Tension pneumoperitoneum is a very rare consequence of acute gangrenous appendicitis. We report a case of a 32-year-old woman who presented with abdominal pain, progressively increasing abdominal distension, profound hemodynamic instability and ventilatory compromise. The diagnosis of tension pneumoperitoneum was confirmed by computed tomography, which showed compression of the intra-abdominal viscera and liver (saddlebag sign) by a large volume of intraperitoneal free air. Urgent needle decompression was done as an emergency measure. Exploratory laparotomy, planned due to persistent peritonitis, revealed gangrenous appendicitis with perforation near its base. Appendicectomy with excision of gangrenous portion of caecum was performed. The purpose of the reporting this case is to highlight that the tension pneumoperitoneum can be, very rarely, associated with gangrenous appendicitis and timely diagnosis is very important for the emergency management of this deadly condition.

Background: Peptic Ulcer perforation is one of the most important and dreaded complication of peptic ulcer disease. In-spite of recent therapeutic management options available, it is still life threatening catastrophe. Sudden release of gastric and duodenal content in peritoneal cavity leads to devastating sequence of events which if not properly managed may lead to death. Age and Gender adjusted analysis of incidence, morbidity and mortality and the effect of ulcerogenic medications, addictions and H. Pylori infection in prognosis were studied here. Postoperative outcomes were also assessed after giving same type of treatments (Preoperative resuscitation, Graham’s Patch repair, and postoperative care) given by same surgical team.Aims and Objectives: The aims and objectives of this study were to investigate the latest trends of incidence, presentation, morbidity and mortality of benign perforated gastro-duodenal ulcer among the various age groups of population and to further study the risk factors associated with these events and study the association of addiction, ulcerogenic medications and H. Pylori infection.Materials and Methods: This observational descriptive study was conducted in R.G.Kar Medical College, Kolkata between the periods from January 2016 to June 2017 among 102 patients.Results: In this study of 102 patients 97% were male patients, maximum number of patient were from the age group 15 -30 years (45.1%).86.3% were from low socio- economic status and 40.2% residing in urban slum. Maximum number of patients presenting within 72 hrs (71%) having zero mortality. Seventy four percent of patients presented with shock if came between 4-5 days with 17.39% mortality. Patient presenting after 5 days had mortality of 75% and shock was 100% finding. Size <1 cm having 1% mortality but if size is >1 cm then mortality was >50.5%.Conclusion: Perforated peptic ulcer is common among males in second and third decade of their life with patients living in rural and urban slum commonly affected. Most common predisposing factors for PPU among younger population were addictions like smoking or alcohol intake. Among the elderly patients, intake of ulcerogenic medications like NSAID and steroids was the most common predisposing factor for PPU. Among patients of non-NSAID associated PPU, Helicobacter pylori infection was the major cause in the pathogenesis of PPU.Asian Journal of Medical Sciences Vol.9(6) 2018 68-75

Traumatic abdominal wall hernia (TAWH) is a rare clinical entity in terms of aetiology. It occurs following a blunt abdominal injury with energy high enough to cause disruption of the musculoaponeurotic layer but not the elastic skin layer. It is often associated with underlying intra-abdominal injuries, which can be diagnosed either clinically or radiologically. We report a case of TAWH in a young man with associated large bowel transection, which remained undiagnosed in the preoperative period owing to its masked features. He was managed surgically, with no recurrence to date. Considering the high volume of blunt abdominal trauma cases that present to the accident and emergency department, only few cases of TAWH have been reported in the literature. Confusion still exists regarding the timing and mode of management of this condition. KEYWORDSAbdominal wall -Traffic accidents -Abdominal hernia -Aetiology -Motorcycles Traumatic abdominal wall hernia (TAWH) is an unusual type of hernia that occurs following a non-penetrating abdominal trauma resulting in breach of the musculoaponeurotic layers of the abdomen with an intact overlying skin. Although blunt abdominal trauma is very common, the incidence of TAWH is low. The diagnosis of TAWH is rarely straightforward owing to the various clinical presentations and management therefore varies substantially. 1 We report a unique case of TAWH following a road traffic accident with associated hollow viscous injury. Case historyA 30-year-old man presented to the accident and emergency department having sustained a high velocity blunt trauma injury over his left flank from a hollow metal pipe two hours earlier while driving a motorcycle. The patient was haemodynamically unstable. He had a tender, irreducible swelling of approximately 15cm x 10cm over the left flank with evidence of an overlying bruise and abrasions (Fig 1). There was no expansile cough impulse over the swelling and the swelling was soft in consistency. General abdominal examination was insignificant and there was no peritonitis. Focused assessment with sonography for trauma showed no intra-abdominal fluid collection. However, ultrasonography indicated a possible parietal breach at the site of the lump. Multidetector computed tomography (CT) of the abdomen revealed a full-thickness defect over the left lumbar region with small bowel herniation (Fig 2).The patient was posted for an exploratory laparotomy by a midline approach. A 20cm loop of jejunum was found to be herniating through a gap of 7cm over the left lumbar region. A complete transection of the descending colon was also noted (Fig 3). Both the proximal and distal ends of the transected colon were also seen to be herniating through the defect. There was collection of stool and blood clots in the ONLINE CASE REPORT Ann R Coll Surg Engl 2016; 98: e133-e135

Background: Mesh fixation during laparoscopic totally extra peritoneal repair is thought to be necessary to prevent recurrence of infections and post-operative complications. However, mesh fixation might increase the postoperative complications and chronic pain. This study was to describe the experience of a single surgeon at R.G. Kar Medical College and Hospital performing this operation. This study evaluates the outcomes of laparoscopic hernioplasty performed with and without mesh fixation at our institution.Aims and Objective: To compare advantage of non-fixation versus fixation of mesh in laparoscopic Totally Extra peritoneal (TEP) repair of inguinal hernias. This study was conducted for analysis of outcome with respect to pain, operative time, intra and postoperative complication, days of hospital stay, recurrence regarding the procedure between fixation and non-fixation of mesh in totally extra peritoneal repair of inguinal hernia.Materials and Methods: The study was conducted in the Department of Surgery, R.G.Kar Medical College and Hospital from January 2011 to April 2012. All patients admitted in General surgical unit presenting with uncomplicated unilateral inguinal hernias were included. A total of 60 patients were included in the study, of which 30 patients underwent TEP repair without fixation of mesh and for remaining 30 patients the mesh was fixed using metallic tacks.Results: Difference in average pain score at 24 hrs, 72 hrs, 1 month and 6 months was significant statistically (p =0.003, p = 0.003, p< 0.001 and p=0.001 respectively) when compared in both groups. There was no recurrence in the study period in either of the groups. The duration of operative time and days of hospital stay was higher in fixation group and was statistically significant.Conclusion: Mesh fixation appears to be disadvantageous in TEP repair of inguinal hernias compared to non- fixation of mesh as it is associated with higher operative time, higher postoperative complication and an increased likelihood of developing chronic groin pain. The omission of mesh fixation did not increase the risk of early hernia recurrence.Asian Journal of Medical Sciences Vol.9(4) 2018 35-40

Background: Laparoscopic cholecystectomy (LC), the procedure of choice for symptomatic gall stone disease. An emerging trend is to perform Low pressure pnuemoperitonium laparoscopic surgery as it has additive advantages over standard pressure to avoid complications while providing adequate working space.Aims and Objectives: The current study was designed with an aim to compare the advantage of low pressure pneumoperitoneum vs standard pressure pneumoperitoneum in laparoscopic cholecystectomy.Materials and Methods: The study was conducted in the department of General Surgery in R.G.Kar Medical College from January 2014 to June 2015. A total of 52 patients with symptomatic gall stone disease were recruited, 26 patients in each group randomly. Some intraoperative and post-operative parameters were studied.Results: All the intra-operative (IO) cardio-respiratory parameters (Pulse, Mean Arterial Pressure (MAP), End tidal CO2, spO2) were recorded just before incision, 20 minutes intra-operatively and before reversal of general anesthesia (GA). The IO parameters in our study, were found to be significant only at 20 minutes IO and before reversal of GA. The post-operative (PO) parameters (Pulse, MAP, Respiratory rate, spO2) and pain by VAS score at 6 hours, 12 hours and 24 hours post-operatively were studied. In PO period, we observed significant differences at 2 hours post-operatively in all parameters except MAP. There was significant difference in pain at 6, 12 and 24 hours when compared in both groups. The shoulder tip pain (STP) and 2 hours PO nausea and vomiting were found to be significantly higher in Standard pressure Laparoscopic cholecystectomy (SPLC) compared to Low pressure Laparoscopic cholecystectomy (LPLC). The operative time, duration of hospital stay and return to normal life after surgery though had differences but it was statisticallyinsignificant.Conclusion: Low pressure laparoscopic surgery is safe with least post operative complications when performed by experienced surgeons even in patients of ASA III.Asian Journal of Medical Sciences Vol.9(4) 2018 17-22