FOCUS Harmonic Scalpel Compared to Conventional Hemostasis in Open Total Thyroidectomy: A Prospective Randomized study
Dr.Raad Saad Al Saffar MBChB , CABS , consultant laparoscopic and thyroid surgeon
Dr. Ali Yaseen Ali , MBChB
Hemostasis in thyroid surgery is of utmost importance for a successful surgery and an uneventful postoperative course.
Aim of the Study:
To make comparison between FOCUS harmonic scalpel and conventional hemostasis regarding operative time , hospital stay, drainage volume and surgical complication in open total thyroidectomy
Patients and methods:
In this study, 120 patients were randomized into 2 groups based on the surgical technique used: group I comprised the conventional clamp-and-tie technique, group II comprised patients in whom the FOCUS Harmonic Scalpel was used in majority of steps . The groups were compared in regard to operative time, complications, and hospital stay and drainage volume .
Comparison of operative time, revealed that the mean operation time was significantly shorter in FOCUS group (71.3±11.1) minutes compared to (85.7± 15.5) minutes in conventional group, (P<0.001).
Similarly , drainage volume was significantly smaller in FOCUS group than conventional, 38.0 ± 14.4 vs. 58.6 ± 23.7 cc cc, respectively, (P<0.001). Hospital stay was significantly longer in conventional group where the duration of stay was 28.2 ± 11.3 hours compared to 20.4 ± 4.3 hours in FOCUS group, (P<0.001).
The FOCUS Harmonic Scalpel can shorten operative time and hospital stay, and less drainage volume . FOCUS Harmonic Scalpel is found to be safe and reliable instrument as the clamp-and-tie technique in total thyroidectomy.
Critical View of Safety during Laparoscopic Cholecystectomy
Dr. Raad Saad Al Saffar
Dr. Haider Abdul Zahraa J. Al Khaqany
Cholecystectomy is the most common surgical procedure done laparoscopicaly worldwide. Many techniques and approaches are used like (infundibular technique, fundus first, partial or subtotal cholecystectomy), However the critical view of safety (CVS) technique is a safe option and appears to minimize bile duct injury. We tried to determine the safety of this technique in patients managed with laparoscopic cholecystectomy (LC). Hence, a prospective study was carried on during 4 years; 2012-2016 and a total of 500 patients with gallstone diseases managed with laparoscopic cholecystectomy at Al Sader Medical city in Al Najaf Al Ashraf governorate. The mean age of the patients was 42.5 (range: 20-65) years. Our patients were 382 Females and 118 males. All LCs were completed successfully with no conversion. Total operating time ranged from 40-70 minutes. No mortalities occurred in the study, CBD injury in only one patient. In conclusion, the Critical View of Safety technique is a safe option and recommended to be the gold standard technique in the laparoscopic cholecystectomy.
LAPAROSCOPIC CHOLECYSTECTOMY IN EMPYEMA OF GALLBLADDER
Dr. Raad S. AL-Saffar ; M.B.Ch.B. , C.A.B.S.,consultant laparoscopic and thyroid surgeon.
Haider Abdul Zahraa Jabbar Al Khaqany M.B.Ch.B.
Background : Empyema of the gallbladder is a potentially fatal complication of gallstones. It is characterized by suppuration superimposed on acute cholecystitis.It has been considered one of the most common causes of difficult Laparoscopic Cholecystectomy.
Aim of the study : To determine the safety and feasibility of Laparoscopic Cholecystectomy in the empyema of the gallbladder.
Patient and Methods : A prospective study of 800 patients suffering from gallstone diseases underwent laparoscopic cholecystectomy from December 2011 to December 2014 in Al Sader medical city , teaching hospital in the holy Najaf governorate , Iraq.
The procedure was performed by standard three-ports technique with few changes made to facilitate dissection according to situation.
Results : 800 patients with male to female ratio 1: 5.25 underwent laparoscopic cholecystectomy . Among these 50 patients (6.25%) patients of empyema of gallbladder were identified and included in the study population.
Laparoscopic cholecystecomy successfully completed in 49 (98%) patients while only one (2%) patient converted to open cholecystectomy due to uncontrolled bleeding.
Conclusion : In well trained and skillful hands of an expert Surgeon , Laparoscopic Cholecysrtectomy is a safe and acceptable option in empyema of gallbladder.
Key Words :Empyema gall bladder, laparoscopic cholecystectomy, safety.
Fundus-first approach for difficult laparoscopic cholecystectomy. Single surgeon experience.
Dr. Raad S. AL-Saffar ; M.B.Ch.B. , C.A.B.S.,consultant laparoscopic and thyroid surgeon.
Dr.Homam Alaa Aty. M.B.Ch.B.
Background: fundus first laparoscopic cholecystectomy was a common technique in open era but not widely used in laparoscopic cholecystectomy, in our study, we try to show its viability in hands of experienced surgeons in difficult cases.
Aim of study: to determine its feasibility in difficult cases of laparoscopic cholecystectomy to decrease bile duct injury and conversion rate.
Patients and methods: a prospective study of 50 patients with gallstone disease planned for laparoscopic cholecystectomy and because of difficult gallbladder the decision of using fundus first or dome down technique have been established in Al Sadur teaching hospital and Al Furat general hospital in holy Njaf city from October 2013 to December 2015.
Results: total number of patients were 50 , 34 were females and 16 were males , all of them underwent fundus first laparoscopic cholecystectomy because it was found that dissection at Calot’s triangle was difficult and anatomy is not clear due to dense adhesions (34 cases), impacted stone in Hartman’s pouch with short cystic duct (7 cases), thick wall and contracted gall bladder (9 cases).
Fundus first laparoscopic cholecystectomy was completed successfully in all cases without conversion.
Conclusion: In hands of experienced surgeon, the fundus first approach is good alternative to conversion to open cholecystectomy in difficult cases.
Key words: fundus first, dome down, difficult laparoscopic cholecystectomy.
A comparison of three methods closure by using subcuticular vicryl suture, metallic skin stapler and a steri-strip adhesive tapes
Dr. Raad S. AL-Saffar ; M.B.Ch.B. , C.A.B.S.,consultant laparoscopic and thyroid surgeon.
Dr. Mohammad K. AL-Shibani ; M.B.Ch.B.
Background: Several new methods of skin closure had been used in surgical practice, and they are acceptable alternative to conventional trans cutaneous suture method, these are; buried subcuticular vicryl suture, skin clips or stapler, and steri-strip adhesive tape. Thus the objective of this trial was to assess the impact of these closure methods on closure time , postoperative incision pain, potential wound complications, cosmetic outcome, and patient satisfaction.
Methods: 75 patients undergoing different elective and emergency operations were enrolled in this prospective randomized trial. They were divided into 3 groups, in each group(n=25), the incision closed by one of 3 methods: subcuticular vicryl suture , skin clips( stapler) or steri- strip adhesive tape. Closure time was assessed in theatre ; postoperative incision pain was assessed at day 1 and day 5 postoperative. wound complications, and procedure patient satisfaction were assessed in the first 10 postoperative days. Assessment of cosmetic scar appearance was evaluated at 4 weeks follow up after operation.
Results: There was significant demographic difference among the three groups (p<0.05).There were no significant differences reported in postoperative incision pain( by visual analogue scale) , wound complications (seroma , infection ,dehiscence ,and granuloma ) , patient procedure satisfaction , and cosmetic scar appearance(p>0.05) . The skin stapler method was faster than other 2 methods (p<0.05).
Conclusion: The three methods of skin closure (subcuticular buried vicryl ,skin clips or stapler and steri- strip) are not routinely plasticizing methods of skin closure in our surgical practice, but they are acceptable new methods and had equal chance of surgeon preference, except in regard to the speed of closure, the skin stapler method is superior to other 2 methods.
Key words: skin closure, subcuticular vicryl, skin stapler, ster-strip adhesive tape.
Complications of Laparoscopic Cholecystectomy
Dr.RAAD S. AL-SAFFAR ,M.B.Ch.B ,C.AB.S., consultant laparoscopic and thyroid surgeon.
Dr. AHMED R. JAWAD , M.B.Ch.B . F.I.C.M.S., digestive surgeon.
Dr.FADHIL A. AL-JANABI, M.B.Ch.B,C.A.B.S. consultant general surgeon.
Objective: To evaluate the complications of laparoscopic cholecystectomy in symptomatic cholecystolithiasis.
Design and duration: Prospective study from 1st September 2007 to 30th December 2010.
Setting: Surgical Unit, Al-Sadur Teaching Hospital, Al-Najaf.
Patients: All patients with cholecystolithiasis who had laparoscopic cholecystectomy.
Methodology: All patients with gallstone disease both symptomatic and asymptomatic, of both sexes and any age were evaluated by history, examination and investigations and the data collected on a preformat.
Patients with chronic liver disease or those deferred by the anesthetist were excluded from the study. All patients underwent laparoscopic cholecystectomy, outcome and complications were analyzed.
Result: 350 patients underwent laparoscopic cholecystectomy in the study period. 305 (87.14%) were females and 45 (12.85%) were males.
Common age group was between 21-40 years (59.42%), bleeding was the commonest complication, occurring from trocar site in 21 (6%), vascular injury in Callot’s triangle in 15 (4.28%) and liver bed in 35 (10%) cases. Spilled gallstones occurred in 18 (5.14%), biliary
leak in 15 (4.28%) including CBD injury in one case. Port site infection was seen in 20 (5.71%), while Conversion to open surgery was in 7 (2%) cases. Bowel injury was not reported in any of cases. Tow cases of subphrenic collection and 7 cases of basal pneuomonia were reported.
Late complications : Port hernia were seen in 3(0.85%) cases .CBD injury and Mortality was NOT reported in any of cases .
Conclusion: LC is a safe and effective procedure in almost all patients with cholelithiasis. Proper preoperative work up, knowledge of possible complications and adequate training makes this operation a safe procedure with favorable result and lesser complications.
Keywords: Laparoscopic cholecystectomy, complications, outcome,Gallstone.
Conversion rate in laparoscopic cholecystectomy:A reviow of 300 cases
Dr. RAAD S. AL-SAFFAR ,M.B.Ch.B ,C.AB.S., consultant laparoscopic and thyroid surgeon.
Dr. ADHIL A. AL-JANABI, M.B.Ch.B,C.A.B.S.,F.A.C.S., consultant general surgeon.
Dr. ABBAS A. AL-JUBORI, M.B.Ch.B., C.AB.S., senior general surgeon.
INTRODUCTION: Prediction of a difficult laparoscopic cholecystectomy (LC) can help the patient as well as the surgeon prepare better for the intra-operative risk and the risk of conversion to open cholecystectomy. The difficult gallbladder is the most common ‘difficult’ laparoscopic surgery being performed by general surgeons all over the world and the potential one that places the patient at significant risk. We present our experience of 300 cases since September 2007 to December 2009 in a single center with respect to conversion to open cholecystectomy.
METHODS: Patients who underwent laparoscopic cholecystectomy (LC) from September 2007 to December 2009 were analyzed. The cases were analyzed in relation to conversion rate to open surgery, factors affecting pulmonary disease were not included in the study.
RESULTS: Out of 300 cases, 52 patients (17.33%) were identified as difficult cases. Laparoscopic cholecystectomy was successfully completed in 295 patients with a completion rate of 98.33%. Laparoscopic procedure had to be converted to the open procedure in 5 patients with a conversion rate of 1.66% of the total LCs performed and 9.6% of the difficult cases. Conversion had to be done due to several reasons.
CONCLUSION: It can be reliably concluded that LC is the preferred method even in the difficult cases. Our study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands the surgeon should keep a low threshold for conversion to open surgery and it should be taken as a step in the interest of the patient rather than be looked upon as an insult to the surgeon.
External tube drainage versus omentopexy in the management of residual hepatic hydatid cyst cavity
Dr.raad al-saffar consultant surgeon. Laparoscopic and thyroid surgery M.B.Ch.B., C.A.B.S.
Dr.Ali M. Al-Saiegh M.B.Ch.B., F.A.C.S., professor in general surgery, medical college.
Dr.Sahib Al-Muthaffer, M.B.Ch.B., D.S.
The aim of this study: our study is confined to the out come of management of the residual cavity of liver hydatid cysts.
Background: Hydatid is a Latin word meaning a drop of water .The causative organism of Hydatid disease is the post-larval metacestode stage of tape worm Echinococcus granulosus has world-wide distribution .Despite the clinical presentation the disease is to be diagnosed and treated at the earliest because the complications of cysts like infection, rupture, biliary obstruction and anaphylaxis may be life-threatening.
Patient and methods: The study was conducted at the department of surgery at Al Sader teaching hospital from the first of December 2008 to the end of October 2009 and included 77 patients have liver hydatid cysts divided into two groups. The residual cavity at the first group (42 patients) was managed by tube drainage procedure while the others (35 patients) managed by omentopexy procedure.
Results: There were 53 females and 24 males in this study .The mean age is (32 years). The peak age incidence from (20-29 years) .Post operative bile leakage was found (9) folds more in patients treated with external tube drain than in patients treated with omentopexy gives high statistical significance between them P value =0.0027 The mean hospital stay was longer for external drainage technique in comparison to Omentopexy group and for complicated cases than uncomplicated cases.
Conclusion: There is no single approach to deal with residual cavity of hydatid cysts of liver, and every case should has its individual way of intervention, we conclude that omentopexy has less morbidity, shorter hospital stay and it is the best technique in managing both complicated and uncomplicated hepatic hydatid cysts.
Tension free inguinal hernia repair comparing “mesh” with “darn” A prospective randomized clinical trial
Dr. Raad S. Al-Saffar M.B.Ch.B ,C.A.B.S.,consultant laparoscopic and thyroid surgeon.
Dr. Ali M. Al-Saiegh M.B.Ch.B., F.A.C.S., professor in general surgery, medical college.
Dr. Haider T.Al-Khassaki M.B.Ch.B. D.S.
Objective: To compare the number of postoperative complications and and early recurrence between Lichtenstein tension free hernioplasty and Darn repair, for inguinal hernia.
Place and Duration of Study: The study was conducted at Department of Surgery, Al-Sadur teaching hospital from 1st august 2007 to 1st august 2008 and included 104 patients.
Study Design: The study design was quasi experimental.
Patients and Methods: A total of 104 patients were selected. 51 patients were treated with Lichtenstein tension free hernioplasty (Group A) and 53 with Darn repair (Group B). Cases were followed up for three months to one year.
Results: the male to female ratio was 51:1. The mean hospital stay was 37.18 hours in group A and 47.17 hours in group B. there was statistically significant difference between the tow groups ( p< 0.05).
The mean operative time was 44.7 minutes in group A and 50.9 minutes in group B. there was statistically significant difference between the tow groups ( p< 0.05). the The total number of postoperative complications was 36, with 15 ( 29.42%) complications occurring in group A and 21( 39.62%) in group B scrotal swelling was the most common complication followed by urinary retention and wound infection in both the study groups. Postoperative complications like scrotal swelling ( 11.77% vs. 16.98%), haematoma ( 5.88% vs. 3.77%), urinary retention (5.88% vs. 9.43%), wound infection ( 1.96 vs. 7.55%) and scar pain ( 3.92% vs. 1.89%) were unsignificantly low in Lichtenstein tension free hernioplasty as compared to Darn repair (P > 0.05). The early recurrence rate in both groups was comparable, There were no recurrences noted till date in any of the two groups under study.
Conclusion: Open inguinal hernia repair with a nylon darn was equivalent to polypropylene mesh with respect to early measures of postoperative outcome and recurrence at 1 year.
Incisional local anesthesia for pain control after abdominal surgery
Dr.Raad S. Al-Saffar , M.B.Ch.B. , C.A.B.S
Dr.Emad A.M.Al-Janabi , M.B.Ch.B. , D.S.
Bach ground:-The optimizing of postoperative pain control is an important aspect in erioperative patient care the use of inscional local anaesthesia in post operative pain control after abdominal operations was proved effective method of analgesia
Aim:-to evaluate the efficacy of postoperative incisional infusion of local anaesthesia bupivicain) in reduction of postoperative pain in abdominal surgical wounds as well as the need for ystemic analgesia and possible side effects of local anaesthesia.Patients and method:-
aprospective randomized placebo controlled clinical trial on 80 patients (39 male 41 female) between 13 –54 years old of different abdominal operations, admitted to El- furat hospital in kufa city from December 2005 to October 2006.The patients were divided in tow groups, intervention group 40 patients and placebo group: 40 patients. The study involve the use of incisional intermittent injection of local anesthesia bupivacaine 0.25% via thin subfascial catheter(in intervention group) for relieve of postoperative pain and assess need for systemic analgesia ( especially opiate) as compared to placebo group in which we inject normal saline via the incisional catheter.
Result:-The study had been discusses age, sex distribution, types of incision, pain assessment by visual analogue score, the need for systemic analgesia & complications of local anesthesia .
The mean visual analogue score of pain was measured in 1st 6th, 12th , 18th , 24th hours after surgery in every patient in both groups were significantly decreased in bupivacaine group in comparism to normal saline group P<0.005.
There is significant decrease for systemic analgesia requirements after operation in intervention group as compared with placebo group (P<0.05).
There is only one minor complication reported in each group (2.5%).
Conclusion:-Study conclude the effectiveness of incisional bupivacaine intermittent injection in relieve of postoperative pain and decrease need for systemic analgesia as shown by many studies.
Key words: incisional local anesthesia, abdominal surgery.
Acute abdomen in elderly patients
Dr. Ali M. Al-Saiegh, MD professor of general surgery, medical college
Dr. Raad S. Al-Saffar, MD consultant laparoscopic and thyroid surgeon
A prospective study was done on 109 patients (61 male and 48 female) above 60 years old. admitted to the emergency unit and surgery floors in Najaf hospital. Complaining of acute abdomen. From May 2004 to Feb. 2005. The mean age was (67.4) years. The largest admission was for age group 60-70(68%).
The study discuss different aspects, such as: age, sex seasonal variation , with percentage of operative to conservative management. complications and mortality rate.
The total number of patients was (109), among them (81) patients (74.3%) were treated operatively; other 28 patients (25.7%) were treated conservatively.
The most common cause of acute abdomen was intestinal obstruction (30%), liver and gall bladder diseases (24.7%), followed by urinary system disorders (19%), then peptic ulcer (8.25%), appendicular disorder (7.3%), gyenecological diseases (3.6%), pancreatic disorders (3.6%) and others represents (2.7%).
The most common complication was chest infection (38.3%), ileus (28.4%), wound infection (19.7%) and thrombophlebitis (16%), mortality rate was (5.5%) of total number of patient.