International Surgery Journal

Acute free gallbladder perforation with atypical presentation: a case report

Nouf Mohammed A. Aldhamdi — 2025-10-28

Gallbladder perforation (GBP) is a rare but potentially fatal complication of biliary tract disease if left untreated. We report the case of a 90-year-old female who presented with generalized abdominal pain associated with diarrhea and chills for three days. Upon examination, the patient was vitally stable, the abdomen was distended with epigastric and right hypochondriac tenderness, and she was positive for Murphy's sign. Laboratory findings showed high levels of liver enzymes, but normal bilirubin levels. Abdominal computed tomography revealed a gangrenous and perforated GB with marked inflammation and free fluid in the pelvis, right para-colic gutter, and GB bed. The patient was managed with intravenous antibiotics and laparoscopic cholecystectomy was successfully performed. The patient had an uneventful postoperative course. The diagnosis of GBP can be easily missed until it is detected intraoperatively because no clinical signs or pathognomonic features suggest the condition. Therefore, a high level of intuition is necessary to promptly establish a diagnosis, particularly in elderly patients. The approach to GBP remains an area of debate, considering many factors, including patient's stability, facility, and surgeon's expertise. Laparoscopic cholecystectomy should be considered as the first line of management in GBP cases, depending on the patient's stability and the surgeon's skills.

Bilateral inferior turbinate necrosis and septal perforation as a complication of nasal packing and sphenopalatine artery ligation for intractable epistaxis

Peter J. Eves — 2025-10-28

A male patient in his mid-70s was referred to ENT services at a regional centre with severe epistaxis. After failing conservative management, including nasal cautery and bilateral packing, the patient proceeded to have an uncomplicated left sphenopalatine artery (SPA) ligation. Six months later he developed nasal blockage and crusting and blew a large amount of foul-smelling necrotic tissue from his nose. Examination and investigation findings revealed loss of most of his nasal septum and both inferior turbinates. This occurred as a rare complication of nasal packing and SPA ligation causing ischaemic necrosis.

3-dimensional model rendering and printing: enhanced visualisation for complex multi-compartment cases

Gavin J. Carmichael — 2025-10-28

Complex surgical oncology demands meticulous preoperative planning, particularly in multi-specialty surgeries. Aligning surgical objectives, considering factors such as surgical intent, approach feasibility and minimization of trauma, is crucial. While traditional imaging modalities like MRI and CT are invaluable for planning, the integration of 3D modelling can provide enhanced visualisation of patient-specific anatomy and pathology. A 3D model was generated from MRI scans using 3DSlicer® software for segmentation and MeshLab® for refinement. Structures such as the bladder, rectum and prostate were manually contoured. The model was printed using a Bambu® Lab A1 3D printer with PLA filament. The printed model informed surgical planning for a multidisciplinary team managing a 60-year-old man with advanced bladder cancer invading the rectum. The 3D model provided detailed spatial understanding of anatomical relationships, improving preoperative planning and intraoperative execution. The surgical procedure, including cystoprostatectomy and Hartmann’s procedure, was successful, with the 3D model providing guidance in the approach and enhancing collaboration among team members. The model’s contribution extended beyond visualisation. It optimized surgical strategy by aiding in delineation of the tumour and enhancing interdisciplinary communication. Its educational utility helped trainees & students grasp pelvic anatomy and surgical techniques. Limitations included time-intensive manual segmentation and reliance on high-resolution imaging. Future advancements, such as automated segmentation and augmented reality, could improve efficiency and intraoperative applicability. 3D modelling and printing proved valuable in managing a rare, complex surgical case, fostering interdisciplinary collaboration and improved patient care. Further research and development could broaden its adoption and impact in surgical practice.

Traumatic hernia associated with Morel-Lavallé lesion in closed abdominal trauma: case report

Leonel L. Lugo — 2025-10-28

The traumatic hernia, is an important cause of laparotomy exploration between all the trauma cases that the trauma surgeon is get used to it. In this case we review a patient case where a traumatic hernia was associated with a morel-Lavalle lesion, these two injuries are associated with an increase in the morbidity sometimes requiring a reconstruction of the abdominal wall with multiples surgeries between, this is a review of the actual guidelines and surgery treatments emphasizing the complex panorama and the even evolving treatments with this kind of injuries.

Successful management of a rare horseshoe perianal fistula using the modified Hanley procedure: a case report

Ibnu Kharisman — 2025-10-28

Horseshoe perianal fistula is a rare, complex anorectal condition characterized by bilateral extension through the ischiorectal fossae, often challenging to treat surgically. We present a rare case successfully managed using the modified Hanley procedure, emphasizing sphincter preservation and complete drainage of the postanal space. The patient achieved complete healing without recurrence or continence compromise. This report underscores the value of the Hanley approach in managing complex horseshoe fistulas.

Small bowel obstruction through an internal hernia caused by a congenital mesenteric defect: an early diagnosis and prompt treatment of a rare condition saved a young life

Maria Chimarios — 2025-10-28

Congenital internal hernias causing small bowel obstruction are extremely rare in adults, with only approximately 28 cases reported in the literature. The condition carries a high mortality rate-up to 50% even with treatment, and nearly 100% without intervention. Diagnosis is particularly challenging due to the nonspecific nature of symptoms and often inconclusive imaging findings. We present a patient diagnosed with a trans mesenteric hernia resulting from a congenital defect. The patient failed conservative management, which included bowel rest, nasogastric tube placement, and monitoring with KUB X-rays. A diagnostic laparoscopy was performed and subsequently converted to a laparotomy. Intraoperative findings revealed a 6 cm defect in the mesentery with approximately 60 cm of small bowel herniating through, showing signs of early ischemia. Bowel viability was restored following reduction, and the mesenteric defect was closed. Congenital mesenteric defects, though rare, are an important consideration in the differential diagnosis of de novo small bowel obstruction, particularly in adults with a virgin abdomen and no history of prior abdominal surgery. Early recognition and prompt surgical intervention are essential, as timely management can significantly reduce the risk of morbidity and mortality.

Extensive omental-to-adnexal venous collateralization in a patient with history of tetralogy of Fallot and vena cava inferior agenesis: a case report

Tuur Debbaut — 2025-10-28

Tetralogy of Fallot (ToF) is a complex congenital cardiac anomaly increasingly associated with long-term extracardiac vascular adaptations. While arterial collaterals in ToF, such as major aortopulmonary collateral arteries, are well documented, venous collateral pathways remain underreported. Congenital agenesis of the inferior vena cava (IVC), a rare anomaly with a prevalence of 0.0005–1%, typically results in extensive venous collateralization through the azygos, gonadal, and retroperitoneal systems. Omental collateralization, however, has not been described in this context. Herein this report presents a 34-year-old woman with surgically repaired ToF who underwent laparoscopic appendectomy for acute appendicitis. Intraoperatively, extensive dilated venous collaterals were observed coursing from the omentum toward both adnexa. The ovaries appeared enlarged with multiple cystic nodules. Postoperatively, persistent pelvic pain prompted further evaluation. Contrast-enhanced computed tomography (CT) revealed congenital agenesis of the infrarenal IVC with collateral drainage via parauterine and omental venous plexuses. The left ovary demonstrated multiple cystic lesions up to 4.2 cm, consistent with chronic venous congestion rather than acute gynecologic pathology. Transvaginal ultrasound confirmed resolving cystic changes and varicose parauterine and omental plexuses. This case illustrates a previously undescribed omental–ovarian collateral circuit in the setting of IVC agenesis, coinciding with repaired ToF. The anomaly likely contributed to chronic pelvic pain and polycystic ovarian morphology, underscoring the clinical significance of venous remodeling in congenital vascular disease. Recognition of such variants is critical, as they may mimic pelvic masses on imaging and complicate surgery through increased bleeding risk. Awareness of rare collateral pathways expands the spectrum of venous adaptations and highlights implications for surgical, radiological, and reproductive management.

Magnet induced small bowel volvulus in a paediatric patient: a case report

Tshepang Arthur Motsepe — 2025-10-28

Ingestion of magnetic objects in children can cause life-threatening complications, such as small bowel perforation and peritonitis. Magnets are known to cause localised bowel ischaemia due to pressure necrosis that results in perforations and fistulae. However, the occurrence of small bowel volvulus, which carries more serious outcomes from the rotational mesenteric strangulation that leads to widespread bowel ischaemia and necrosis, is rarely reported. We present the case of a 4-year-old boy who developed an acute abdomen after swallowing magnetic pellets, which were discovered during laparotomy. Although magnet ingestion is a recognised cause of abdominal surgical emergencies, the risk of a volvulus underscores the need for a more urgent and decisive approach to obviate significant morbidity and mortality.

Robotic-assisted TAPP repair of supraumbilical hernia using the CMR™ Versius robotic system without composite mesh: a case report

Mirza Faraz Beg — 2025-10-28

Robotic surgery offers improved visualization, ergonomics and instrument dexterity. The CMR™ Versius robotic system presents a promising alternative to traditional platforms for hernia surgery. We report a robotic-assisted TAPP repair for a supraumbilical hernia using the Versius system. Surgical workflow, port placement, mesh deployment and docking time were documented. The surgery was completed without complications using a self-fixating polypropylene mesh, avoiding costly composite materials. The patient recovered uneventfully and was discharged on the second postoperative day. Robotic-assisted TAPP repair using the CMR™ Versius platform is safe, ergonomic and cost-effective. Avoiding fixation devices and composite mesh offers economic advantages. The system holds promise for routine abdominal wall hernia repairs.

Prolapsing posterior urethral polyp with hypospadias in a neonate

Ameya S. Muzumdar — 2025-10-28

Urethral polyps occur as polypoidal masses of urethra. These lesions predominantly present as solitary lesions rather than multifocal growths. These constitute approximately 1% of all benign urogenital neoplasms making them a rare entity. A male neonate presented at birth with a prolapsing urethral mass through a proximal penile hypospadiac meatus. After thorough evaluation for other associated anomalies patient underwent excision of the mass. Histopathology revealed a fibroepithelial polyp. Urethral polyp is a rare anomaly of the urethra. Surgical management is tailored to the specific nature and location of the polyp and the patient's general condition. Surgical excision should be undertaken with utmost care of local tissues.

Flap and FiLaC™ duo heals a complex grade IV anal fistula: case report of a surgical success

Nobby Maniranjan — 2025-10-28

Complex anal fistulas, particularly those classified as grade IV, present significant management challenges due to their intricate anatomy, risk of recurrence, and potential for sphincter damage leading to incontinence. Traditional sphincter-sparing techniques such as anal mucosal advancement flap has been widely used, while minimally invasive approaches like fistula laser closure (FiLaC™) have emerged as adjunctive therapies. This case report describes a successful treatment of a 44-year-old male with a complex trans-sphincteric fistula using a combination of mucosal advancement flap and FiLaC™ laser ablation. A 44-year-old male presented with chronic purulent discharge from multiple perianal swellings for three years. Magnetic resonance imaging (MRI) fistulogram identified a grade IV complex trans-sphincteric fistula (St. James's University Hospital Classification) with a single internal opening at 6 o'clock and multiple ramifications. Under regional anesthesia, the patient underwent surgical exploration. Three external tracts located at 1, 3, and 5 o'clock positions were traced to a single trans-sphincteric internal opening. The internal opening was closed with 2-0 vicryl sutures. Laser ablation using FiLaC™ was performed after thorough curettage, followed by creation and advancement of a healthy anal mucosal flap to cover the internal opening.

Traumatic radial artery pseudoaneurysm with cephalic venous graft repair

Andrea N. Dias — 2025-10-28

A pseudoaneurysm of the radial artery is a rare vascular abnormality most frequently resulting from penetrating injuries or iatrogenic etiologies. The lack of structural integrity predisposes it to complications, including, but not limited to, rupture. In the given case, a middle-aged man presented with a pulsating mass over the flexor aspect of the right forearm secondary to a traumatic injury previously managed with debridement and suturing. Physical examination demonstrated a cystic swelling with a positive Nicoladoni-Branham sign. Doppler ultrasound findings were suggestive of an arteriovenous malformation. The lesion however was found to be a pseudoaneurysm intraoperatively. The patient underwent an exploratory surgery, including ligation and pseudoaneurysm excision, followed by reconstruction of the radial artery using a cephalic venous graft. Post operatively, the patient exhibited satisfactory healing with a healthy, patent graft. The increasing utilisation of the radial artery in procedures such as catheterisation owing to its accessibility, lower complication rates and faster recovery, establishes it as a key site for pseudoaneurysm formation. The absence of standardized diagnostic criteria complicates timely diagnosis and management of pseudoaneurysms, thereby increasing the risk of complications.

Reinforcement clipping over energy-sealed arteries: a technical caution

Rajnish Talwar — 2025-10-28

Energy-based vessel sealing is a trusted technique in modern surgery. However, the application of mechanical clips over a thermally sealed vessel can paradoxically disrupt the integrity of the seal. A 55-year-old male underwent radical surgery for a retromolar trigone malignancy. The facial artery was sealed with LigaSure and secondarily clipped. On postoperative day four, torrential bleeding from the stump led to a cardiac arrest. Re-exploration revealed that the clip had transected the energy-sealed segment. Reinforcement clipping over energy-sealed stumps may compromise vessel integrity. If additional control is needed, clips should be applied before sealing, not after. This case highlights the need for adherence to energy device principles and avoidance of reinforcement clipping over thermally sealed vessels.

Gastric pneumatosis in the preterm neonate: incidental finding or NEC spectrum

Rajib Bora — 2025-10-28

Gastric pneumatosis is a condition defined as air within the wall of the stomach, however, is an extremely rare sign during neonatal period. Due to an association of this entity with Necrotizing enterocolitis (NEC) which is a fulminant condition with high morbidity and mortality in neonates, finding gastric pneumatosis especially in a premature neonate should alert the clinician. Other causes have also been identified like gastric outlet obstruction or displaced nasogastric or orogastric tube in stomach wall. This entity should not be confused with free air in abdomen and can be managed conservatively. We herein present a case of a premature neonate with a finding of gastric pneumatosis and culture-proven sepsis who was managed conservatively.

When size meets skill: the surgical ordeal of a giant retroperitoneal liposarcoma

K. Sreekanth — 2025-10-28

Retroperitoneal liposarcomas represent an uncommon subset of soft tissue sarcomas, typically exhibiting an indolent growth pattern and remaining clinically silent until attaining a size sufficient to exert mass effect on adjacent organs. Lesions measuring 30 cm or more in maximal diameter are exceedingly rare, with only a limited number of such cases documented in the literature. This report presents a 32-year-old woman from Zambia presented with a history of progressive abdominal distension over the past eight years. She had been diagnosed with a retroperitoneal liposarcoma and was referred to our centre for further management. Contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed a large, predominantly fat-density lesion arising from the right retroperitoneum, measuring approximately 194×274×301 mm. The mass occupied most of the abdominal and pelvic cavities, encasing and displacing the right kidney, proximal ureter, and renal vessels. The right adrenal gland was also encased, and the bowel loops were displaced toward the left side. The duodenum, ascending colon, pancreas, and inferior vena cava (IVC) were displaced superiorly and to the left, with the lesion abutting the inferior surface of the liver. Complete surgical excision of the retroperitoneal tumour was achieved, including an en bloc right nephrectomy. Massive retroperitoneal liposarcoma is an extremely rare neoplasm with a high risk of recurrence, influenced by factors such as histological subtype, tumour grade, presence of metastases, and completeness of surgical excision. In the present case, a complete resection was achieved, including an en bloc right nephrectomy. The patient will be monitored closely with periodic clinical and radiological follow-up to enable early detection of any recurrence.

Jejunal atresia (type 3A) with jejunoileal fistula: a case report of jejunal atresia with rare presentation

Surishta K. Rana — 2025-10-28

A six-month-old girl presented to pediatrics emergency with features suggestive of subacute presentation of intestinal obstruction. Laparotomy revealed type 3A jejunal atresia with jejunoileal fistula. The proximal jejunal end having narrow pinpoint connection with distal segment at 10 cm distal to atretic site. A mesenteric defect noted in between two segments. A long thick fibrovascular band found arising at the mesenteric defect site and distally attached to splenic flexure.

Veins that bulge: understanding rare venous aneurysm of the upper extremity: a case report

Rajib Bora — 2025-10-28

Venous aneurysm (VA) of upper extremity is an extremely rare condition in children. The reported incidence of upper limb VA is around 10% which mostly presents as an asymptomatic mass. Due to subtle clinical presentation and resemblance to common soft tissue lesions, evaluation of VA requires careful clinical examination with radiological imaging. We present a rare case of VA in a 16-year male in forearm involving the cephalic vein that was managed successfully with surgical excision.

Pancreatic schwannoma with cystic degeneration: a rare tumor mimicking cystic neoplasm

Nived Rao Balmoori — 2025-10-28

Pancreatic schwannomas are rare benign nerve sheath tumours, accounting for <1% of pancreatic neoplasms. Their radiological and clinical presentation often mimics cystic pancreatic neoplasms, leading to diagnostic uncertainty. Authors present the case of a 56-year-old female with early satiety and anorexia for four months. CECT abdomen revealed a 9×8 cm lobulated, septated, hypodense cystic lesion with peripheral wall calcifications, arising from the head and uncinate process of the pancreas, suggestive of macrocystic neoplasm. Exploratory laparotomy revealed a well-encapsulated, exophytic, solid-cystic mass arising from the pancreatic head, abutting but not infiltrating adjacent duodenum, SMV and SMA. Complete excision was performed. Histopathology showed spindle cell lesion, and immunohistochemistry confirmed schwannoma with ancient change (S100+, SOX10+, CD117–, DOG1–, CD34–, Desmin–, Ki67 <1%). Postoperative course was uneventful. Pancreatic schwannomas, though rare, should be considered in the differential diagnosis of cystic pancreatic lesions. Immunohistochemistry is essential for definitive diagnosis. Complete surgical excision offers excellent outcomes.

Technical details of laparoscopic sleeve gastrectomy with attention to staple line leak and hemorrhage: discussion of 3,031 consecutive cases

Christian A. Gonzalez — 2025-10-28

Background: Laparoscopic sleeve gastrectomy continues to rise as an effective surgical procedure for weight loss in obese patients. With that, gastric staple line leak and hemorrhage remain the most serious complications and occur in up to 3% of all cases. Each complication is associated with a high degree of morbidity and mortality for the patient as well as substantial cost of care for institutions and payers. Techniques to minimize the risk of sleeve gastrectomy leak and hemorrhage have been published although no universally agreed upon set of techniques exists. This report updates a single-surgeon experience with an approach to sleeve leak and hemorrhage prevention over 10 years.

Methods: 3,031 consecutive sleeve gastrectomy cases between 2012 and 2021 were reviewed retrospectively. Patient characteristics, incidence of leaks and hemorrhage, and percent body weight loss at 6 months were reported for each year. Conceptual and technical changes aimed towards leak and hemorrhage reduction are presented.

Results: With the implementation of the described techniques of sleeve gastrectomy, the rate of sleeve leaks fell from 3.8% in 2012 to 0% in 2015 through 2021, and hemorrhage fell from 1.3% in 2012 to 0.1% in 2018 through 2021. Weight loss remained consistent, as depicted by 6-month change in body weight and percent excess BMI lost.

Conclusion: In this single-surgeon experience, sleeve gastrectomy leak rate fell to 0.0% and staple line hemorrhage rate fell to 0.1% with the implementation of specific technical modifications in the procedure, spanning over 3,031 consecutive cases.

Comparison of fistulectomy and fistulotomy in low variety perianal fistula

Mohammad Al-Mamun — 2025-10-28

Background: Fistula in ano is an abnormal tunnel between the anal canal and perianal skin, often causing pain and discharge. This study aims to compare the outcomes of fistulectomy and fistulotomy in patients with low variety perianal fistula.

Methods: This cross-sectional, descriptive study was conducted at the Department of Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from April to September 2012. Fifty patients with low variety perianal fistula underwent fistulectomy (n=25) or fistulotomy (n=25) under spinal anesthesia, with pre- and postoperative antibiotics and analgesics. Outcomes assessed included hospital stay, wound healing, pain, workload, and cost, with weekly follow-up for six weeks.

Results: Among 50 participants (mean age 40 years; fistulectomy 39, fistulotomy 41), 82% were male (M: F 5:1 versus 4:1). Most were laborers (38%), shopkeepers (26%), or farmers (18%). Prior anorectal abscesses accounted for all fistulae (spontaneous rupture 80%, incision and drainage 20%). Common complaints were discharge 96%, pain 80%, swelling 64%; purulent discharge 90%. Posterior fistulae predominated (70%). Postoperative pain scores were 8.88 versus 5.20 (p<0.001), hospital stay 4.65 versus 4.08 days (p<0.001), and wound healing 31 versus 29 days (p=0.001) for fistulectomy versus fistulotomy; 18 patients had temporary urinary retention (1 catheterized).

Conclusion: Fistulotomy is the preferred treatment for low variety perianal fistula, offering faster healing, shorter hospital stays and lower patient and healthcare burden compared to fistulectomy.

Validation and comparison of clinical predictive scores for testicular torsion in children with acute scrotum

Asmir Jonuzi — 2025-10-28

Background: Testicular torsion scoring systems, based on a combination of clinical and imaging factors, have been developed to improve the diagnostic accuracy of testicular torsion in patients presenting with acute scrotum. This study aimed to validate and compare two current testicular torsion scores the Boettcher Alert Score (BAL) and the Testicular Workup for Ischemia and Suspected Torsion (TWIST)-in a retrospective cohort of pediatric patients with acute scrotum.

Methods: We conducted a retrospective study of all pediatric patients admitted to our institution for acute scrotum between January 2010 and December 2022. Patients were categorized into the testicular torsion (TT) group and the non-testicular torsion (NTT) group. Collected data were used to calculate the scoring systems and perform statistical analyses.

Results: A total of 241 patients were included, of whom 80 (33.2%) had testicular torsion. The mean age in the TT group was 13 years. The optimal individual cut-off value for the BAL score was >1 (sensitivity 90%, specificity 80.75%), and for the TWIST score >4 (sensitivity 82.5%, specificity 80.75%). A high-risk TWIST score >5 had a specificity of 80.75% and a negative predictive value (NPV) of 90.28%, while a BAL score of 4 showed a specificity of 98.48% and NPV of 94.2%. The area under the ROC curve was slightly higher for the BAL score (0.917; 95% CI, 0.875–0.949) than for the TWIST score (0.897; 95% CI, 0.851–0.932). The difference between the two scores was not statistically significant.

Conclusion: The TWIST and BAL clinical scores have significant diagnostic value and may assist in the evaluation of testicular torsion in children. Both scores could be incorporated into a standardized approach for assessing pediatric acute scrotum, potentially reducing time to definitive diagnosis, and minimizing ischemia duration.

Comparative evaluation of topical phenytoin versus povidone iodine dressing in the healing of diabetic foot ulcers: a randomized controlled trial

Pulivarthi Aakaash Hemanth — 2025-10-28

Background: Diabetic foot ulcers (DFUs) are a crucial diabetes consequence that frequently leads to slow healing, infection and the need for amputation. Povidone iodine (PVP-I) is a widely used antiseptic, whereas phenytoin has lately emerged as a promising wound healing agent due to its proliferative and antibacterial effects. Hence the current study aims to compare the efficacy of topical phenytoin and povidone iodine dressings in promoting healing of diabetic foot ulcers.

Methods: A randomized controlled trial was conducted at Navodaya Medical College Hospital, Raichur among 124 patients with grade 1 or 2 diabetic foot ulcers were randomly assigned to two groups which are Group A (phenytoin dressing) and Group B (povidone iodine dressing). Ulcer area was measured at baseline and on Days 3, 5, 7, 10 and 14. Percentage reduction in ulcer area, slough clearance and granulation tissue formation was measured and subjected to statistical analysis.

Results: Both groups showed significant reduction in ulcer area by Day 14, with greater improvement in Group A (22.03±9.86%) than in Group B (13.85±5.62%) (p=0.001). Mean absolute reduction in ulcer area was higher in the phenytoin group (6.03 mm² vs. 3.99 mm², p=0.004). Slough clearance was achieved in 95.2% of patients in Group A versus 82.3% in Group B. Granulation tissue appeared earlier and was more robust in Group A. No significant adverse effects were reported.

Conclusions: Topical phenytoin dressing is significantly more effective than povidone iodine in accelerating up the healing of diabetic foot ulcers.

Validation of the G10 scoring system in predicting conversion from laparoscopic to open cholecystectomy in department of surgery at a tertiary medical centre of North India: a prospective observational study

Ankush Chauhan — 2025-10-28

Background: Laparoscopic cholecystectomy (LC) is the gold standard for managing symptomatic cholelithiasis. However, intraoperative challenges may necessitate conversion to open cholecystectomy (OC), which increases morbidity. The G10 score aims to stratify surgical difficulty and predict conversion risk. To evaluate the effectiveness of the G10 scoring system in predicting the need for conversion from LC to OC.

Methods: This hospital-based, prospective observational study was conducted at GSVM Medical College, Kanpur, between November 2023 and November 2025. A total of 146 patients with chronic cholecystitis undergoing elective LC were included. G10 scores were recorded intraoperatively. Data analysis included descriptive statistics, chi-square tests, independent t-tests, logistic regression, and ROC curve analysis using SPSS v23.0.

Results: Among the 146 patients, 24 (16.4%) required conversion to OC. The mean G10 score in the converted group was 6.08 compared to 3.4 in the non-converted group (p<0.001). ROC AUC was 0.87, indicating strong predictive value. Significant predictors included adhesions from previous surgeries, gallstones >1 cm in Hartmann’s pouch, and presence of pus or bile (all p=0.00). Logistic regression model accuracy was 80%.

Conclusion: The G10 score is a reliable intraoperative predictor of conversion from LC to OC. Its application supports better surgical planning and improved patient outcomes.

Evaluation of early surgical and functional outcomes of anterolateral thigh free flap and radial forearm free flap for reconstruction of soft tissue defects of oral cavity

Nabina Rahman — 2025-10-28

Background: Anterolateral thigh free flap (ALTFF) and radial forearm free flap (RFFF) are preferred for oral cavity reconstruction due to reliability, high success, and low donor-site morbidity. The aim of this study was to evaluate the early surgical and functional outcomes of ALTFF and RFFF in the reconstruction of soft tissue defects of the oral cavity.

Methods: This prospective observational study was conducted in the department of plastic surgery, NIBPS, Dhaka, from July 2020 to December 2021. A total of 20 patients who required free flap reconstruction following surgical resection of oral cavity lesions, with or without adjacent soft tissue or bone involvement, were included.

Results: The mean patient age was 54.8±8.48 years, with a female predominance (60%). All defects were in the cheek, most commonly involving the angle of the mouth (60%). ALTFF was used in 55% and RFFF in 45% of cases. Flap survival was 90.9% for ALTFF and 77.7% for RFFF. Functional outcomes were satisfactory. ALTFF donor sites were closed primarily, while RFFF donor sites required STSG, with 33.3% showing minor graft loss. Donor site morbidity was higher in RFFF cases.

Conclusions: Both ALTFF and RFFF are reliable for reconstruction of oral cavity soft tissue defects, providing high flap survival and acceptable functional results.

Comparison of outcomes between onlay and intraperitoneal onlay mesh plus ventral hernia repair: a prospective study

Sachin Kumar — 2025-10-28

Introduction: Ventral hernias are common surgical conditions requiring either open (Onlay) or laparoscopic (Intraperitoneal Onlay Mesh (IPOM) Plus) repair. This study compares their outcomes to guide clinical decision-making.

Methods: A prospective study was conducted at Ganesh Shankar Vidyarthi Memorial Medical College, Kanpur and Jeevanshree Hospital, Maharashtra, randomized 94 patients with ventral hernias (defect size 3-7 cm, age 18-60 years) into Onlay (n=47) or IPOM Plus (n=47) groups. Outcomes included operative time, hospital stay, surgical site infection (SSI), hematoma, seroma, pain (Visual Analog Scale (VAS)), return to activities/work, and recurrence. Data were analyzed using T-tests and chi-square tests (p<0.05).

Results: IPOM plus resulted in longer operative times (94.19±12.34 vs. 53.85±10.56 min, p<0.001), but shorter hospital stays (2.09±0.87 vs. 4.18±1.23 days, p<0.001) and faster return to daily activities (8.34±2.01 vs. 11.40±2.56 days, p<0.001) and work (14.72±3.12 vs. 18.36±3.89 days, p=0.030). The IPOM Plus group had lower rates of hematoma (0% vs. 25.5%, p<0.001), seroma (10.6% vs. 34%, p=0.006), and SSI (4.3% vs. 27.7%, p=0.002). Acute postoperative pain was lower in IPOM plus, while chronic pain and recurrence rates were comparable.

Conclusions: IPOM plus offers reduced complications and faster recovery, despite longer operative times, making it preferable for suitable patients. Recurrence rates are comparable.

Unlocking arteriovenous fistula success: a prospective randomized controlled trial on intraoperative IV heparin for superior vascular access outcomes

Mahatab Singh Rajawat — 2025-10-28

Introduction: End-stage renal disease (ESRD) prevalence is rising globally, making vascular access for haemodialysis increasingly important. Arteriovenous fistula (AVF) remains the gold standard for durable vascular access, but early failure due to thrombosis remains a concern. The use of intraoperative heparin to improve patency is debated. To assess the effect of a single intraoperative intravenous dose of heparin on early AVF patency and postoperative complications.

Methods: This prospective randomized controlled trial was conducted from January to December 2019 at the Institute of Nephrourology, Bangalore. A total of 240 patients undergoing AVF creation were randomized into two groups: Group A received 5000 IU IV heparin intraoperatively (n=130) and Group B underwent surgery without heparin (n=110). Primary outcome was AVF patency on postoperative days 1 and 8. Secondary outcomes included postoperative bleeding, hematoma, infection, and thrombosis. Statistical significance was set at p<0.05.

Results: Baseline characteristics and AVF type distribution were comparable between groups. On day 1, RCAVF patency was significantly higher in the heparin group (96.5% vs. 84.2%, p=0.01). On day 8, RCAVF patency remained higher in the heparin group (94.4% vs. 80.2%, p=0.007). BCAVF patency improvement was not statistically significant. Complication rates did not differ significantly.

Conclusions: A single dose of intraoperative IV heparin significantly lowers thrombosis rates and enhances patency in both radiocephalic and brachiocephalic AVFs. Notably, the improvement reached statistical significance in radiocephalic fistulas, highlighting its potential as a simple yet powerful intervention especially in AVFs with small-caliber vessels.

Early outcomes after TAPP vs. Lichtenstein repair: a prospective cohort from a resource limited surgical unit in South India

Peranbu Loganathan — 2025-10-28

Background: Inguinal hernia repair is a globally prevalent surgical procedure. Despite declining age-standardized prevalence, the absolute global burden is increasing, necessitating optimized surgical strategies. Open Lichtenstein and laparoscopic (TAPP/TEP) mesh repairs represent the two dominant surgical approaches, each with distinct perioperative profiles and patient outcomes. This study prospectively compared these techniques to provide evidence-based guidance for surgical decision-making in resource-constrained healthcare settings.

Methods: A prospective observational comparative study was conducted at a tertiary care teaching hospital in Chennai, India, between July 2022 to December 2023. Sixty eligible patients (59 male, 1 female; mean age ~45 years) with inguinal hernias were allocated to Lichtenstein open repair (n=30) or TAPP laparoscopic repair (n=30) based on clinical suitability patient factors, and surgeon discretion. Primary outcomes included operative time, postoperative pain (Visual Analog Scale-VAS at 12, 24, 48 hours), length of hospital stay, and time to return to work. Secondary outcomes were complications (infection, seroma, hematoma). Statistical analysis employed independent t-tests and chi-square/Fisher's exact tests (p<0.05 significant).

Results: Operative time was significantly longer for TAPP (113.33±12.41 minutes) compared to Lichtenstein (61.50±11.23 minutes; p<0.001). However, the TAPP group demonstrated significantly lower VAS pain scores at 12 hours (4.83±0.70 vs. 7.60±0.77), 24 hours (2.97±0.72 vs. 5.03±0.85), and 48 hours (1.73±0.45 vs. 3.40±0.93; all p<0.001). Hospital stay was shorter for TAPP (4.97±0.85 days vs. 6.70±1.75 days; p<0.001), and return to work was faster (10.30±1.54 days vs. 18.50±2.80 days; p<0.001). Complication rates (infection, seroma, hematoma) were low and comparable between groups (infection: p=0.492; overall complications <5%). Direct hernias were more frequently repaired laparoscopically (p=0.042).

Conclusion: While laparoscopic (TAPP) inguinal hernia repair requires significantly longer operative time and expertise, it offers substantial advantages in the early postoperative recovery, including reduced pain, shorter hospital stay, and faster return to normal activities, with equivalent safety profile compared to open Lichtenstein repair. These benefits support the role of laparoscopic repair, particularly in younger patients and when rapid functional recovery is prioritized, despite its technical demands.

The power flap: streamlining the PMMC for consistent surgical outcomes

Sasikanth Maddu — 2025-10-28

Background: The gold standard for reconstructive surgery is free flap reconstruction. Nevertheless, in developing nations, the high volume of cases, along with infrastructural and resource limitations, has led to the continued use of pectoralis major musculocutaneous flap (PMMC). This article seeks to share our experiences with the harvesting of PMMC flap and the associated outcomes.

Methods: A total of 45 patients were retrospectively assessed for reconstruction over a period of 5 years (January 2019 to February 2024). Of these, 30 patients underwent reconstruction using the PMMC flap following a stream lined protocol. The outcomes of the reconstruction, categorized as either successful or unsuccessful, along with any complications that arose, were thoroughly evaluated. Data was analyzed using SPSS version 26.0.and presented a numbers and percentages.

Results: The largest proportion of patients fell within the 41–60 age range, accounting for 63.33%. The buccal mucosa was identified as the most frequent location for primary lesions, affecting 21 patients (70.00%). Among the 30 patients who received PMMC flap reconstruction following a standardized technique making it a streamlined protocol, there were no instances of complete flap loss, resulting in a success rate of 100%. However, one case did report necrosis of the breast mound where standardization was not considered.

Conclusions: Based on our experience, PMMC flap remains a practical choice for reconstruction, particularly in settings with limited resources. Present approach was standardized by clearly defining the steps of the flap elevation by making it thin and less bulky, increasing its reach, minimizing the donor site morbidities and reducing the donor site deformities. With this stream lined protocol even a junior most plastic surgeon can perform the surgery confidently without facing significant complexity.

Diagnostic efficiency of clinical RIPASA score in acute appendicitis: a prospective study

Manmohan Singh — 2025-10-28

Background: Accurate diagnosis of acute appendicitis (AA) remains a challenge in emergency surgical settings. The RIPASA score is a clinical tool developed to improve diagnostic accuracy, especially in Asian populations. This study aims to evaluate and compare the positive predictive value of biochemical markers (WBC, CRP) with the RIPASA score in diagnosing acute appendicitis.

Methods: This prospective, hospital-based comparative study was conducted at RNT Medical College, Udaipur. A total of 84 patients presenting with suspected acute appendicitis between January 2023 and July 2024 were included. Clinical evaluation was performed using the RIPASA score, and biochemical markers (WBC and CRP) were assessed. Histopathology confirmed the diagnosis. Diagnostic accuracy was evaluated through sensitivity, specificity, PPV, NPV, and ROC curves.

Results: The RIPASA score showed the highest diagnostic performance with an AUC of 0.87, sensitivity of 82.3%, and specificity of 89.1%. WBC count (>11,100/μl) had a sensitivity of 85.8% and specificity of 72.4% (AUC=0.781). CRP (>40.0 mg/L) showed moderate accuracy with 72.7% sensitivity and 76.5% specificity (AUC=0.56). RIPASA score showed a moderate positive correlation with WBC (Pearson’s r=0.47, p<0.01) and a strong positive correlation with CRP (Pearson’s r=0.61, p<0.01), while WBC and CRP also showed a weak but significant correlation (Pearson’s r=0.35, p<0.05).

Conclusion: RIPASA score is more reliable than CRP and correlated well with WBC in diagnosing acute appendicitis. Combining clinical scoring with selective biochemical markers enhances diagnostic accuracy.

The utility of CT scan for identifying hollow viscus injury in blunt abdominal trauma: a systematic review

Marium Gul Muhammad — 2025-10-28

Introduction: Computed tomography (CT) is the preferred imaging modality for assessing blunt abdominal trauma and is the gold standard for detecting hollow viscus injuries. CT may occasionally miss significant injuries in such settings. This systematic review examines the incidence of hollow viscus injury in blunt abdominal trauma and evaluates the diagnostic accuracy of the initial trauma CT.

Method: A keyword search for PubMed, SCOPUS, Web of Science and Embase was undertaken. Key words “hollow viscus injury” and “blunt abdominal trauma” were used. Inclusion criteria included blunt abdominal trauma, adult population and English language. This search identified 1826 studies. After abstract screening and full text review, 15 studies met criteria to be included in this review.

Result: All studies were retrospective in design and were from trauma centers. A total of 20199 patients had CT scans upon admissions following blunt trauma. The incidence of hollow viscus injury was found to be 14.45% (n=2920/20199). Location of injuries included stomach 0.079% (n= 16/20199), duodenum 0.41% (n=84/20199), Ileum/jejunum 1.65% (n=333/20199), large intestine 0.81% (n=164/20199) and unspecified bowel injuries 11.5% (n=3049/20199). There were a total of 217/20199 (1.07%) injuries that were missed on the initial CT scan. Patients with hollow viscus injury, but negative initial CT scans, were identified within 36 hours of presentation.

Conclusion: Although CT scan is a very effective and widely used method for identification of hollow viscus injury in blunt trauma, it is not always definitive. Patients with hollow viscus injury that were missed on initial CT scans were identified within 36 hours of presentation.