Journal of Surgery

Circumcision is one of the oldest known surgical procedures which are practiced around the globe. During Circumcision foreskin of male penis is excised for social, cultural, religious and medical reasons. Ritual circumcision is one of the major determinants for its practice. Traditionally it is undertaken as a mark of cultural as well as religious identity and integrity. It not only improves penile hygiene but also reduce the risk of infections like urinary tract infection, HIV and other sexually transmitted diseases. It also reduces the risk of penile cancer when performed in neonates. According to an estimate one in every three males are circumcised worldwide. Although it is universally practiced but it is not clearly known how this practice came in to existence? Many theories and explanation have been given to answer this question. Before the evolution of the modern system of the medicine, the health system was fully dependent on the traditional system of medicine. Amongst them Unani system of the medicine was most popular. Physician and surgeons of this system of medicine laid down the concept of medicine and surgery and greatly emphasized on their progress. Like other surgical procedure, surgeons of Unani medicine made remarkable contribution in the development of operative procedure of the circumcision. The main aim of this paper is to review the global practice of circumcision, its historical background, its traditional and modern methods and the input of Unani surgeons in their evolution.

Emphysematous cystitis is a very rare form of lower urinary tract infection with gas formation. It commonly presents with suprapubic pain associated with lower urinary tract symptoms (LUTS). Predisposing factors are old age, diabetes mellitus, female gender, urinary tract obstruction and neurogenic bladder. Most frequent causative pathogens are Escherichia coli and Klebsiella pneumonia. Imaging is essential to confirm the diagnosis. Prompt treatment marks in improved outcome and better prognosis. It should be considered as one of the differentials of acute urinary retention with UTI. Here we present a case of emphysematous cystitis in an immunocompetent host presenting as acute urinary retention.

Background: The modification of the pelvic volume strongly influences the blood loss in “open book” fractures. Assessment of the degree of the changes helps in further management of the trauma patient.
Aim: The aim of this study was to create a three-dimensional pelvic model for the measurement of pelvic size. Methods: Using computer software we created three-dimensional models of the pelvis, based on CT images of 21 patients. To simulate an “open book” pelvic fracture we generated 2, 4, 6, 8 and 10 cm pubic disjunctions on the virtual model. In each modification we measured the pelvic diameters and we calculated the pelvic volume. The mathematical model used for calculation was the truncated elliptical cone.
Results: The mean pelvic volume was 1005.97 cm3. The transverse diameter increased significantly at 2 cm of pubic disjunction (p=0.0228). At 6 cm pubic disjunction significant modifications were noticed in promonto-suprapubic (p=0.0057) and biischiadic (p=0.0221) diameters. The pelvic volume increases significantly at only 4 cm pubic disjunction (p=0.0442). At 10 cm disjunction an increase of over 50% of the original volume occurred.
Conclusion: By measuring the pubic disjunction on CT image we can appreciate the pelvic volume increase. CT scan with bone visualization may be useful in previewing the magnitude of the hemorrhage in victims of blunt traumatic injuries associated with pelvic fracture, but further in vivo studies may be necessary.

Splenic hydatid cyst is a rare disease. The aim of this study is to specify epidemiologic features, diagnostic tools, and therapeutic modalities of this disease.
Materials and methods: This is a retrospective study of 28 patients operated on by open and laparoscopic approach for a splenic hydatid cyst between January 1990 and December 2017 in First Surgical Clinic of "St. Spiridon" University Hospital of Iasi. The demographic data, localization, diagnosis, treatment methods, and the length of postoperative hospital stay of patients with splenic hydatid cysts were evaluated.
Results: Our study group included 16 women and 12 men with a mean age of 47.82 years. 17 patients had solitary splenic involvement and 11 patients had multiple organ involvement. Abdominal pain was the most common symptom. Splenomegaly was detected on physical examination in 12 patients. Ultrasound examination and CT scan revealed a cystic mass in the spleen in all cases. All patients were operated on by laparoscopic approach-6 cases (one conversion) and by open approach-22 cases: 26 total splenectomies and 2 conservative procedures for the spleen being performed. It is sometimes difficult to perform laparoscopic approach because of close adhesions with adjacent organs. No postoperative death was recorded, and the overall morbidity was 23.3%.
Conclusions: Splenic hydatid cysts are rare, being more common in endemic areas; in our region the incidence of splenic hydatid cysts is low. The splenic hydatid cyst may become a challenging surgical problem. The management must be individualized. Laparoscopic approach is feasible in selective cases.

Introduction: Gallbladder disease is common and results in high health care costs. Indeed, estimates of the lifetime risk of gallstone formation are as high as 10% to 20% of the general population. The natural history of symptomatic gallstone disease is such that approximately 70% of patients will continue to have episodic symptoms or experience a complication of gallstones within 2 years of initial diagnosis. Adding to this potential confusion is the occurrence of abdominal pain thought to resemble gallbladder pain but without gallstones present. Laparoscopic cholecystectomy remains the gold standard for treatment of symptomatic cholelithiasis. However, persistent symptoms after cholecystectomy occur in 10 to 33% of patients. Although a variety of clinical characteristics have been evaluated as preoperative factors associated with outcome after cholecystectomy, preoperative symptoms are generally used as a reference point for diagnosis and determination of need of cholecystectomy. Characterizing and identifying symptoms that predict relief from upper abdominal pain after cholecystectomy could better guide physicians to recommend cholecystectomy so as to reduce morbidity, mortality and cost and minimize unnecessary surgery.
Aim: The objective of this study is to identify symptoms predicting complete relief of upper abdominal pain (UAP) after cholecystectomy to help better selection of patients who might benefit from surgery.
Subjects and methods: This study is a prospective analysis involving 950 adult patients undergoing cholecystectomy for symptomatic cholelithiasis. The study included 721 females (75.89%) and 229 males (24.11%). The patients were asked to complete a previously-validated biliary symptoms questionnaire (BSQ) before operation and 3 months postoperatively as well. At the end of the last questionnaire, each patient was required to define whether (as overall) his symptoms were relieved or not. Our patients were divided into two groups according to pain relief after surgery; Group (I) included patients who had pain relief after surgery (713 patients-75.05%) and group (2) included patients who did not have pain relief after surgery (237 patients-24.95%).
Results: Our study shows that the likelihood of having pain relief is greater in patients who have UAP onset one year or less preoperatively, UAP of short duration, UAP occurring most frequently in the evening or at night time and whose pain awakens them by night, patients who do not have lower abdominal pain, patients who have normal bowel habit pattern, patients who have infrequent nausea attacks, patients who do not often have excessive gas bloat or burps and patients who do not suffer concomitant GERD or IBS.
Conclusion: Laparoscopic cholecystectomy is an effective management option for symptomatic cholelithiasis, with a cure rate of 75.05% in our study. Better rates of pain relief can be achieved by better selection of patients, as sub analysis of symptoms showed better cure rates in the subgroups. The followings were found as good predictors of outcome: older age, female patients, short onset of the disease (≤ 1 year), infrequent attacks of pain once or less per week, short duration of attacks less than 30 minutes, attacks occurring by night or awakening the patient by night, attacks of moderate to severe intensity, patient with normal bowel habits, absence of lower abdominal symptoms, absence of gas bloating, and absence of GERD or IBS. Our study shows that pain relief progressively increases with increasing the number of positive predictive symptoms, being the best at the level of 4 positive predictive symptoms. Further larger studies are still needed to further define reliable prognostic symptoms to assure better selection of patients.

Anastomotic leaks (AL) still represent a major possibly life-threatening complication after colorectal surgery. The clinical presentation varies from mild symptoms to peritonitis and sepsis, which toughens the early diagnosis even for experienced surgeons. Numerous risk factors have been identified in the development of AL. The presence of bacterial strains such as Pseudomonas aeruginosa or Enterococcus faecalis are associated with higher AL rates, thus antibiotic prophylaxis seems to reduce complications. Male gender, advanced age, higher ASA fitness score, malnutrition and personal history of radiotherapy, diabetes mellitus and chronic kidney disease also lead to higher AL rates. The localization of the tumor also represents an important risk factor, as distal tumors have been identified as a predictor for AL. No differences have been found between open versus laparoscopic surgery as well as hand-sewn versus stapled anastomoses. The timing of the operation and the experience of the operating teams also affects both short and long-term. Early identification of AL is the key to reduction of mortality rates, thus scoring systems such as the Dutch Leakage Score have been developed and validated to aid surgeons for timely diagnosis. Modern imaging techniques and laboratory biomarkers further shorten the delay to a proper and early diagnosis. Computed tomography can identify even subclinical AL, leading to improved outcomes. Laboratory biomarkers such as C-reactive protein and procalcitonin are validated by large randomized studies as useful tools for exclusion of AL, possessing high negative predictive values.

Abdominoperineal resection remains the “gold standard” for cancers of the lower rectum and of the anal canal as a result of the failure of the primary conservative care. Total pelvic exenteration leaves an important pelviperineal defect which requires reconstruction techniques to be applied when primary closure cannot be performed.

Pelvic floor reconstruction is required and various complications, especially infectious, may occur in this area. The pelvis can be reconstructed using flaps. The perineal reconstruction that uses the numerous perforator flaps described lately raises the following question: which flap should be chosen?

Each flap and its variants have their own advantages and disadvantages, and the choice of the appropriate reconstructive technique involves a collaboration between the gastrointestinal oncology surgeon, the radiologist, the anaesthesiologist and the plastic surgeon in order to identify when and which surgical reconstruction is to be preferred, using reconstruction algorithms to choose the appropriate technique. Various studies are presented describing the experience of one or more centers regarding reconstruction options and the decisional tree adopted in the form of an algorithm both in relation to neoadjuvant irradiation therapy and without irradiation.

Background: Orthopedic Surgical site infection is a problem being faced and suffered by both health care providers and patients despite adoption of updated institutional policies of infective prevention by hospitals. However, presence of social, cultural, and environmental factors might affect the behaviors of health care workers regarding adherence to institutional policies of infective prevention. As a result, perspectives of infection control personnel and nurses that aim to control and prevent orthopedic surgical site infection should be explored and described.
Methods: The study employed qualitative content analysis approach to collect data about infection control personnel and nurses providing care for orthopedic surgery patients through conducting one-to-one interviews.
Results: Four themes representing the perspectives of nurses and infection control personnel towards control and prevention of orthopedic surgical site infection emerged from data collected through 15 interviews; the themes were attention to health care outcomes, adherence to guidelines, maintaining positive attitudes to health care, and adopting interdisciplinary team.
Conclusion: The perspectives of nurses and infection control personnel perspectives towards control and prevention of orthopedic surgical site infection suggest the need to set strategies that facilitate adherence to guidelines of infection control and to provide appropriate modalities that enhance the attention to health care responsibilities and outcomes.

Colorectal cancer continues to be a leading cause of death across the world, in spite of advances in detection and treatment. The concept of chemoprevention has come into the highlight once again, after almost four decades of arguments and counter arguments. At this point, we go back into the history of chemoprophylaxis, to look at the various modalities that were once promising and their current status in the literature.

The agents used for chemoprophylaxis are many and hence we decided to classify them according to the level of evidence available. A literature search was performed with keywords including, but not exclusively “colorectal cancer”, “prevention”, “prophylaxis”, and “diet”. Studies were reviewed and only chemo-preventive agents were looked at in detail, though some dietary extracts and other factors of potential interest to a clinician have been noted. Though these agents are yet to be used in primary prevention of colorectal cancer, the evidence for some is overwhelming enough to require further investigation.