included presenting symptoms, pain severity, neurological and functional status, PSA levels, laboratory parameters, histology result, and timelines to biopsy, diagnosis, and treatment. Descriptive statistics were used for analysis.

Results: The mean age was 70.6±11.3 years. Pain was the most common symptom (60%), mainly lower back pain (88.9%). Other presentations included lower limb weakness (31.1%), limb swelling (31.1%), anaemia (28.9%), and nephropathy (28.9%). All patients had advanced disease; 82.2% had metastases, with a mean PSA of 591.9 ng/ml. pADT was administered in 95.6% of cases. At four weeks, 88.9% achieved pain scores <3 and 44.4% were pain-free; nephropathy resolved in 84.6%. Significant improvements were observed in pain, motor function, and functional status (p<0.002). Time to biopsy and histology averaged 18.6±37.0 and 18.4±14.0 days, respectively.

Conclusions: pADT offers rapid symptomatic relief and represents a pragmatic interim strategy in resource-limited settings, though strengthening diagnostic pathways remains essential.

Clinical significance of gender‑specific urodynamic investigation in evaluating bladder functional recovery in patients with lumbar intervertebral disc prolapse

2026-05-20T18:37:41+0530

Background: Lumbar intervertebral disc prolapse (LDP) frequently causes neurogenic bladder dysfunction due to sacral root compression. Urodynamic investigation is the gold standard for assessment, but the influence of gender on bladder functional recovery after decompression surgery remains unclear. Objectives were to evaluate the clinical significance of gender-specific urodynamic investigation in assessing bladder functional recovery after lumbar decompression surgery in patients with LDP.

Methods: This prospective longitudinal study included 30 patients (20 males, 10 females) with LDP who underwent microdiscectomy. Urodynamic parameters-maximum cystometric capacity (MCC), post-void residual urine (PVR), maximum detrusor pressure (Pdetmax), bladder compliance (BC), and maximum flow rate (Qmax)-were measured preoperatively and three months postoperatively. Gender-specific changes were analysed using paired t test, Wilcoxon signed-rank test, and McNemar-Bowker test.

Results: Preoperative urodynamic abnormalities were present in 73.3% of patients, with no significant gender differences at baseline. In males, significant improvements were observed in MCC (+14.95 ml, p=0.009), PVR (-16.06 ml, p<0.001), and Qmax (+4.90 ml/s, p<0.001). In females, only PVR showed a significant reduction (-54.86 ml, p=0.001). Overall, urodynamic normalisation occurred in 18.8% of males but in none of the females. Detrusor overactivity resolved in 25% of males versus 0% of females.

Conclusions: Gender significantly influences urodynamic recovery following lumbar decompression for LDP. Males attain more extensive and pronounced improvements, whereas females demonstrate limited recovery. Gender-specific urodynamic assessment is of considerable clinical importance for prognostication and personalized rehabilitation.

Early outcome of distally based C-ring cross finger flap for the reconstruction of degloved amputation stumps and volar and dorsal defects of the fingers

2026-05-02T12:14:46+0530

Background: Degloved amputation stumps and volar or dorsal finger defects are challenging to reconstruct. The distally based C-ring cross finger flap offers larger size and wider rotation than conventional flaps, but prospective outcome data are limited.

Methods: This prospective observational study included 40 patients undergoing reconstruction of degloved amputation stumps or volar/dorsal finger defects using the distally based C-ring cross finger flap at Dhaka Medical College Hospital (December 2022-January 2024). Outcomes assessed included flap dimensions, viability (necrosis: marginal <10%, partial 10-20%, significant>20%, complete), flap-related complications (venous congestion, infection, wound dehiscence), donor site morbidity (infection, re-skin grafting) and range of motion (ROM) of proximal (PIP) and distal (DIP) interphalangeal joints. Overall functional outcome was classified as good, satisfactory or poor.

Results: Mean flap area was 6.46 cm² (wound area 5.11 cm²). No necrosis occurred in 57.5%; marginal necrosis in 22.5%, partial in 10%, significant in 7.5%, complete loss in 2.5%. Venous congestion occurred in 25%, infection in 10%, wound dehiscence in 10%; 55% had no complications. Donor site morbidity was absent in 65%; infection and re-skin grafting each occurred in 17.5%. Full ROM was achieved in 100% of PIP joints and 97.5% of DIP joints. Overall outcome was good in 70%, satisfactory in 22.5%, and poor in 7.5%.

Conclusions: The distally based C-ring cross finger flap is a reliable technique for reconstructing degloved amputation stumps and finger defects, providing adequate coverage, acceptable flap survival, manageable complications, low donor site morbidity and excellent joint mobility with 70% achieving good functional outcomes.

Outcome of heterodigital neurovascular island flap for reconstruction of pulp defect of thumb

2026-05-02T12:37:03+0530

Background: The reconstruction of thumb pulp defects requires durable coverage and fine sensibility restoration. The heterodigital neurovascular island flap offers glabrous, sensate tissue and is widely used, although local outcome data are limited.

Methods: This prospective observational study was conducted at the National Institute of Burn and Plastic Surgery, Dhaka, from January 2023 to June 2024. Thirty patients with thumb pulp soft-tissue defects underwent reconstruction using a heterodigital neurovascular island flap. Outcomes assessed included flap viability, donor site morbidity, sensory recovery and patient satisfaction. Data were analyzed using SPSS version 26.0.

Results: The mean age was 30.7±12.3 years; most patients were male (83.3%). Trauma was the leading cause (86.7%) and most defects exceeded 5 cm² (53.3%). Flap survival was favorable, with 80% uneventful cases; minor complications included marginal necrosis (10%) and infection (6.7%). Donor site morbidity was low (76.7% uneventful). All patients regained pain sensation by day 5 and 66.7% regained tactile sensation by day 14. Mean static two-point discrimination improved from 4.65±0.46 mm at 3 weeks to 3.70±0.59 mm at 3 months, approaching the contralateral thumb (3.33±0.61 mm; p=0.02). Good outcomes were observed in 80% of cases, with high patient satisfaction (83.3%).

Conclusions: The heterodigital neurovascular island flap is a reliable technique for thumb pulp reconstruction, providing satisfactory sensory recovery, high flap survival and minimal complications.

Microbiological profile and antibiotic resistance patterns in complicated versus uncomplicated acute appendicitis: a prospective cohort study from a tertiary care centre

2026-04-23T00:00:55+0530

Background: Acute appendicitis is a common surgical emergency with variable microbiological patterns influencing disease severity and outcomes. Regional data from South India remains limited.

Methods: A prospective cohort study was conducted on 100 patients diagnosed with acute appendicitis at a tertiary care centre. Patients were classified into uncomplicated (UAA) and complicated appendicitis (CAA). Intraoperative samples were subjected to microbiological analysis and antibiotic sensitivity testing.

Results: Out of 100 patients, 60% had UAA and 40% had CAA. Mean age was significantly higher in CAA (50.33±7.2 years) compared to UAA (31.82±7.46 years, p<0.001). Culture positivity was 100% in CAA and 50% in UAA. Polymicrobial infections were observed exclusively in CAA (62.5%). Common organisms included Escherichia coli, Bacteroides and Pseudomonas. High resistance rates were observed for meropenem (34%), ceftriaxone (30%) and amoxicillin (31%). Surgical site infections occurred only in CAA (25%).
Conclusions: Complicated appendicitis demonstrates a distinct microbiological profile with higher polymicrobial infection and antibiotic resistance. Empirical antibiotic therapy should include anaerobic coverage and be guided by regional antibiograms.

Prospective observational study of blunt abdominal trauma and hemoperitoneum

2026-05-02T10:46:10+0530

Background: The early recognition and appropriate management of solid organ injuries in blunt abdominal trauma are pivotal in improving patient outcomes. The aim of this study was to evaluate the factors affecting outcome of solid organ injury with blunt abdominal trauma and hemoperitoneum.

Methods: A prospective observational study was conducted over a period of two years at a tertiary care centre providing advanced trauma and emergency surgical services in Western Maharashtra. A total of 44 patients presenting with blunt abdominal trauma and radiological or clinical evidence of solid organ injury with hemoperitoneum were included. Demographic characteristics, mechanism of injury, clinical presentation, imaging findings, associated injuries, management strategies, and outcomes were analysed.

Results: Among the 44 patients, the majority (38.6%) were aged 16–30 years, and males constituted 84.1% of the cohort. Road traffic accidents were the most common cause of injury (61.4%). Associated injuries were present in 38.6% of patients. Computed tomography revealed mild intraperitoneal fluid collection in 22.7% of cases. Only 6.8% of patients required operative management, with intraoperative findings showing liver injury in two patients and splenic injury in one patient. The overall mortality rate was 4.5%. Younger age and associated head injury were significantly associated with mortality. Clinical shock at presentation significantly influenced the management approach.

Conclusion: Blunt abdominal trauma with solid organ injury predominantly affects young males and is most commonly caused by road traffic accidents. Mortality is mainly associated with high-grade splenic injury and concomitant head injury. Continuous monitoring of haemoglobin levels and clinical signs of shock is essential for guiding management and predicting outcomes rather than relying solely on the patient’s condition at admissions.

Comparing outcomes of open versus minimally invasive total mesorectal excision after total neoadjuvant therapy in rectal cancer: a national cancer database analysis

2026-06-08T00:07:06+0530

Background: Total neoadjuvant therapy (TNT), in which systemic chemotherapy and pelvic radiation are delivered before surgery, improves pathological complete response, disease-free survival and treatment compliance in locally advanced rectal cancer. Large-scale data comparing open and minimally invasive surgery (MIS) approaches to total mesorectal excision (TME) specifically after TNT are lacking.

Methods: The national cancer database was queried (2010–2020) for adults with clinical stage II–III rectal adenocarcinoma who received chemoradiotherapy and at least two chemotherapeutic agents before TME. Stage I or IV disease, primary resection without neoadjuvant therapy and MIS converted to open were excluded. Univariate analysis and multivariable logistic regression were performed. The primary outcome was inadequate lymph node retrieval (<12 nodes); the secondary outcome was 90-day postoperative mortality.

Results: A total of 5,962 patients were included; 3,111 (52.2%) underwent MIS and 2,851 (47.8%) underwent open TME. Inadequate lymph node retrieval was less frequent with MIS (27.1%) than open surgery (33.2%) (OR 0.80; 95% CI 0.71–0.90; p<0.001). 90-day mortality was lower with MIS (0.8%) than open surgery (2.2%) (OR 2.46 for open; 95% CI 1.51–4.03; p<0.001).

Conclusions: After TNT for rectal cancer, an MIS approach to TME was associated with a higher likelihood of adequate lymph node harvest and lower 90-day mortality than open surgery. These differences may reflect improved pelvic exposure, although selection bias toward more advanced tumors in the open cohort cannot be excluded. Prospective studies are warranted.

Biliary microbial colonization and antibiotic susceptibility in chronic calculous cholecystitis: a prospective observational study

2026-06-09T11:03:29+0530

Background: One of the most common indications of cholecystectomy in the world is chronic calculous cholecystitis. Despite the fact that bile is physiologically sterile, gallstone disease predisposes microbial colonization by bile stasis, mucosal damage, and ascending infection. Bile microorganisms can be a contributor to infectious postoperative complications and affect the choice of perioperative antibiotics. Since there are regional differences in microbial flora and resistance to antibiotics, institution-specific data are required in evidence-based antimicrobial practice.

Methods: This was a prospective observational study design, based in a hospital and carried out on 87 patients who were undergoing cholecystectomy as a treatment of chronic calculous cholecystitis at a tertiary care centre in Uttar Pradesh after gaining ethical permission. Aseptically, intraoperative collection of about 2 ml of bile was done and subjected to regular microbiological procedures. The bacterium was identified using Gram staining and biochemical techniques after being cultured on blood agar and MacConkey agar. To determine antibiotic susceptibility, the Kirby-Bauer disc diffusion method was used in accordance with the Clinical and Laboratory Standards Institute (CLSI) guidelines.

Results: Of the 87 patients who took part in the research, 70 (or 80.4% of the total) had cholecystectomy by laparoscopy, 12 (13.8%) had the procedure done openly, and 5 (5.8% of the total) had to have the procedure changed to open because laparoscopy failed. Biles were observed to be positive in 20 (23) patients, and sterile bile in 67 (77) patients. The most common isolate was Escherichia coli (45%), then Klebsiella pneumoniae (25%), then Enterococcus faecalis (15%), and Pseudomonas aeruginosa (15%). E. coli was more sensitive to cefuroxime and ciprofloxacin, and Klebsiella pneumoniae were intermediate to piperacillin-tazobactam and meropenem. Enterococcus faecalis was found to be sensitive to vancomycin and linezolid whereas Pseudomonas aeruginosa was found to be more sensitive to amikacin and piperacillin–tazobactam. Culture-positive patients had higher chances of postoperative wound infection, but this was not statistically significant.

Conclusion: Biliary microbial colonization was observed in about the quarter of patients with chronic calculous cholecystitis with Escherichia coli being the most common isolate. The high degree of antibiotic susceptibility variability underscores the need to have local antibiograms to optimize the use of antimicrobials during perioperative periods. Routine bile culture can be useful in the high-risk patients that undergo cholecystectomy who are selected.

Laparoscopic versus open hernia repair: a meta-analysis of post operative pain, recurrence rate and return to activity

2026-05-16T20:26:33+0530

Herniorrhaphy is among the most commonly performed surgical procedures worldwide. Open and laparoscopic techniques remain the principal approaches, but the long-term comparative benefits of laparoscopy are debated. This systematic review and meta-analysis evaluated outcomes of laparoscopic versus open hernia repair. A systematic search of PubMed and DOAJ (2010-2025) was conducted in line with PRISMA guidelines. Eligible studies included patients ≥12 years undergoing elective inguinal or incisional hernia repair. Primary outcomes were postoperative pain (acute and chronic), recurrence, and time to return to normal activity/work. Data were pooled using review manager 5.4 with a random-effects model. Risk of bias was assessed with ROB 2.0 for randomized trials and the Newcastle–Ottawa scale for observational studies. Ten studies involving over 8,500 patients were included. Laparoscopic repair was associated with significantly lower early postoperative pain (MD=-1.22, 95% CI-1.67 to -0.78, p<0.001; I²=65%). No significant difference was observed for chronic pain (RR=0.85, 95% CI 0.34-2.14, p=0.74; I²=93.7%). Recurrence rates were comparable between approaches (RR=1.12, 95% CI 0.67-1.86, p=0.66; I²=70.1%). Return to normal activity was earlier with laparoscopy (MD=-5.12 days, 95% CI-7.45 to -2.79, p<0.001). Laparoscopic repair provides advantages in reducing early pain and accelerating recovery, without increasing recurrence risk. Evidence for chronic pain reduction is inconclusive due to study heterogeneity. Further high-quality, multicentre trials with standardized outcomes are needed.

Stensen's duct reconstruction associated with facial trauma: a case report

2026-06-05T07:05:25+0530

Facial lacerations involving the parotid duct are rare injuries (0.1% to 0.3% of facial lacerations in major trauma studies) but clinically important in the field of maxillofacial and plastic surgery. Its position on the cheek and proximity to the buccal branch of the facial nerve put it at risk for penetrating injuries, lacerations, and crush damage. If not diagnosed and treated, these lesions can cause sialoceles, parotid-cutaneous fistulas, chronic infections, and functional problems, which can lower the patient's quality of life. The secret of success in repair is knowledge of regional anatomy.

Logistical surgical challenges in performing thyroidectomy on huge multinodular goiters in austere limited resource settings: a case report, ideal management protocols, review of literature and pictorial presentation

2026-04-13T22:26:25+0530

Thyroidectomy is a safe procedure when performed by competent well-trained surgeon in ideal settings. However not all centers have settings that adhere to recommended standard preoperative, intraoperative, and postoperative well laid guidelines. Surgeons in such settings must improvise ingenious methods to try to comply with recommended guidelines. Patients in resource limited settings present late with huge benign or malignant multinodular goiters with limited preoperative investigative modalities due to financial constraints. These settings create logistical challenges for the attending surgeons in such settings. Thyroidectomy also carries a high legal ramification potential due to its high complication potential index from its anatomical proximity of potential lethal or life changing complications by iatrogenic injury to adjacent structures such as Recurrent Laryngeal Nerve, parathyroid glands, or the large caliber blood vessels. It is the author’s intention to highlight these logistical challenges and not recommend or advocate the practice in such settings to be adopted as the standard of care.

Acute perforated appendicitis secondary to a foreign body: a case report

2026-04-17T00:12:10+0530

Acute apendicitis is one of the most frequent causes of acute abdomen and a common surgical emergency worldwide. Although most cases are due to luminal obstruction from lymphoid hyperplasia or fecaliths, the presence of foreign bodies as a cause of perforated appendicitis is exceptional, with a reported prevalence of 0.0005%. We present a case of a 63-year-old male with typical abdominal pain of appendicitis, where the presence of a foreign body in the appendix was identified by abdominal tomography as a possible trigger of the inflammatory process. An open appendectomy was performed without complications, resulting in adequate postoperative evolution after antibiotic management. This case emphasizes the importance of considering foreign bodies as a rare etiology of perforated appendicitis, especially in adults without a history of ingesting unusual objects. Early diagnosis and timely surgical intervention are key to reducing morbidity and improving the prognosis.

Three-anchor repair of acute partial distal pectoralis major rupture in a Jiu-Jitsu athlete: a case report

2026-04-20T22:37:38+0530

Pectoralis major (PM) tendon tears are uncommon but increasingly reported injuries, particularly among young, active males participating in high-demand sports and weightlifting. Surgical repair is generally recommended for young athletes to optimize strength, function, and cosmesis. We present a 22-year-old male with no significant medical history who sustained an indirect eccentric contraction injury to his right PM tendon during jiu-jitsu training. He experienced acute sharp pain and functional limitation. Initial conservative management with oral analgesics and physical therapy failed, leading to surgical intervention approximately one month post-injury. Preoperative MRI suggested a tear at the humeral insertion, but intraoperative findings confirmed a partial rupture involving the distal fibers of both superior and inferior sternocostal portions. The tendon was repaired using three suture anchors with SutureTape and FiberTape in a Krackow configuration. At 4-week follow-up, the patient demonstrated good motor recovery with satisfactory range of motion and improved quality of life. Secure anatomic reattachment of the PM tendon using three suture anchors achieved stable fixation and restoration of the humeral footprint. This technique is reproducible and effective for partial distal tears in active patients, with favorable early clinical outcomes

Loss of definitive care: the hidden value of emergency temporizing management in a severe occupational crush hand injury

2026-04-26T22:23:16+0530

Severe hand injuries are frequently encountered in industrial settings and may lead to substantial long-term functional impairment. Although they are rarely life-threatening, they are often limb- and function-threatening, requiring time, structured, and carefully prioritized management. A 34-year-old male presented with a severe occupational crush injury affecting four digits, sparing of the thumb. The injury associated with partial amputation of the little finger, complete tendon loss in the middle finger with absence of active motion, and partial tendon injury in the ring finger. Neurovascular assessment revealed preserved perfusion with variable functional impairment across the affected digits. Initial emergency management included copious irrigation, debridement, and temporary suturing for hemostasis and soft tissue stabilization. Definitive surgical repair was recommended; however, the patient was subsequently lost to follow-up. This case highlights the important and often underappreciated role of emergency temporizing management in preserving tissue viability and maintaining the potential for functional recovery, particularly when access to definitive surgical care is interrupted.

Laparoscopic Heller myotomy in sigmoid megaesophagus: function preserving surgery as an alternative to esophagectomy in end stage achalasia

2026-04-29T18:56:56+0530

End-stage achalasia with sigmoid megaesophagus represents a therapeutic challenge. Esophageal resection has traditionally been favored, although it is associated with significant morbidity. Laparoscopic Heller myotomy has emerged as a function-preserving alternative in selected patients; however, its use in cases with severe respiratory symptoms and moderate esophageal angulation has not been widely documented. Herein, we report the case of a 43-year-old male with progressive dysphagia, regurgitation, unintentional weight loss, and severe respiratory symptoms (dyspnea and orthopnea). The preoperative Eckardt score was 10 (severe achalasia). Imaging studies demonstrated sigmoid megaesophagus (grade IV) with an esophageal angulation of 75°. Laparoscopic Heller myotomy with intraoperative endoscopy was performed, and 300 mL of retained food content was aspirated. The patient had a favorable postoperative course, with immediate symptom resolution and an Eckardt score of 1 at two months. The hiatal release with anchoring technique (pull down) was not required due to the manageable angulation. Laparoscopic Heller myotomy is an effective option for the management of selected patients with end-stage achalasia and sigmoid megaesophagus, even in the presence of severe respiratory symptoms and moderate esophageal angulation. Appropriate patient selection and meticulous surgical technique allow esophageal preservation with low morbidity and excellent clinical outcomes.

Continent appendicovesicostomy in a patient with congenital obstruction of the renal pelvis and multiple kidney transplantations: a detailed case report

2026-05-10T22:32:47+0530

Congenital obstruction of renal pelvis, also known as ureteropelvic junction (UPJ) obstruction presents as a functional obstruction at the ureteropelvic junction primarily resulting from smooth muscle abnormalities of ureter and pelvis. Appendicovesicostomy commonly known as the Mitrofanoff procedure, is a reconstructive urological surgical technique that utilizes the appendix to create a continent catheterizable channel among the skin and bladder. A 30-year old patient visited the surgical department of Grodno regional clinical hospital with complaints of periodic urine leakage from a fistula in the umbilical region. The condition had been present for a prolonged period with a past medical history of congenital obstruction of renal pelvis and multiple kidney transplantations. Preoperative laboratory investigations revealed mild anemia, with mild decrease in hemoglobin levels, with normal leucocyte and platelet count. A diagnosis of a persistent fistula associated with appendicovesicostomy was established based on these findings from fistulography, CT and cystography. This case report presents a rare persistent umbilical fistula following a continent appendicovesicostomy in a patient with a history of congenital renal pelvis obstruction and multiple kidney transplants.

Spontaneous interparietal posterior rectus sheath hernia presenting as small bowel obstruction in a virgin abdomen: a case report

2026-05-14T21:12:09+0530

Spontaneous posterior rectus sheath/interparietal hernias are exceedingly rare, with only a limited number of case reports published in the literature, particularly in patients without history of prior abdominal surgery. They may present diagnostic difficulty because the herniated bowel can remain contained within the abdominal wall layers without an obvious external bulge. We report a 65-year-old woman with hypertension and asthma, with prior hysterectomy via a transvaginal approach and no prior abdominal surgery, who presented with one day of abdominal pain, nausea, vomiting, and more than 24 hours of obstipation. Laboratory evaluation showed leukocytosis of 13.3×10⁹/L, with otherwise unremarkable chemistry and coagulation studies. CT demonstrated small bowel obstruction secondary to a right upper abdominal wall hernia, with a short segment of small bowel herniating between the transversus abdominis and rectus abdominis muscles, mild upstream dilation, small bowel feces sign, and reactive simple fluid in the hernia sac. Given persistent obstruction despite initial nonoperative management, the patient underwent operative exploration. The incarcerated small bowel was reduced from an obstructed interparietal abdominal wall hernia. The bowel was viable after reduction, and no resection was required. The hernia sac was excised and the fascial defect was closed. This case highlights a rare cause of small bowel obstruction in a virgin part of the abdominal wall and emphasizes the importance of careful CT review for deep abdominal wall hernias.

Autologous abdominal fat graft transposition for ischemic foot lesion with tendon exposure: a case report and literature review

2026-06-19T06:53:09+0530

The management of complex wounds such as diabetic foot ulcers, chronic arterial insufficiency lesions, and sacral pressure ulcers is on the rise in recent years due to the chronic nature of these wounds, the potential to become infected, and the difficulty in healing. Microsurgical reconstruction and local flaps are options but may not be possible in patients with significant vascular compromise. The autologous fat grafting has evolved from a simple volume filler to a potent biological modulator because it contains adipose-derived stem cells (ASCs) and growth factors. We discuss the physiologic mechanics of fat grafting and its advantages and disadvantages in the context of complex ischemic lesions.

A rare case of an unusual presentation of flank pain

2026-06-19T06:53:06+0530

Iliopsoas abscess (IPA) is an uncommon retroperitoneal infection with insidious onset and nonspecific clinical features. Image-guided percutaneous catheter drainage (PCD) is widely regarded as first-line therapy, but multiloculation, viscous pus, gas formation, and extensive anatomic spread predict PCD failure and warrant open surgical drainage. A 67-year-old woman with hypertension, treated breast cancer, prior stroke, and remote deep venous thrombosis presented with right-sided flank pain and a large fluctuant, tender subcutaneous mass. Computed tomography revealed a 14×2×5.8 cm multiloculated retroperitoneal collection involving the entire length of the right iliopsoas muscle from the crus of the right hemidiaphragm to the iliacus, with extension through the right posterolateral abdominal wall into the subcutaneous fat. She had undergone two unsuccessful interventional radiology-guided drainages at an outside facility. The white blood cell count was 29,000/µl and blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA); there was no evidence of osteomyelitis or endocarditis. After culture-directed antibiotics were initiated, the patient underwent staged open exploration through a right flank incision, with drainage of more than one litter of purulent material. Penrose drains were placed and the wound was left open for daily dressing changes. A two-week follow-up computed tomography (CT) demonstrated near complete resolution. Primary IPA is rare and prone to recurrence when initial drainage is incomplete. In multiloculated, anatomically extensive, or PCD-refractory disease, early conversion to open surgical drainage is essential to achieve definitive source control and prevent the cumulative morbidity of repeated unsuccessful intervention.

Emergency management of incarcerated rectal prolapse: combined Altemeier and Thiersch procedures in a surgical emergency

2026-04-28T16:18:28+0530

Incarcerated complete rectal prolapse is an uncommon but potentially life-threatening colorectal emergency because delayed treatment may lead to vascular compromise, bowel gangrene, and perforation. Surgical management depends on the patient’s physiological status, bowel viability, and anal sphincter function. A 59-year-old man presented with abdominal pain, recurrent vomiting, abdominal distension, constipation, and a protruding rectal mass. He had type 2 diabetes mellitus and hypertension and appeared cachectic. Examination revealed gross abdominal distension, absent bowel sounds, and bilious aspirate following Ryle’s tube insertion. Per rectal examination demonstrated a 15 cm irreducible prolapsed rectum that was edematous, congested, and non-reducible. Concentric mucosal folds confirmed incarcerated procidentia with impending ischemia. Emergency perineal proctosigmoidectomy (Altemeier procedure) under regional anesthesia was performed, followed by hand-sewn coloanal anastomosis. Because of marked anal sphincter laxity, a Thiersch repair using polypropylene encirclement suture was added. The postoperative course was uneventful, with early return of bowel function and no evidence of anastomotic leak, wound complication, or early recurrence. The patient was discharged on postoperative day 3. In emergency incarcerated rectal prolapse, a combined perineal approach using Altemeier resection with Thiersch reinforcement can provide safe and effective treatment, particularly in patients with redundant bowel and significant anal sphincter weakness.

The great mimicker of the bladder: paraganglioma masquerading as urothelial carcinoma

2026-04-19T02:04:47+0530

Urinary bladder paraganglioma is an exceptionally rare extra-adrenal neuroendocrine tumor arising from chromaffin cells, accounting for less than 0.05% of all bladder tumors. Due to nonspecific clinical presentation and overlapping radiological features, it is frequently misdiagnosed as urothelial carcinoma. Definitive diagnosis relies on histopathology with immunohistochemistry. A 63-year-old female presented with increased urinary frequency for eight months without hematuria or catecholamine-related symptoms. Imaging revealed a polypoidal lesion in the posterior bladder wall with calcification, suggestive of malignancy. The patient underwent transurethral resection of bladder tumor. Histopathology showed tumor cells arranged in nests with characteristic “salt and pepper” chromatin, raising suspicion of paraganglioma. Immunohistochemistry demonstrated positivity for chromogranin and synaptophysin, with negative epithelial markers and a low Ki-67 index, confirming the diagnosis. The postoperative course was uneventful. Bladder paragangliomas are rare and often indistinguishable from urothelial carcinoma clinically and radiologically. Non-functional tumors further complicate diagnosis. Histopathological overlap necessitates immunohistochemical confirmation. Transurethral resection may be both diagnostic and therapeutic in localized cases. Bladder paraganglioma should be considered in the differential diagnosis of bladder tumors. Early recognition and immunohistochemistry are essential for accurate diagnosis. Complete surgical excision with long-term follow-up is recommended.

Uncommon presentation of ventral hernia with strangulated falciform ligament and small bowel: a case report and its implication

2026-04-19T10:01:05+0530

Ventral hernias containing the falciform ligament are exceedingly rare. Only a limited number of cases describing incisional hernias with falciform ligament involvement have been reported in the literature. We present a case of a strangulated ventral hernia containing the distal portion of the falciform ligament along with a gangrenous segment of the mid-ileum. The patient underwent emergency exploratory laparotomy with resection of the gangrenous ileal segment and excision of the involved falciform ligament, followed by primary end-to-end ileo-ileal anastomosis. This case highlights the diagnostic challenges and surgical considerations associated with this rare entity.

Laparoscopic right salpingo-oophoropexy for torsion in a young patient thought to have acute appendicitis

2026-04-25T14:20:20+0530

Acute appendicitis is a common surgical emergency. However, it also has many mimickers i.e. other clinical conditions which closely mimic it vis-à-vis symptoms, signs, imaging and laboratory investigations. In female patients many of these mimickers happen to be gynecological conditions. The authors, herein, present the case of a 22 years old unmarried female who was pre-operatively diagnosed to have acute appendicitis. But, intra-operatively she was found to have acute torsion of the right fallopian tube – ovary complex. She was successfully managed laparoscopically without excision, thereby, hopefully; not diminishing her future fertility.

Fibroadenoma of the Skene’s gland: a rare paraurethral tumor in a postmenopausal female

2026-05-06T22:06:37+0530

Skene’s glands are paraurethral structures homologous to the male prostate and are an uncommon site for neoplastic lesions. Fibroadenoma, a benign biphasic tumor typically arising in the breast, is exceedingly rare in this location. A 70-year-old female presented with a 3-month history of a paraurethral swelling associated with difficulty in micturition. Local examination revealed a bright red paraurethral mass at the 11-12 O’clock position, clinically mimicking a urethral caruncle without associated discharge or bleeding. The lesion clinically mimicked a urethral caruncle and was surgically excised. Histopathological examination demonstrated a well-circumscribed biphasic lesion composed of slit-like and tubular glands within fibromyxoid stroma. The glands were lined by benign cuboidal to columnar epithelium with a preserved basal cell layer and focal apocrine change. No cytological atypia was identified. A diagnosis of fibroadenoma of the paraurethral (Skene’s) gland was made. Fibroadenoma of the Skene’s gland is an exceptionally rare entity. Histopathological evaluation is essential for diagnosis, and complete surgical excision results in excellent outcomes.

"Pellet storm": a case of 'mis-lead-ing' foreign body removal

2026-05-07T11:26:51+0530

Retained lead foreign bodies from industrial blast injuries pose dual challenges: complexity of immediate surgical extraction and long-term systemic lead toxicity risk (plumbism). Lead pellet injuries can result in blood lead levels (BLL) exceeding safe thresholds (>10 μg/dl adults), with severe toxicity at BLL >80 μg/dl. Surgical decision-making must balance the risks of invasive extraction against the risks of retained metallic lead. A 40-year-old male sustained a workplace blast injury when a lead welding machine exploded. He presented with a 5×6×2 cm wound on the lateral right thigh with active hemorrhage, partially charred subcutaneous tissue, and visible lead pellets. Initial radiographs demonstrated 98 round radio-opaque foreign bodies scattered throughout the right femur, thigh musculature, and one pellet in the left thumb. Primary survey confirmed hemodynamic stability (GCS 15/15, BP 122/80 mmHg, SpO₂ 97%). Femoral and popliteal pulses were intact bilaterally. Following re-suscitation and wound stabilization, exploratory surgery under C-arm fluoroscopic guidance achieved extraction of 78 pellets from vastus lateralis and medialis via medial and lateral thigh incisions. Approximately 20 pellets adjacent to the neurovascular bundle in the posterior com-partment were deliberately left in situ to avoid iatrogenic vascular or nerve injury. Estimated blood loss: 600 mL; intraoperative transfusion administered. Postoperative course complicated by wound infection on day 5, managed with debridement, culture-directed antibiotics, vacuum-assisted closure (VAC) therapy, and split-thickness skin graft. Patient discharged in haemody-namic stable status and, ambulatory with healed wound. Two-month follow-up showed no signs of infection, sinus tract formation, or clinical plumbism (patient subsequently lost to follow-up). This case illustrates the surgical challenge of balancing maximal foreign body extraction against the risk of neurovascular injury in penetrating trauma with multiple retained projectiles. The decision to leave ~20% of pellets in situ near critical structures reflects established trauma principles prioritizing preservation of neurovascular function over complete foreign body re-moval. Long-term plumbism risk remains uncertain; prospective data on lead toxicity from re-tained pellets are limited, though existing case series suggest elevated BLL can persist for months to years. Clinical and serological surveillance (serum lead levels, complete blood count) is recommended but was not completed in this case due to loss of follow-up.

Acute midgut volvulus with extensive small bowel necrosis in an adult secondary to intestinal malrotation with mobile cecum: a rare case report

2026-05-12T16:13:07+0530

Intestinal malrotation is a rare congenital anomaly in adults caused by incomplete rotation and fixation of the midgut during embryological development. Adult presentation is uncommon and may remain undiagnosed until complications such as midgut volvulus occur, leading to bowel ischemia and necrosis. Prompt diagnosis and surgical intervention are crucial to prevent morbidity and mortality. We report the case of a 38-year-old adult presenting with acute severe abdominal pain, recurrent bilious vomiting, and progressive abdominal distension. Clinical examination suggested acute intestinal obstruction with evolving peritonitis. Contrast-enhanced computed tomography revealed abnormal bowel orientation with twisting of mesenteric vessels producing the whirlpool sign and features of bowel ischemia. Emergency exploratory laparotomy was performed. Intraoperative findings demonstrated intestinal malrotation with midgut volvulus, extensive distal small bowel gangrene, and associated mobile cecum with pelvic appendix. The patient underwent derotation of the volvulus, resection of nonviable bowel, primary ileoileal end-to-end anastomosis, proximal diversion ileostomy, and appendicectomy. Postoperatively, the patient recovered gradually with restoration of bowel function. Surgical site infection with serous discharge corresponding to Southampton grade III wound infection developed but was managed successfully, and the patient was discharged in stable condition. Adult intestinal malrotation presenting with acute midgut volvulus is a rare but life-threatening surgical emergency. Early radiological diagnosis, especially recognition of the whirlpool sign on computed tomography, and urgent surgical management are essential for favorable outcomes. Intestinal malrotation should be considered as a differential diagnosis in adults presenting with acute abdomen and intestinal obstruction.

Computed tomography-detected portal venous gas managed conservatively: a case series emphasising clinical-radiological correlation

2026-04-20T04:54:53+0530

Portal venous gas (PVG), historically considered a critical radiological finding associated with life-threatening conditions such as mesenteric ischemia and sepsis, and often prompting urgent surgical intervention, is increasingly recognised in a wider spectrum of clinical scenarios with the advent of high-resolution computed tomography (CT). This case series describes three patients in whom PVG was identified on CT and successfully managed without surgery, with underlying causes including sepsis from a urinary source with gas-forming organisms, gastric distention with pneumatosis, and suspected ischemic colitis in the setting of preserved hemodynamic stability. All patients were treated conservatively with intravenous antibiotics and demonstrated favourable outcomes, underscoring the importance of interpreting PVG as a radiological sign rather than an automatic surgical indication. Clinical context, hemodynamic stability, laboratory findings, and adjunctive investigations remain central to guiding management, and recognition of benign or iatrogenic causes is essential to avoid unnecessary operative interventions.

Limberg flap as the standard treatment for pilonidal sinus

2026-06-19T06:53:05+0530

Pilonidal sinus disease (PSD) is a chronic inflammatory condition of the sacrococcygeal region predominantly affecting young adult males. Traditional surgical approaches such as wide excision with secondary healing or primary midline closure are associated with prolonged healing and higher recurrence rates. Off-midline flap procedures, particularly the Limberg flap, have demonstrated improved outcomes with faster recovery and lower recurrence. This retrospective case series included five male patients aged 20–30 years with chronic or recurrent PSD who underwent rhomboid excision with Limberg flap reconstruction between July 2023 and October 2024 at a district hospital. Operative details, postoperative outcomes, complications, and follow-up data were analyzed. The mean operative time was 45±15 minutes. Closed suction drains were removed on postoperative day 5±1. Two patients developed mild wound edge erythema that resolved with conservative treatment. No flap necrosis, wound infection, or seroma formation occurred. Complete wound healing was achieved within three weeks in all patients. During a follow-up period of 6–18 months, no recurrence was observed. Limberg flap reconstruction is a safe and effective technique for the treatment of pilonidal sinus disease, offering rapid wound healing, minimal complications, and low recurrence. Proper surgical technique and postoperative care are essential for optimal outcomes.