Emergency Exploratory Laparotomy Research Articles

THORACIC SEGMENTAL SPINAL ANAESTHESIA IN UPPER ABDOMINAL SURGERIES AND SIMPLE MASTECTOMY-A CASE SERIES

Objective: To observe safety and efficacy of Segmental thoracic spinal anesthesia (STSA) in upper abdominal and breast surgeries. Methods: 14 cases were selected, out of which 6 laparoscopic cholecystectomy (LC), 4 open cholecystectomy (OC), 3 emergency exploratory laparotomy and 1 simple mastectomy. Under full aseptic precaution, segmental thoracic spinal anesthesia was administered through midline approach in T8-9 space for upper abdominal surgeries and T5-6 space in a simple mastectomy. Using 25G Quincke spinal needle 1.5 ml [7.5 mg] of 0.5% Isobaric Levobupivacaine mixed with 0.4 ml (20µg) Fentanyl was given in abdominal surgeries and 1.2 ml [6 mg] of 0.5% Isobaric Levobupivacaine mixed with 0.4 ml (20µg) Fentanyl in simple mastectomy. Results: Age group of patients ranged from 25 to 65 y, Male: Female ratio of 4:10, Body Mass Index (BMI) range of 22 to 24.9 with physiological status of ASA I to ASA III. Hemodynamically, hypotension was observed in every patient after 5-10 min of STSA well managed with fluid and vasopressors with no bradycardia. Average width of sensory block was T3 to L1-2 in upper abdominal surgeries and T1 to T8 in a simple mastectomy. Motor block was Modified Bromage Scale (MBS) of 0 to 1 during and postoperatively. Regarding analgesia, Visual Analogue Scale (VAS) score was 0 intraoperatively and 0-1 postoperatively. Sedation score was 2 both intraoperatively and postoperatively with no significant complications and good patient and surgeon satisfaction. Conclusion: Segmental thoracic spinal anaesthesia is a safe and effective procedure with good patient and surgeon satisfaction.

Endovascular treatment of traumatic pseudoaneurysm of the ileal branch of the superior mesenteric artery in a 9-year-old girl: Case report and literature review.

Visceral artery aneurysm is a rare and potentially fatal vascular condition that typically affects the superior mesenteric or inferior mesenteric arteries, the splenic, hepatic, and celiac arteries, as well as their branches. Visceral artery aneurysms can usually be treated using endovascular intervention, open surgery, or percutaneous thrombin injection. A 9-year-old girl was admitted to our trauma center with abdominal and bilateral leg pain after a car accident involving a head-on collision. Abdominal computed tomography (CT) showed bowel herniation through a muscle defect in the left lateral abdominal wall. There was a small amount of fluid around the liver and spleen, mild thickening of the small bowel wall, and infiltration in the small bowel mesentery, indicating the possibility of small bowel injury. Emergent exploratory laparotomy was performed. After resection of the ischemic parts of the terminal ileum and sigmoid colon, intestinal continuity was reestablished. Primary repair was performed on a traumatic left lateral abdominal wall hernia. She recovered well postoperatively without any complications. A follow-up abdominal CT scan after 2 months showed a pseudoaneurysm of the ileal branch of the superior mesenteric artery. Despite the absence of any gastrointestinal symptoms, the pseudoaneurysm was treated by endovascular intervention using numerous coils because of the significant risk of delayed rupture or massive bleeding. Follow-up abdominal CT scan after 6 months showed complete occlusion and resorption of the pseudoaneurysm. Although it is technically challenging, endovascular coil embolization may be a feasible technique in children with traumatic visceral artery pseudoaneurysms without complications.

Bladder explosion during transurethral resection of bladder tumour: a case report and review of literature

BackgroundBladder explosion during transurethral resection of bladder tumors (TURBTs) is a rare and less recognised, but terrifying complication.Case presentationWe present a case of 72-year-old male patient of a large bladder tumour who sustained an intravesical explosion during TURBT requiring an emergency exploratory laparotomy and repair.ConclusionsUrologists should be cognizant of this unique complication and ensure the necessary techniques and precautions for its prevention.

Abdominal apoplexy in late trimester of pregnancy: Case reports

Background: Abdominal apoplexy or Idiopathic Spontaneous Intraperitoneal Hemorrhage (ISIH) is rare and refers to intra-abdominal hemorrhage caused by spontaneous rupture of blood vessels in the abdominal cavity or retroperitoneum. The clinical diagnosis of abdominal apoplexy during pregnancy is rarer, and often made only after emergent exploratory laparotomy is performed for unstable vital signs and severe anemia. Affected by an enlarged uterus during pregnancy, the symptoms and signs of acute abdomen may be confused with placental abruption or other more common complications of pregnancy. Case presentation: Both cases in the study showed that the main symptoms were abdominal pain, hypotension, nausea, vomiting, and other associated blood loss symptoms of varying degrees. Due to its sudden onset, this dangerous condition with no typical symptoms and signs can be easily misdiagnosed, two cases were given urgent surgery finally. At a 12-month follow-up, no abnormalities were observed during medical examinations of both mother and child. Conclusions: The clinical diagnosis of abdominal apoplexy during pregnancy usually needs emergent exploratory laparotomy to find the hemorrhagic spot. We analyzed and summarized two cases of abdominal apoplexy in the late third trimester of pregnancy in and aims to provide certain clinical reference for surgeons when seeing the abnormal sustaining abdominal pain during pregnancy so that adverse pregnancy outcomes can be avoided.

The Prediction of Mortality Using APACHE II Score in Patients Presenting with Peritonitis and Undergoing Emergency Exploratory Laparotomy

The Prediction of Mortality Using APACHE II Score in Patients Presenting with Peritonitis and Undergoing Emergency Exploratory Laparotomy

Successful management of an advanced interstitial ectopic pregnancy in a resource-limited setting: a case report

BackgroundInterstitial ectopic pregnancy is an ectopic gestation developing in the uterine part of the fallopian tube. The condition is rare and presents challenges for clinical as well as radiological diagnosis. This case report presents a rare case of interstitial ectopic pregnancy diagnosed intraoperatively.Case presentationA 36-year-old Black woman, referred from a peripheral health facility, presented at the emergency department with severe abdominal pains, vaginal spotting, nausea, and vomiting, with a 2-month history of irregular menstrual flow. Clinical and laboratory findings were suggestive of an acute abdomen likely due to a ruptured ectopic pregnancy (ultrasound was not available). An emergency exploratory laparotomy was done, which revealed a right adnexal ruptured interstitial pregnancy of a lifeless female fetus weighing 500 g (estimated mean gestational age of 22–23 weeks). The left fallopian tube looked normal. The site of rupture was repaired, followed by cleaning and closure of the abdomen. The post-operative period was uneventful, and the patient was discharged on postoperative day 7.ConclusionInterstitial pregnancies are uncommon and rarely attain advanced gestational ages, as in this case, compared with other tubal ectopic pregnancies. However, women presenting with signs of hypovolemic shock and acute abdomen, with a positive pregnancy test, warrant a high index of suspicion.

Ileal perforation-etiopathology and outcome – An observational study

Background: Ileal perforations have a diverse etiology and often present with perforative peritonitis in the surgical emergency. This study is based on the scenario of management of ileal perforation encountered in a tertiary teaching hospital in West Bengal. Aims and Objectives: The aim and objective of this study is to document and evaluate the post-operative outcome based on the diverse etiopathology, clinical presentation, and surgical management performed in patients having ileal perforation. Materials and Methods: A prospective cross-sectional observational study was conducted in the Deben Mahata Government Medical College, Purulia, West Bengal, for a period of 2 years from February 2020 to January 2022 with 60 patients introperatively diagnosed with ileal perforation. Emergency exploratory laparotomy was done in all the cases presenting with perforative peritonitis. Ileal perforation was identified and an edge biopsy was taken. Appropriate surgical treatment in the forms of primary repair/resection-anastomosis/resection-ileostomy was done. The histopathological report was reviewed following surgery. The patients were evaluated in the post-operative period for post-operative morbidity and mortality. Results: Typhoid fever (68.33%) was the predominant cause in our study. The most common symptoms were abdominal pain (93%), fever (85%), and abdominal distension (75%). Widal test was performed preoperatively and was positive in 41 cases (68.33%). In our study, primary repair (58.33%), resection-anastomosis (15%), and resection-ileostomy (26.67%) were the main surgical treatment performed. Sepsis, surgical site infections (SSIs), fecal fistula, and wound dehiscence were the common post-operative complications found. Among them, SSI (51.67%) was the most common post-operative complication (P<0.0001) found and fecal fistula was the most dreaded post-operative complication with 50% mortality. Histopathological reports following surgery showed cases were mainly due to enteric fever (51.67%) and tuberculosis (25%). Conclusion: Early surgical intervention was the mainstay of treatment of ileal perforation. Delayed presentation of perforation is responsible for the development of surgical site infections (SSIs). Uncontrolled generalized sepsis, wound dehiscence, and fecal fistula were the main causes of post-operative mortality.

Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) scoring system in predicting postoperative mortality in patients undergoing emergency laparotomy: A retrospective study.

There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy. This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study's primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients. The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer-Lemeshow (H-L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H-L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively. Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

Successful pregnancy outcome with a large ruptured juvenile granulosa cell tumor: A case report

Background: Juvenile granulosa cell tumors (JGCTs) are rare sex cord stromal tumors diagnosedmainly in premenarchal girls and women younger than 30 years. Case presentation: A 19-year-old primigravida at 36 weeks of gestation presented to the labor ward withcomplaints of generalized abdominal pain, headaches, and reduced fetal movements for two days.Ultrasound revealed a left-sided 15.7 by 15 cm large cyst and a solid mass of increased vascularity withmaternal ascites. The biophysical profile of the fetus was 4/8 (no movement or tone but the presence ofrespiration and amniotic fluid). An emergency exploratory laparotomy was performed, and intraoperativefindings revealed a massive torsed right ovary with a ruptured ovarian mass with grossly edematous and necrosed fallopian tubes. Following a safe cesarean section delivery of the fetus, a right salpingo-oophorectomy with cystectomy was performed. The histopathological results confirmed the diagnosis of JGCT FIGO stage IC2. Postoperatively, the patient was treated with six sessions of chemotherapy(cisplatin and paclitaxel). Post-chemotherapy magnetic resonance imaging showed normal abdominalviscera with minimal free fluid in the posterior cul de sac and a normal left ovary. Inhibin B levels droppedto 3.17, and the patient is on follow-up for the next 5 years with repeated tumor marker testing andcomputed tomography scans.Conclusion: JGCT is a very uncommon pregnancy tumor, and aggressive treatment is necessary foradvanced-stage tumors such as the one in this case to prevent recurrence or even death.

Retrospective Study on Indication and Outcome of Emergency Exploratory Laparotomy in a Peripheral Medical College of West Bengal

Retrospective Study on Indication and Outcome of Emergency Exploratory Laparotomy in a Peripheral Medical College of West Bengal

Spontaneous splenic rupture associated with scrub typhus: a case report

BackgroundScrub typhus, an acute febrile disease with mild to severe, life-threatening manifestations, potentially presents with a variety of complications, including pneumonia, acute respiratory distress syndrome, cardiac arrhythmias (such as atrial fibrillation), myocarditis, shock, peptic ulcer, gastrointestinal bleeding, meningitis, encephalitis, and renal failure. Of the various complications associated with scrub typhus, splenic rupture has rarely been reported, and its mechanisms are unknown. This study reports a case of scrub typhus-related spontaneous splenic rupture and identifies possible mechanisms through the gross and histopathologic findings.Case presentationA 78-year-old man presented to our emergency room with a 5-day history of fever and skin rash. On physical examination, eschar was observed on the left upper abdominal quadrant. The abdomen was not tender, and there was no history of trauma. The Orientia tsutsugamushi antibody titer using the indirect immunofluorescent antibody test was 1:640. On Day 6 of hospitalization, he complained of sudden-onset left upper abdominal quadrant pain and showed mental changes. His vital signs were a blood pressure of 70/40 mmHg, a heart rate pf 140 beats per min, and a respiratory rate of 20 breaths per min, with a temperature of 36.8 °C. There were no signs of gastrointestinal bleeding, such as hematemesis, melena, or hematochezia. Grey Turner's sign was suspected during an abdominal examination. Portable ultrasonography showed retroperitoneal bleeding, so an emergency exploratory laparotomy was performed, leading to a diagnosis of hemoperitoneum due to splenic rupture and a splenectomy. The patient had been taking oral doxycycline (100 mg twice daily) for 6 days; after surgery, this was discontinued, and intravenous azithromycin (500 mg daily) was administered. No arrhythmia associated with azithromycin was observed. However, renal failure with hemodialysis, persistent hyperbilirubinemia, and multiorgan failure occurred. The patient did not recover and died on the fifty-sixth day of hospitalization.ConclusionsClinicians should consider the possibility of splenic rupture in patients with scrub typhus who display sudden-onset abdominal pain and unstable vital signs. In addition, splenic capsular rupture and extra-capsular hemorrhage are thought to be caused by splenomegaly and capsular distention resulting from red blood cell congestion in the red pulp destroying the splenic sinus.Graphical abstract

An Emergency and Challenging Life-Saving Surgery in a Newborn with Imperforate Anus in a Remote Village in South Sudan – A Case Report

Anorectal malformation, a congenital defect is usually detected at birth and managed by a multispeciality team in a tertiary care hospital. We present a case of a five day old neonate, born in a remote village in South Sudan, who presented in a critical condition to our field hospital and was managed with basic resources. A 5 day old neonate was detected with imperforate anus and presented to our hospital on day 5 with abdominal distension, severe dehydration, tachycardia and tachypnoea. Radiographic investigations revealed findings suggestive of a high ano-rectal malformation. The neonate underwent an emergency exploratory Laparotomy with diversion double barrel Colostomy in a set up catering for adult combatants. The neonate gradually improved before developing burst abdomen managed with emergency wound closure. The neonate gradually accepted breast feeds and was discharged for subsequent need for definitive surgery. This was a challenging surgery with respect to the resources available at a field hospital catering to adult combatants.

IDIOPATIC SCLEROSING ENCAPSULATING PERITONITIS

ABSTRACT Introduction: Sclerosing Encapsulating Peritonitis (SEP) is a rare syndrome characterized by a chronic inflammatory process that leads to the formation of a thick fibrocollagenous membrane that surrounds and entraps intra-abdominal organs. As a result, although some cases may be asymptomatic, patients commonly develop symptoms of intestinal obstruction, and the diagnosis is often made incidentally during intra-abdominal surgeries. Case report: A 37-year-old male patient, a chronic alcoholic, was admitted with severe abdominal pain for seven days associated with abdominal distension, anorexia, and fever. Abdominal examination revealed signs of peritoneal irritation. Chest X-ray and abdominal computed tomography showed pneumoperitoneum and a large fluid collection, with signs of wall thickening extending through the pelvic cavity, parietocolic gutters, anterior abdominal cavity, and hepatodiaphragmatic space, causing compression of the hepatic parenchyma and displacement of intestinal loops. Due to these findings, the patient underwent an emergency exploratory laparotomy, in which a fibrocollagenous membrane, extensive bowel obstruction, and an abscess were identified. A total of 4.5 liters of purulent secretion were drained, the fibrous membrane was excised, the abdominal cavity was copiously washed, and a drain was placed in the upper right quadrant. He had a satisfactory resolution of the condition, without postoperative complications, and was discharged 11 days after the procedure. Conclusion: Initially, conservative management should be prioritized due to the technical difficulty of surgery and possible complications. However, in case of greater the level of peritoneal involvement and tissue adhesion, there is a higher chance of failure of conservative management, and surgical intervention may become necessary. Keywords: Peritonitis. Fibrosis Peritoneal. Intestinal Obstruction.

Hypoganglionosis and Isolated Crohn’s Disease of the Terminal Ileum Presenting with Perforation Mimicking Appendicular Mass in a 72-Year-Old Asian Lady

A very unusual and interesting case of a 72-year-old Indian female with a background of chronic constipation since early infancy presented in emergency critical condition with acute perforative peritonitis and right lower quadrant fullness, guarding and tenderness. Laboratory studies showed high inflammatory markers and provisional diagnosis of walled off appendicular perforation was made. Radiographs and multi scanner computed tomography (MSCT) was found to have pneumoperitoneum secondary to the terminal ileal stricture with perforation. The patient underwent emergency exploratory laparotomy following initial resuscitation, resection and anastomosis of the ileal stricture, peritoneal toilet and extramucosal biopsies of rectosigmoid colon were performed. Histopathology confirmed isolated Crohn’s disease of terminal ileum with stricture and associated hypoganglionosis. Subsequent colonoscopy and biopsies showed no active Crohn’s disease but had nonspecific colitis of the left colon due to associated hypoganglionosis. The postoperative period was uneventful. The patient is doing well at follow up with conservative management of the hypoganglionosis with laxatives, dietary changes, life style modifications and dietary supplements.

Implementation of mandatory blood alcohol screening in trauma patients: A retrospective study from a tertiary trauma center in a Middle Eastern country

BackgroundAlcohol consumption is a significant risk factor for several types of injuries and trauma recidivism and remains an important public health concern worldwide. We aimed to describe the implementation of mandatory alcohol screening and the AUDIT tool among trauma patients admitted to a level 1 trauma center in a country with a partial ban on alcohol consumption. MethodsThis was a retrospective analysis of trauma patients (>12 years old) who required hospital admission and underwent blood alcohol concentration (BAC) screening between 2014 and 2019. This was achieved via an enzymatic method using alcohol dehydrogenase for ethanol detection in the plasma and serum samples. Trauma patients with a BAC <2.2 mmol/L were referred to as “negative”, and BAC >2.2 mmol/L was referred to as “BAC positive”. A comparative analysis was performed between the two BAC groups. Alcohol Screening, Brief Intervention, Referral for Treatment [ASBIRT] program, and AUDIT were applied. ResultsA total of 7326 BAC screening tests were performed on 7284 patients during the study period. With slight variation over the years, the compliance rate was 77% (70.4%–85.3%), and the test positivity rate was 10% (8.6%–12.5%). There were 42 repeated admissions, of which seven patients were BAC positive at every admission. Young age and non-Arab patients were more likely to test positive, and the main mechanism of injury (MOI) was road traffic-related trauma (p < 0.05). Assault and self-inflicted injuries were significantly higher in BAC-positive patients than in BAC-negative patients (18% vs. 4% and 2.7% vs. 1.3%, respectively; p = 0.001). The injury severity score (ISS) and mortality rate were comparable between the study groups. Patients with a positive BAC were significantly more likely to undergo pan-CT scan in the emergency department, intubation, and exploratory laparotomy than those with a negative BAC. In patients who sustained injuries due to assault, all-terrain vehicles, or motorcycle crashes, there was a significant association between the positivity of BAC tests and the patient's ISS. ConclusionDespite improvements in BAC screening in trauma admissions over the years, almost 20% of cases were missed. Although the mortality rates were comparable, alcohol consumption burdens resources in terms of excess imaging, intubation, open abdominal surgery, and possible disability. Further studies are needed to understand the key obstacles and challenges to achieving optimum compliance for screening in trauma settings.

An Exceptional Rarity: Coexisting Amebic Enterocolitis and Metastatic Colon Adenocarcinoma Deceptively Resembling Crohn's Disease Grossly

Abstract Introduction/Objective Amebiasis is a parasitic infection that is rare in developed countries but mimic crohn’s disease or colon malignancy. Amoeboma of the large intestine, a subtype of amebiasis, is an even rarer condition that can be challenging to differentiate from colorectal carcinoma. While co-occurrence of these two conditions is exceedingly rare, we present a unique case of severe fulminant necrotizing colitis with perforation, which coexisted with metastatic colon adenocarcinoma. Methods/Case Report A 54-year-old female with no travel history, recently diagnosed with sigmoid colon cancer and liver metastasis, presented with acute worsening of her chronic abdominal pain. Upon examination, a sigmoid/rectal mass with local invasion of the bladder and left salpinx, along with liver metastases, was discovered. The patient underwent an emergent exploratory laparotomy, total abdominal colectomy, and end ileostomy due to concerns for perforation. The colon's mucosa displayed a cobblestone-like appearance with diffusely raised tan areas, erosions, exudate, and intervening brown mucosa (Figure 1). Microscopic examination revealed amebic trophozoites invading submucosa diffusely with ingested RBCs in cytoplasm, small round nucleus with dot-like karyosome (figure 2), involving the colon and attached terminal ileum, with perforations in the terminal ileum and ascending colon. The trophozoites were further confirmed by negative CD68 stain, and strongly PAS stain. Additionally, metastatic adenocarcinoma (figure 3-5) was found in two lymph nodes, along with tumor deposits in the mesenteric fat, but no primary adenocarcinoma was identified despite extensive search and sampling. Postoperatively, the patient completed an antibiotic course for Entamoeba, with a smaller lesion near the gallbladder responded, the hepatic lesion remained unchanged, indicating metastatic disease. Results (if a Case Study enter NA) NA Conclusion Although the colectomy specimen's gross findinds initially suggested Crohn's disease, the overall microscopic features favored amebic colitis due to the presence of numerous amebic trophozoites and the patient's lack of IBD history.This case highlights the potential coexistence of colonic amebiasis and colorectal carcinoma, which can mimic each other. This case serves as a reminder to avoid delayed diagnosis and treatment of ameboma infection in patients with colon malignancy history, even in non-endemic countries like the United States. .

Adjusting the Split: Examining Complications After Emergency Exploratory Laparotomy in Older Adults

IntroductionOlder adults experience higher rates of complications after an emergency exploratory laparotomy (EEL). To better understand the shift to an aging population in the United States, identifying how age may influence these complications in older patients is important. The current standard age category for older adult patients is ≥65. We analyzed postlaparotomy complications using a lower age split. MethodsA retrospective analysis was done on patients who required an EEL from October 2015 to December 2019 at an academic medical center. Patient demographics and hospital course variables were collected. Differences in complications in patients aged ≥/<55 y and ≥/<65 y were measured using univariate and multivariable analyses. ResultsA total of 481 patients were reviewed. Both patient groups of ≥55 and ≥65 were typically male, White, had 3+ comorbidities, Medicare insurance, were retired, and presented in extremis to the emergency department. Patients aged ≥55 y had significant rates of pulmonary complications and inpatient mortality (odds ratio 2.2, 2.7, respectively). Patients aged ≥65 y had significant rates of genitourinary and cardiac complications (odds ratio 2.3, 1.8, respectively). ConclusionsPatients aged ≥55 y undergoing EEL had higher odds of experiencing pulmonary complications and death during their index hospitalizations, which was not present with the standard ≥/<65-y-old patient analysis. Those aged ≥65 y experienced index genitourinary and cardiac complications. The ≥/<55 age split has a unique set of complications that should be considered. Given the increased odds of inpatient mortality and types of complications in patients aged ≥55 y, the current age split for older adults should be reconsidered.

Abdominal Ectopic Gestation In The Second Trimester At A District Hospital: A Rare Case

Introduction: Abdominal ectopic pregnancies are uncommon forms of ectopic pregnancies. They might be unnoticed until late in pregnancy and are associated with an increased risk of maternal complications and mortality. This is a case report of an abdominal ectopic gestation diagnosed at the first visit to a district hospital in Ghana and how it was managed in a low-resource setting.&#x0D; Case Presentation: A 28-year-old gravida 4 parity 3, presented with 4 months history of amenorrhoea associated with recurrent bleeding per vaginum. Ultrasound showed a slightly bulky uterus with very scanty echogenic material within the endometrial cavity. There was however a right adnexal gestational sac with a live foetus at 19 weeks + 4 days and no free fluid was seen in the pouch of Douglas. The patient was counselled and prepared for an emergency exploratory laparotomy and intraoperative findings showed normal size uterus of about 8 weeks in size with an unruptured right adnexae gestation. The gestational sac was in the region of the right ovary which could not be visualised and attached to the uterus via the ovarian ligament with a normal-looking right tube. Post-operative recovery was uneventful and she was discharged three days later. &#x0D; Conclusion: Abdominal ectopic gestation can pose a diagnostic challenge, particularly in low-resource settings. There is a need for clinicians to have a high index of suspicion and provide timely surgical intervention necessary to reduce complications and mortality associated with the condition.&#x0D;

A Clinical Comparative Study of Rectus Sheath Closure Techniques in Emergency Exploratory Laparotomy: Evaluating "Far-Near-Near-Far" vs. Conventional Closure Approach.

Midline exploratory laparotomy is essential in emergency surgery, and effective closure of the abdominal wall is crucial for optimal healing and reduced complications. The far-near-near-far technique for rectus sheath closure has gained attention due to potential advantages over conventional closure due to the fact that even if one suture gives way it does not affect the nearby suture and the rectus sheath is still held in place. This study aims to compare these techniques in emergency exploratory laparotomy. This single-center prospective observational study included all patients undergoing emergency exploratory laparotomy at a tertiary care hospital. Patients were categorized into two groups based on the closure technique used: conventional closure or far-near-near-far technique. Sociodemographic data and comorbidities were collected. Operative time, closure time, and postoperative complications were assessed. Statistical analysis was performed using IBM SPSS Statistics 22.0(IBM Corp., Armonk, NY). The study included patients with a mean age of 42.14 years. Operative and closure times did not significantly differ between the groups. There was no significant difference in comorbidities between the two techniques. The incidence of wound infection, dehiscence, burst abdomen, incisional hernia, and sinus formation did not significantly differ between the groups. Late complications were also similar. The far-near-near-far technique for rectus sheath closure in emergency exploratory laparotomy showed comparable outcomes to conventional closure methods. No significant differences were found in operative time, closure time, or postoperative complications. This study contributes to the understanding of different closure techniques, allowing surgeons to make informed decisions.

A case of duodenal perforation and pancreatic bleeding after flexible ureteroscopy for right renal pelvis UTUC

Upper tract urothelial carcinoma (UTUC) can be managed by flexible ureteroscopy (f-URS) and tumor laser ablation if kidney-sparing surgery is possible. This procedure can be affected by minor to serious complications, including life-threatening sepsis, ureteral strictures, and ureteral and renal pelvis injuries. The case of a 53-year-old man with history of high grade right renal pelvis and bladder tumor who undergone multiple endoscopic treatments and has already refused radical surgery is reported. F-URS and laser ablation with Thulium: YAG laser for UTUC recurrence of the right renal pelvis was performed, but the procedure was stopped due to significant bleeding which impaired vision. Postoperatively, the patient developed hematemesis and hemodynamic instability due to duodenal lesion and active bleeding documented at CT scan. An emergency exploratory laparotomy was performed to drain hemoperitoneum, repair duodenal lesion and concurrent radical right nephroureterectomy was carried out. A second surgery was necessary for repairing duodenal fistula. After 1 week the patient presented again with recurrent hematemesis and hemorrhagic shock. He underwent angiography and selective embolization of the duodenal branch of superior mesenteric artery and as well as branches of gastroduodenal artery successfully and the patient recovered with no other complications. This is the first case of duodenal perforation and pancreatic bleeding due to flexible ureteroscopy and laser ablation of right renal pelvis urothelial carcinoma.