Background:Day-care open haemorrhoidectomy under local anaesthesia (LH) may be the most costeffective approach to haemorrhoidectomy. This prospective randomized trial compared outcome after LH from patients' and clinical perspectives with that after day-care open haemorrhoidectomy under general anaesthesia (GH).Methods: Forty-one patients with third-degree haemorrhoids were randomized to LH (19) or GH (22). Patient demographics were comparable. A single haemorrhoid was excised in 15 patients, and two and three haemorrhoids in 13 each. Independent nurse-led assessment and clinical evaluation were carried out for 6 months. Outcome measures were mean and expected pain scores at 30, 60 and 90 min, then daily for 10 days, and satisfaction scores at 10 days, 6 weeks and 6 months. Secondary outcomes were journey time within the day-surgery unit and overall cost.Results: Pain was worse following LH than GH at 90 min after surgery (P = 0·028), but pain scores on reaching home were similar. Maximum pain was experienced on day 3 after LH and on day 6 after GH. From day 1 onwards, daily pain scores were lower in the LH group, and there was a significant difference on day 8 (mean (95 per cent confidence interval) 3·61 (2·74 to 4·48) for LH versus 5·29 (4·12 to 6·45) for GH; P = 0·027). Mean pain over 10 days, expectation and satisfaction scores were similar in the two groups. LH had a shorter journey time and was less expensive than GH.Conclusion: LH has similar tolerance and clinical outcome to GH, and is associated with a shorter journey time and lower cost. Registration number: NCT00503269 (http://www.clinicaltrials.gov).

Total scalp avulsion injury with cervical spine injury is rare. This article is to describe the technical difficulties and precautions to be taken during anatomical replantation. The patients with cervical spine injury should not be considered as an absolute contraindication for anatomical replant if patients are fit for general anaesthesia. We found that the supratrochlear and supraorbital vessels which are anterior and superficial temporal vessels which are lateral can be used to replant without much technical difficulty. We conclude that anatomical replant is always better keeping in mind the technical limitations of anatomical replant in case of cervical spine injury.

Flap failure from microvascular thrombotic occlusion is a rare but significant cause for unsuccessful reconstructive surgery. We encountered thrombosis of arteriovenous loop in a patient undergoing phallus reconstruction. Further investigations revealed underlying previously asymptomatic hypercoagulable state due to protein-S deficiency in addition to long-term exogenous testosterone administration. Role of thrombophilia testing, thrombogenic potential of testosterone and the need for therapeutic perioperative anti-coagulation in such situations are described here.

anaesthesia for inguinal hernia repair using data from a randomized clinical trial. Br J Surg 2007; 94: 500-505. 2 Beattie GC, McAdam TK, McIntosh SA, Loudon MA. Day case stapled haemorrhoidopexy for prolapsing haemorrhoids. Colorect Dis 2006; 8: 56-61. 3 Ganio E, Altomare DF, Milito G, Gabrielli F, Canuti S. Long-term outcome of a multicentre randomized clinical trial of stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy. Br J Surg 2007; 94: 1033-1037. 4 Riss S, Riss P, Schuster M, Riss T. Long term results after stapled anopexy for symptomatic haemorrhoidal prolapse. Eur Surg 2008; 40: 30-33. Authors' reply: Randomized clinical trial comparing day-care open haemorrhoidectomy under local versus general anaesthesia (Br J Surg 2008; 95: 555-563)

Fournier’s gangrene is rapidly progressive and potentially fatal infective necrotising fasciitis affecting the external genitalia, perineal or perianal regions. Among many sources of infection, perianal surgical manipulation is one of the major contributing factors. A 45-years diabetic patient who had recently undergone surgical debridement elsewhere to treat a perianal abscess visited SDM Ayurvedic hospital with mild scrotal pain and an unhealthy surgical wound. He was treated surgically with broad-spectrum antibiotics, strict control of hyperglycemia, regular minimum debridement of wound and dressing with a Yashtimadhu taila (an herbal oil with Glycyrrhiza glabra, Emblica officinalis, Sesamum indicum and cow milk as active ingredients) famous for its wound healing property. The patient gradually recovered and the wound was gradually healed with secondary intention.