that nasal congestion with respiratory difficulty is 1 of the worst symptoms, which were most difficult to tolerate after bimaxillary orthognathic surgery including Le Fort I osteotomy. 7 Second, naso-tracheal intubation is usually required for the orthognathic surgery, which causes mucosal swelling inside nasal airway due to damage or irritation to the nasal mucosa. Furthermore, patients with intermaxillary fixation immediate after the surgery have difficulty in oral breathing.Regarding to treatment, conservative managements such as rest, oxygen therapy, and pain control with analgesia are preferred. Supplying oxygen will increase the diffusion pressure of nitrogen in the subcutaneous tissue and mediastinum. If resolving the pneumomediastinum is fail, mediastinotomy should be performed making incision in the supraclavicular fossa posterior to the sternocleidomastoid muscle and in the suprasternal notch. In our cases, case 1, 2, and 4 patients with treated with high oxygenation but case 3 patient were treated with both oxygenation and suprasternal notch incision.In conclusion, we reported 4 cases of subcutaneous emphysema with or without pneumomediastinum after orthognathic surgery. It can be occurred by cervical fascia injury or alveolar ruptures. To preventing the pneumomediastinum after the orthognathic surgery, traumatic naso-tracheal intubation, excessive positive pressure ventilation, intermaxillary fixation immediate after the surgery and increase of intra-alveolar pressure of the patients should be avoided. Plain chest radiography is useful tool for initial diagnosis of pneumomediastinum, however chest CT describes exact extent of lesion. Conservative management with pain control and oxygenation can be done first and mediastinotomy also performed if resolving the air is failed.

Background: Routine neck exploration for isolated penetrating neck injuries (PNIs) in hemodynamically stable patients increases the frequency of unnecessary interventions and complications. Current management protocol involves the no zone approach which uses physical examination and computerized tomographic angiography (CTA) to guide treatment. The aim was to assess the validity of the no-zone approach in the management of isolated PNIs in hemodynamically stable patients.Methods: This retrospective study included patients with isolated PNIs with soft signs who were hemodynamically stable. They were classified into patients with negative CTA findings and were managed conservatively and patients with positive CTA findings suspecting aerodigestive tract injuries (ADTIs) who were submitted to further selective investigations to confirm or rule out these injuries. Detected injuries were managed accordingly.Results: This study included 106 PNIs patients who had soft signs and were hemodynamic stable. 37 cases (34.9%) had negative CTA findings and were managed conservatively. Sixty nine patients (65.1%) had positive CTA findings and were subjected to subsequent selective investigations and revealed 3 patients with negative endoscopic findings who passed without need for any surgical intervention. Therefore, 40 (37.7%) patients were saved from surgery with no missed injuries. Patients with definitive injuries (66 patients) underwent neck exploration and managed accordingly. No missed injuries were recorded in this study. Complications were detected in 6 cases (5.7%) while death was recorded in 2 cases (1.9%).Conclusions: No-zone approach offers a safe management protocol for isolated PNIs in hemodynamically stable patients. It provides no missed injuries, negligible rates of negative exploration and minimal complications and mortality.

Background and aim: Minimally invasive procedures; laparoscopic cholecystectomy (LC) and Mini-Laparotomy cholecystectomy (MC), have largely replaced the traditional cholecystectomy. The aim of our study was to compare short term outcomes of LC versus MC for the treatment of gallstones. Patients and methods: This is a prospective study that included patients with gallstones who were referred, randomized and enrolled in the study for elective LC or MC at Sohag University hospital, Egypt; between December 2012 and December 2014. Operation, anaesthesia, rescue analgesics and postoperative care were standardized. The patients were assessed for operation time as primary outcome; length of hospital stay, postoperative pain, and surgical conversion and perioperative complications as secondary outcomes. The patient's outcome was recorded up to four weeks postoperative. Results: Of 220 patients, 110 underwent LC and 110 underwent MC. The mean operative time for MC group was 42.3 ±14.7 which was significantly lower than LC 52.1 ± 19.5 (p value 0.018). There was no statistically significant difference in both groups as regard length of hospital stay, post operative pain, and conversion rate or perioperative complications. Conclusion: MC is an appropriate minimal invasive procedure for cholecystectomy without the financial resources for laparoscopic equipment and rightly trained surgical teams.

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