Surgery Research and Practice The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Skin Staples: A Safe Technique for Securing Mesh in Lichtensteins Hernioplasty as Compared to Suture Thu, 03 Apr 2014 11:06:12 +0000 Background. Lichtenstein tension free repair is the most commonly used technique due to cost effectiveness, low recurrence rate, and better patient satisfaction. This study was done to compare the duration of surgery and postoperative outcome of securing mesh with skin staples versus polypropylene sutures in Lichtenstein hernia repair. Materials and Methods. A total of 96 patients with inguinal hernia undergoing Lichtenstein mesh repair were randomly assigned into two groups. The mesh was secured either by using skin staples (group I) or polypropylene sutures (group II). Results. The operation time was significantly reduced from mesh insertion to completion of skin closure in group I (mean 20.7 min) as compared to group II (mean 32.7 min) with significant value and less complication rate in group I as compared to group II. Conclusion. Mesh fixation with skin staples is as effective as conventional sutures with added advantage of significant reduction in the operating time and complications or recurrence. The staples can be applied much more quickly than sutures for fixing the mesh, thus saving the operating time. Infection rate is significantly decreased with staples. Anand Munghate, Sushil Mittal, Harnam Singh, Gurpreet Singh, and Manish Yadav Copyright © 2014 Anand Munghate et al. All rights reserved. Resection Leads to Less Recurrence Than Strictureplasty in a Paediatric Population with Obstructive Crohn’s Disease Tue, 01 Apr 2014 08:17:45 +0000 Introduction. Resection and strictureplasty are used to treat patients with obstructive Crohn’s disease. Strictureplasty is preferable in adults as it retains bowel length. This study aims to identify differences in outcomes of children undergoing strictureplasty and resection for obstructive Crohn’s disease. Method. Patients under 20 years undergoing surgery over a nine-year period were included. Data was collected on procedures for stenotic Crohn’s disease. Patients were divided into 2 groups: Group 1 treated with strictureplasties and Group 2 resections. Postoperative complications and recurrence rates were recorded. Kaplan-Meier method was used to analyze the data. Results. Twenty-six patients and 40 operations were identified. Mean age was 15.6 years (7.2–19.4) with equal numbers of males and females. Mean follow-up was 45.9 months (0.1–149.9). 20/40 procedures involved the terminal ileum; 9/40, the ileocolic junction; 8/40, the upper GI tract; and 3/40, the colon. Group 1 consisted of 19 strictureplasties and Group 2 consisted of 13 resections and 8 combined procedures. Significantly more patients in Group 1 required further surgery (11/19 versus 3/21; ). Conclusion. Allowing for variations in disease duration, severity, and previous medical management, these data suggest that resection is preferable to strictureplasty in treating obstructive Crohn’s disease in children and adolescents. Richard Bamford, Ashley Hay, and Devinder Kumar Copyright © 2014 Richard Bamford et al. All rights reserved. A Comparative Study between the Outcome of Primary Repair versus Loop Ileostomy in Ileal Perforation Thu, 27 Mar 2014 09:57:01 +0000 Introduction. Ileal perforation peritonitis is a common surgical emergency in the Indian subcontinent and in tropical countries. It is reported to constitute the fifth common cause of abdominal emergencies due to high incidence of enteric fever and tuberculosis in these regions. Methods. Sixty proven cases of ileal perforation patients admitted to Surgical Emergency were taken up for emergency surgery. Randomisation was done by senior surgeons by picking up card from both the groups. The surgical management was done as primary repair (group A) and loop ileostomy (group B). Results. An increased rate of postoperative complications was seen in group A when compared with group B with 6 (20%) patients landed up in peritonitis secondary to leakage from primary repair requiring reoperation as compared to 2 (6.67%) in ileostomy closure. A ratio of 1 : 1.51 days was observed between hospital stay of group A to group B. Conclusion. In cases of ileal perforation temporary defunctioning loop ileostomy plays an important role. We recommend that defunctioning ileostomy should be preferred over other surgical options in cases of ileal perforations. It should be recommended that ileostomy in these cases is only temporary and the extra cost and cost of management are not more than the price of life. Sushil Mittal, Harnam Singh, Anand Munghate, Gurpreet Singh, Anjna Garg, and Jyoti Sharma Copyright © 2014 Sushil Mittal et al. All rights reserved. Treatment of Sternoclavicular Joint Osteomyelitis with Debridement and Delayed Resection with Muscle Flap Coverage Improves Outcomes Wed, 12 Mar 2014 08:07:32 +0000 The objective of this study was to evaluate the efficacy of various treatment options for sternoclavicular joint osteomyelitis. We evaluated patients with a diagnosis of sternoclavicular joint osteomyelitis, treated at our hospital from 2002 to 2012. Four treatment options were compared. Three out of twelve patients were successfully cured with antibiotics alone (25%). Debridement with or without negative pressure therapy was successful for one of three patients (33%). Simultaneous debridement, bone resection, and muscle flap coverage of the acquired defect successfully treated one of two patients (50%). Debridement with delayed bone resection and muscle flap coverage was successful in five of five patients (100%). Osteomyelitis of the sternoclavicular joint is a rare disease that has become more prevalent in recent years and can be associated with increasing use of long-term indwelling catheters. Initial debridement with delayed bone resection and pectoralis major muscle flap coverage can effectively treat sternoclavicular joint osteomyelitis. Jason L. Muesse, Shanda H. Blackmon, Warren A. Ellsworth IV, and Min P. Kim Copyright © 2014 Jason L. Muesse et al. All rights reserved. What Is the Role of Hysteroscopic Surgery in the Management of Female Infertility? A Review of the Literature Mon, 03 Mar 2014 12:55:43 +0000 The position of hysteroscopy in current fertility practice is under debate. There are many randomized controlled trials on technical feasibility and patient compliance demonstrating that the procedure is well tolerated and effective in the treatment of intrauterine pathologies. However, no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women is available. A literature review was performed to explore the available information regarding the role of hysteroscopy in the evaluation and management of female infertility as well as to ascertain evidence that treatment of these uterine abnormalities improves fertility. The debate regarding the role of hysteroscopic surgery in the management of female infertility remains as the published studies did not reach a consensus on the benefit of such an intervention in this setting. The randomized trials do not clearly demonstrate that surgical correction of all intrauterine abnormalities improves IVF outcome. However, published observational studies suggest a benefit for resection of submucosal leiomyomas, adhesions, and endometrial polyps in increasing pregnancy rates. More randomised controlled studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected intrauterine pathology in women with unexplained subfertility or prior to assisted reproductive technology. Márcia Mendonça Carneiro Copyright © 2014 Márcia Mendonça Carneiro. All rights reserved. Utility of Preoperative CA125 Assay in the Management Planning of Women Diagnosed with Uterine Cancer Thu, 27 Feb 2014 11:50:18 +0000 Objective. This study assesses the role of preoperative serum CA125 levels in the planning treatment options for women diagnosed with uterine cancer. Material and Method. Ninety five consecutive patients diagnosed with uterine cancer during a four-year period were identified. Age ranged from 35 to 89 years with a mean age of 69 years. The preoperative CA125 levels were dichotomised at 28 U/mL (using ROC analysis to identify the best discriminating threshold for 5-year survival). This level was then correlated with preoperative prognostic indicators: patient age, tumour grade, and histopathological tumour cell type. Survival data was plotted using Kaplan-Meier curves and analysed using the log-rank test. Univariate and multivariate analysis were performed to identify the predictors of overall survival. Results. The mean age of patients was 69 years (range: 35–89). On univariate analysis, the use of preoperative CA125 levels of greater or less than 28 U/mL correlated significantly with age , the grade of disease and unfavourable tissue type . This threshold CA125 level had a sensitivity of 75%, specificity of 76%, positive predictive value of 35% and negative predicative value of 96.25%, and a likelihood ratio of 3.12 for predicting nodal disease. Using a threshold of preoperative CA125 level of 28 U/mL (area under curve: 0.60) was also a significant predictor of 5-year survival (log-rank test, ). Using Cox multivariate survival analysis to identify predictive preoperative factors overall, unfavourable cell type was the strongest predictor of survival (Chi square = 36.5, df = 4, and ), followed by preoperative CA125 level (CA125 > 28 U/mL, ) and unfavourable preoperative grade (). Amongst patients with a favourable histological tissue type (endometrioid), preoperative CA125 levels predicted overall survival (Chi square = 6.039, df = 2, ); however unfavourable preoperative grade did not (). Overall, at five-year follow-up, while there were no deaths among the women with preoperative serum CA125 less than 12 U/mL, eleven of the twenty-three deaths (47.82%) in the study occurred in women with a preoperative CA125 more than 28 U/mL. Conclusions. A preoperative CA125 assay for women with uterine cancer is a relatively inexpensive, reproducible, and objective test which provides valuable information regarding the risk of metastatic disease and overall likelihood of long term survival. Patients with a low likelihood of metastatic/nodal disease (favourable tissue type and CA125 level < 28 U/mL) and significant comorbidities may benefit from avoiding an extended complete staging procedure. Alternatively, a high level of CA125 may prompt further imaging and multidisciplinary discussions to plan for individualised management and consideration for recruitment to clinical trials. N. Povolotskaya, N. Das, K. Dhar, D. Brinkmann, F. Gardner, and R. Woolas Copyright © 2014 N. Povolotskaya et al. All rights reserved. Alterations in the Coagulation System during Major Visceral Surgery in Children Wed, 26 Feb 2014 08:44:33 +0000 Purpose. The description of the alterations in the hemostatic system in children undergoing abdominal surgery is sparse. Enhanced clinical outcomes for previously untreatable conditions have led to an increased incidence of venous thromboembolic complications. Alterations in children’s coagulation system during major abdominal operations compared to minor procedures were examined. Methods. Children (0–12 years) undergoing either laparotomy, thoracotomy, or minor surgery were included. Participants were divided into two groups: group 1 was open laparotomy including operations for solid abdominal tumours and thoracotomy, while group 2 was minor surgery. Activated partial thromboplastin time (aPTT), D-dimer, INR, and fibrinogen were measured. Results. Both groups had a shorter aPTT, higher INR, and lower fibrinogen concentrations after the operation, while D-dimer was unaltered. The changes were, however, discrete and probably not clinically significant. On day 3, all parameters except aPTT in group 1 (not measured in group 2) indicated a continuous coagulation activity. Conclusion. The tendency for coagulation activity altered based on the length and degree of surgery. A continuously altered activity was observed compatible with the reported increased risk of venous thromboembolism at day 3. However, before introducing thromboprophylaxis guidelines larger series of multicentre studies are needed. Hayarpi H. Kordjian, Mads Nybo, and Niels Qvist Copyright © 2014 Hayarpi H. Kordjian et al. All rights reserved. Nonfunctional Metastatic Parathyroid Carcinoma in the Setting of Multiple Endocrine Neoplasia Type 2A Syndrome Thu, 20 Feb 2014 09:57:23 +0000 Parathyroid carcinoma is a very rare malignancy. It has been associated with hyperparathyroidism-jaw tumour syndrome, familial isolated primary hyperparathyroidism, and multiple endocrine neoplasia type 1 (MEN-1) and 2A (MEN-2A) syndromes. We report a 54-year-old man with a MEN-2A which presents with a nonfunctional metastatic parathyroid carcinoma and a pheochromocytoma in the absence of medullary thyroid carcinoma. Only a few cases of parathyroid carcinoma have been reported in the literature associated with this syndrome. María Posada-González, Joaquín Gómez-Ramírez, Manuel Luque-Ramírez, Mercedes Guijarro, Elena Martín-Pérez, Ana Rodríguez-Sánchez, Iñigo García-Sanz, and Eduardo Larrañaga Copyright © 2014 María Posada-González et al. All rights reserved. Flow Cytometric Evaluation of T Cell Activation Markers after Cardiopulmonary Bypass Thu, 06 Feb 2014 09:16:17 +0000 Background. Cardiopulmonary bypass surgery (CPBS) is associated with an increased risk for infections or with subsequent organ dysfunction. As T cell activation is a central mechanism during inflammatory processes, we developed an assay to evaluate T cell activation pathways in patients undergoing CPBS. Methods. Blood was obtained from eleven patients undergoing CPBS preoperatively, on postoperative day (POD)-3, and on POD-7 and was stimulated with different concentrations of Concanavalin A (ConA). Cyclosporine and sirolimus, inhibiting different pathways of the T cell cycle, were added to blood ex vivo. Expression of T cell activation markers CD25 and CD95 was analyzed by flow cytometry. Results. In untreated blood, expression of CD25 and CD95 significantly increased with higher ConA concentrations and decreased for all ConA concentrations for both antigens over the study time . Independently from the ConA concentration, inhibition of CD25 and CD95 expression was highest preoperatively for sirolimus and on POD-3 for cyclosporine. At all time points, inhibition of CD25 and CD95 expression was significantly higher after cyclosporine compared to sirolimus treatment . Conclusion. Our results showed that different pathways of T cell activation are impaired after CPBS. Such knowledge may offer the opportunity to identify patients at risk for postoperative complications. Maja-Theresa Dieterlen, Hartmuth B. Bittner, Attila Tarnok, Jens Garbade, Stefan Dhein, Friedrich W. Mohr, and Markus J. Barten Copyright © 2014 Maja-Theresa Dieterlen et al. All rights reserved. Complications following Treatment of Trochanteric Fractures with the Gamma3 Nail: Is the Latest Version of Gamma Nail Superior to Its Predecessor? Thu, 06 Feb 2014 00:00:00 +0000 Gamma nail is a cephalomedullary implant that was developed for the treatment of pertrochanteric hip fractures and has been successfully used for over 20 years. During this period, modifications of design and instrumentation have occurred to combat the intra- and postoperative complications that were associated with the use of early designs. The purpose of this study was to compare the complications observed with the use of the Gamma3 nail (G3N) with those seen following use of the previous trochanteric gamma nail (TGN). This study prospectively recorded the intra- and postoperative complications of 175 patients treated with the Gamma3 nail and compared them with those of a historical cohort of 192 patients treated with the trochanteric gamma nail. We encountered less intra- and postoperative complications with the use of Gamma3 nail. Femoral fractures and lag screw cutout were significantly lower. The reoperation rate was significantly higher in the TGN group. Gamma3 nail has proved to be a safe and efficient implant for the treatment of pertrochanteric fractures. The improvement of the biomechanical characteristics has led to a significant decrease in complication rates, demonstrating superiority over its predecessor. Dimitrios Georgiannos, Vasilios Lampridis, and Ilias Bisbinas Copyright © 2014 Dimitrios Georgiannos et al. All rights reserved. Melanoma of the Urinary Bladder: A Review of the Literature Sun, 12 Jan 2014 11:59:22 +0000 Background. Melanomas of the urinary bladder and urethra are rare. Aims. To review the literature on the disease. Methods. Various Internet databases were used to identify reported cases of the disease. Results. Less than 30 cases of primary melanoma of the urinary bladder and urethra have been reported in the literature and they have been associated with melanosis and commonly with metastases. The lesions may be primary or metastatic with no gender preference. The diagnostic features include pigmented raised lesions which histologically exhibit spindled or epitheliod cells, necrosis, mitotic figures, and atypical melanocytes. Immunohistochemically they stain positively with S100; HMB45; and other melanocyte markers, but negatively with Keratin and Vimentin. The treatment involves excision and possibly IL-2. The prognostic factors include size and depth of invasion as well as metastatic lesions. Conclusions. Less than 30 cases (about 24 cases) of the disease have been reported. There are also reports of metastatic melanomas of the urinary bladder emanating from primary melanomas originating elsewhere. Diagnosis of the primary disease is based upon the histological appearance of the lesion, positive staining with S100 and HMB45, and evidence of absence of melanoma elsewhere. Primary melanoma of the bladder is usually a fatal lesion. Anthony Kodzo-Grey Venyo Copyright © 2014 Anthony Kodzo-Grey Venyo. All rights reserved. Solitary Fibrous Tumour of the Pleura Presenting as a Spontaneous Massive Haemothorax Thu, 09 Jan 2014 06:08:52 +0000 Solitary fibrous tumours of the pleura are rare neoplasms. These tumours are generally asymptomatic and incidentally diagnosed. Symptoms, if present, are nonspecific such as cough, dyspnea, and chest pain. This report describes the case of a 38-year-old woman admitted to our department after the onset of a right massive spontaneous haemothorax requiring emergency surgical treatment. Intraoperatively a bleeding pleural mass was found to be the cause of the haemothorax. The tumour was successfully resected and the patient made an uneventful recovery. Histological examination revealed the mass to be a solitary fibrous tumour of the pleura. Giampiero Negri, Alessandro Bandiera, Paola Ciriaco, Giulio Melloni, Angelo Carretta, George Ian Cremona, and Piero Zannini Copyright © 2014 Giampiero Negri et al. All rights reserved. Autologous Fat Transfer: An Aesthetic and Functional Refinement for Parotidectomy Wed, 08 Jan 2014 16:33:05 +0000 Parotidectomy is a surgical procedure associated to functional (Frey’s syndrome) as well as aesthetic (facial asymmetry) complications that can be very disturbing for the patient. Several procedures have been described to primarily avoid or secondarily reconstruct the facial defect and treat the neurological iatrogenic syndrome. Autologous fat transfer was primarily used in 10 cases to avoid such complications. It is an easy technique widely used in cosmetic and reconstructive surgery. This technique gives very satisfying long-term results on the cosmetic as well as on the physiological point of view. Pierre G. Vico, Axel Delange, and Axel De Vooght Copyright © 2014 Pierre G. Vico et al. All rights reserved. Modern Management of the Exstrophy-Epispadias Complex Sun, 05 Jan 2014 12:42:06 +0000 The exstrophy-epispadias complex is a rare spectrum of malformations affecting the genitourinary system, anterior abdominal wall, and pelvis. Historically, surgical outcomes were poor in patients with classic bladder exstrophy and cloacal exstrophy, the two more severe presentations. However, modern techniques to repair epispadias, classic bladder exstrophy, and cloacal exstrophy have increased the success of achieving urinary continence, satisfactory cosmesis, and quality of life. Unfortunately, these procedures are not without their own complications. This review provides readers with an overview of the management of the exstrophy-epispadias complex and potential surgical complications. Brian M. Inouye, Ali Tourchi, Heather N. Di Carlo, Ezekiel E. Young, and John P. Gearhart Copyright © 2014 Brian M. Inouye et al. All rights reserved. An Intra-Abdominal Pseudocyst around a Ventriculoperitoneal Shunt due to Streptococcus Infection 7 Years after Shunt Surgery Sun, 05 Jan 2014 11:55:08 +0000 In 1999, a 50-year-old woman underwent ventriculoperitoneal (VP) shunt surgery for hydrocephalus after subarachnoid hemorrhage. She was hospitalized for fever and recurrent systemic seizures in November 2006. Head computed tomography (CT) showed only old changes. The seizures and fever were controlled by medicinal therapy. However, in December, her consciousness level suddenly decreased, and she showed progressive lower abdominal distension. Head CT showed marked ventriculomegaly, and abdominal CT showed a giant cystic mass at the shunt-tube tip in the lower abdominal cavity. Because thick pus was aspirated from the intra-abdominal mass, we diagnosed the patient with acute obstructive hydrocephalus due to an infected abdominal pseudocyst. Laparotomy and direct cyst drainage were performed, and antibiotic therapy against Streptococcus, the causative pathogen, was administered. The VP shunt tube was replaced. The postoperative course was uneventful, and postoperative CT showed hydrocephalus improvement and no pseudocyst recurrence. Abdominal pseudocysts, which are rare after VP shunt surgeries, usually occur after the subacute postoperative course in younger cerebral hemorrhagic cases. Our case was quite rare because the cyst developed in the chronic phase in an older patient and was caused by streptococcal infection. The cyst components should be examined before cyst drainage when choosing surgical strategies. Arata Tomiyama, Jun-ichi Harashina, Hitoshi Kimura, Keisuke Ito, Yoshihiko Honda, Hiroyuki Yanai, and Satoshi Iwabuchi Copyright © 2014 Arata Tomiyama et al. All rights reserved. Endoscopic Endonasal Transsphenoidal Resection for Pituitary Apoplexy during the Third Trimester of Pregnancy Thu, 02 Jan 2014 13:34:45 +0000 Pituitary apoplexy is an uncommon phenomenon typically characterized by vascular insufficiency or acute hemorrhage into a pituitary adenoma. The overall incidence of pituitary apoplexy ranges between 1 and 25% of all pituitary adenomas. With the widespread use of MRI technology, the diagnosis of asymptomatic intratumoral hemorrhage is closer to 10%. The authors report a case of a 27-year-old female in her 36th week of pregnancy who presented with severe onset headache and acute left-sided vision loss. MRI of the brain revealed a large hemorrhagic mass occupying the sella turcica. The patient underwent an emergent endoscopic endonasal transsphenoidal resection for pituitary apoplexy. Postoperatively, the patient’s neurologic deficit resolved. Minimally invasive endoscopic endonasal transsphenoidal resection of pituitary apoplexy can be safely utilized in third trimester pregnant women presenting with acute severe neurologic deficits. Adesh Tandon, Juan Alzate, Patrick LaSala, and Marvin P. Fried Copyright © 2014 Adesh Tandon et al. All rights reserved. Coronary Artery Bypass Graft Surgery: The Past, Present, and Future of Myocardial Revascularisation Thu, 02 Jan 2014 12:52:18 +0000 The development of the heart-lung machine ushered in the era of modern cardiac surgery. Coronary artery bypass graft surgery (CABG) remains the most common operation performed by cardiac surgeons today. From its infancy in the 1950s till today, CABG has undergone many developments both technically and clinically. Improvements in intraoperative technique and perioperative care have led to CABG being offered to a more broad patient profile with less complications and adverse events. Our review outlines the rich history and promising future of myocardial revascularization. Michael Diodato and Edgar G. Chedrawy Copyright © 2014 Michael Diodato and Edgar G. Chedrawy. All rights reserved. Glomus Jugulare Presenting with Isolated Facial Nerve Palsy Thu, 02 Jan 2014 12:06:08 +0000 Glomus jugulare is a rare slow growing tumor occurring within the jugular foramen that rarely presents with isolated symptoms. Although histologically benign, these tumors are locally destructive because of their proximity to the petrous bone, the lower cranial nerves, and the major vascular structures (Miller et al. (2009) and Silverstone (1973)). We wish to report a glomus jugulare tumor eroding the petrous bone and producing an ipsilateral peripheral facial weakness. The mechanism of this erosion is discussed. Angelica A. Nunez, Luis R. Ramos-Duran, and Albert C. Cuetter Copyright © 2014 Angelica A. Nunez et al. All rights reserved. Perioperative Avulsion of a Left Internal Mammary Artery Graft in a Patient with Syphilis Thu, 02 Jan 2014 11:50:39 +0000 Avulsion of a graft after coronary artery bypass grafting surgery is a rare but very serious complication which leads to massive bleeding and possible life-threatening cardiac tamponade. In this paper we report a very rare case of a left internal mammary artery graft avulsion on the day of surgery in a patient with syphilis. Vasily I. Kaleda, Sergei A. Belash, Alexei V. Barsuk, and Kirill O. Barbuhatti Copyright © 2014 Vasily I. Kaleda et al. All rights reserved. The Use of the S-MART Tourniquet in Hand Surgery: A Safe and Effective Way to Provide a Bloodless Field Thu, 02 Jan 2014 11:03:53 +0000 We have retrospectively reviewed our use of the S-MART sterile silicon ring self-exsanguinating tourniquet in 300 consecutive minor hand surgical procedures. A total of 3 postoperative complications were identified, only 1 of which was directly related to the tourniquet’s use. We outline the reasons of why we feel that this device provides a safe and effective bloodless field and the benefits of its use. O. Templeton-Ward, J. Feher, and P. Davey Copyright © 2014 O. Templeton-Ward et al. All rights reserved. Patient Aesthetic Satisfaction with Timing of Nasal Fracture Manipulation Thu, 02 Jan 2014 11:01:56 +0000 Introduction. To determine patient cosmetic satisfaction following nasal fracture manipulation under general anaesthetic when offered at different time intervals after injury. Materials and Methods. Prospective chart review of adult patients with nasal fractures treated by closed reduction at a busy district general hospital in Greater London over a 10-month period. Patients were asked by a standardised telephone interview about satisfaction with nasal cosmesis pre- and postoperatively using a Likert scale. Results. Seventy-six of 106 patients presented for nasal manipulation at up to 9 weeks after injury and were successfully contacted (72%) postoperatively. Forty-nine patients (64%) reported that they still would have had the surgery in retrospect. Those done within 1-2 weeks after injury resulted in the highest mean satisfaction score (). There was a negative correlation between patient satisfaction and timing of surgery (, ). Of the patients satisfied or very satisfied with their procedure, 96% had it done within 4 weeks. Conclusion. The majority of patients treated with closed reduction of nasal fractures under general anaesthetic are satisfied with the cosmetic outcome and would still have undergone surgery in retrospect. Increasing time of surgery after 2 weeks resulted in lower patient satisfaction. Sunil Dutt Sharma, Ivor Kwame, and John Almeyda Copyright © 2014 Sunil Dutt Sharma et al. All rights reserved. Deltopectoral Flap in the Era of Microsurgery Thu, 02 Jan 2014 10:05:25 +0000 Background. Our study aimed to review the role of deltopectoral (DP) flap as a reconstructive option for defects in the head and neck region in the microvascular era. Methods. All patients who received DP flap reconstruction surgery at the Department of Surgery, Queen Mary Hospital, between 1999 and 2011 were recruited. Demographic data, indications for surgery, defect for reconstruction, and surgical outcomes were analyzed. Results. Fifty-four patients were included. All but two patients were operated for reconstruction after tumour resection. The remaining two patients were operated for necrotizing fasciitis and osteoradionecrosis. The majority of DP flaps were used to cover neck skin defect (63.0%). Other reconstructed defects included posterior pharyngeal wall (22.2%), facial skin defect (11.1%), and tracheal wall (3.7%). All donor sites were covered with partial thickness skin graft. Two patients developed partial flap necrosis at the tip and were managed conservatively. The overall flap survival rate was 96.3%. Conclusions. Albeit the technical advancements in microvascular surgery, DP still possesses multiple advantages (technical simplicity, reliable axial blood supply, large size, thinness, and pliability) which allows it to remain as a useful, reliable, and versatile surgical option for head and neck reconstruction. R. C. L. Chan and J. Y. W. Chan Copyright © 2014 R. C. L. Chan and J. Y. W. Chan. All rights reserved. Laparoscopic Cholecystectomy Performed by Residents: A Retrospective Study on 569 Patients Thu, 02 Jan 2014 09:04:52 +0000 Introduction. Aim of this study was to evaluate the safety of laparoscopic cholecystectomy performed by residents. Materials and Methods. We retrospectively reviewed 569 elective laparoscopic cholecystectomies. Results. Duration of surgery was min for residents versus   min for staff surgeons, . Rate of conversion was 3.2% for residents versus 2.7% for staff surgeons, . There was no difference in the rates of intraoperative and postoperative complications for residents (1.2% and 3.2%) versus staff surgeons (1.5% and 3.1%), and . Postoperative hospital stay was days for residents versus   days for staff surgeons, . One death in patients operated by residents (1/246) and one in patients operated by staff surgeons (1/323) were found, . No difference in the time to return to normal daily activities between residents ( days) and staff surgeons ( days) was found, . Shorter duration of surgery when operating the senior residents ( minutes) than the junior residents ( minutes), . Conclusion. Laparoscopic cholecystectomy performed by residents is a safe procedure with results comparable to those of staff surgeons. Dario Pariani, Stefano Fontana, Giorgio Zetti, and Ferdinando Cortese Copyright © 2014 Dario Pariani et al. All rights reserved. Bilateral Psoas Haematomata Complicating Renal Transplantation Thu, 02 Jan 2014 09:00:43 +0000 Background. The challenge in managing patients undergoing renal transplantation is how to achieve optimum levels of anticoagulation to avoid both clotting and postoperative bleeding. We report a rare case of severe postoperative retroperitoneal bleeding including psoas haematomata complicating renal transplantation. Case Report. SM, a 55-year-old female, had a past history of aortic valve replacement, cerebrovascular event, and thoracic aortic aneurysm and was on long-term warfarin that was switched to enoxaparin 60 mg daily a week prior to her living donor transplantation. Postoperatively, she was started on a heparin infusion, but this was complicated by a large retroperitoneal bleed requiring surgical evacuation on the first postoperative day. Four weeks later, she developed features compatible with acute femoral neuropathy and a CT scan revealed bilateral psoas haematomata. Following conservative management, she made steady progress and was discharged home via a community hospital 94 days after transplantation. At her last visit 18 months after transplantation, she had returned to full fitness with excellent transplant function. Conclusion. Patients in established renal failure who require significant anticoagulation are at increased risk of bleeding that may involve prolonged hospitalisation and more protracted recovery and patients should be carefully counselled about this. Jacob A. Akoh, Tahawar A. Rana, and Daniel Higgs Copyright © 2014 Jacob A. Akoh et al. All rights reserved.