The COVID-19 pandemic has impacted health-care systems worldwide, mandating novel measures to protect patients and health-care workers. In addition to the stratification of risks in terms of patient, anesthesia, and surgery, surgeons will now have to consider infectious risks associated with the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus in their preoperative assessment. It is imperative that surgeons adapt to this new challenge, which is likely to be a part of the foreseeable future. This review aims to guide the operating surgeon to make informed decisions regarding risks associated with the virus, and how to best prepare for the same. It is a collation of the current knowledge in the field and covers (a) SARS-CoV-2 epidemiology, clinical characteristics, and testing; (b) strategies for stratification of surgeries; (c) preoperative testing; (d) preoperative considerations; (e) intraoperative concerns; (f) precautions to be followed in the performance of open as well as laparoscopic surgery; and (e) issues related to resumption of elective surgery.

Introduction: Our aim was to evaluate the surgical outcome and ethical considerations in adopting stapled hemorrhoidopexy (SH) in low-resource settings. Methods: This prospective comparative study of patients with Grade III hemorrhoids was conducted at our institute from December 2017 to July 2019. Short-term surgical outcome and the results of a short questionnaire associated with ethics were evaluated. Results: Sixty patients were operated on for third-degree hemorrhoids, thirty each in Group conventional hemorrhoidectomy (CH) and Group SH. The SH group had better postoperative pain control at 0, 1, and 4 weeks (P = 0.001), but this difference became insignificant at 12 weeks. Overall recurrence was more in SH group (11.37%) as compared to CH group (2.7%), and it was statistically significant (P = 0.01). The mean operative time was significantly less in the SH group (43 min vs. 50 min, P = 0.006). Similarly, the mean hospital stay was significantly less in the SH group as compared to the CH group (2.27 days vs. 3.83 days, P = 0.001). Survey of the operating surgeons revealed that all the three surgeons involved assessed the effectiveness and safety of SH through literature; the main motivation behind performing new technique in resource-poor settings was learning a new technique and teaching purpose. Conclusion: The main value of this research is to describe the adoption of surgical stapler into clinical practice in low-resource settings. Our analysis suggests that, in a rapidly developing area of surgical innovation, adoption of SH in resource-poor settings can give the same outcome as in expert hands.

Background: Bile leakage is a well-known serious complication of treatment of gallstones and other procedures on the bile duct. They are important because they are preventable; however, once they occur, they may be associated with considerable morbidity and mortality. This study intends help to get a differentiated point of view of treating bile leak. Materials and Methods: This was a prospective study. All bile leak cases admitted between August 1, 2015, and July 31, 2020, were examined and the results were noted. Results: A total of 1485 cholecystectomies were done in the given period. Chronic cholecystitis was the most common indication for surgery. Most leaks were treated conservatively. Conclusions: Most common site of bile leak was found to be gall bladder bed, duct of Luschka, and other minor bile ducts. Most of the postoperative bile leaks were managed conservatively and by endoscopic procedures, rarely requiring re-operation.

Objectives: The current study aimed to assess the impact of microdiscectomy surgery on quality of life (QOL) in postoperative patients across many facets of life to identify the most commonly affected ones. Our research question was, “does majority of postlumbar microdiscectomy patients have good QOL postsurgery?” Patients and Methods: In a single tertiary care center in southern region, Saudi Arabia, ninety-seven patients who underwent discectomy at Aseer Central Hospital (ACH) in southwestern Saudi Arabia from 2015 to 2017 were included in this study. ACH is the only tertiary care center in Asir province. Patients with spinal fractures or incomplete files were excluded. Patients' files were reviewed for data extraction. A phone call was made to all patients and they were asked to answer the five questions of the five domains of the EuroQoL 5-dimension 5-level (EQ-5D-5 L) QOL questionnaire. After considering other variables and adjusting for potential confounders, we assessed the amount of patients' satisfaction in the 5 domains of EQ-5D-5 L. Results: The study included 97 patients whose ages ranged from 28 to 56 years with a mean age of 42.6 ± 10.8 years. Nearly 61% of the patients were male. In all, 56.7% of patients reported a high QOL, while 4.1% of them had a poor QOL. About 82% of the included patients had no or minimal self-care problems, while 65.9% of the patients had no or minimal pain. Conclusions: The researchers concluded that about half of the patients who underwent lumbar microdiscectomy had a high QOL. The greatest improvements following microdiscectomy were recorded for self-care, mobility, and psychological status, while the lowest improvements were noted for pain and discomfort.

Background: Panfacial fractures are defined as fractures of the craniomaxillofacial complex involving bones in the lower, middle, and upper thirds of the facial skeleton. The aim of the current study is to report the prevalence, sociodemographics, and pattern of panfacial fractures in Najran, Kingdom of Saudi Arabia. Materials and Methods: This was a retrospective study of panfacial fractures seen and managed in a major referral hospital in the southern province of the Kingdom of Saudi Arabia over a 10-year period from 2008 to 2018. Data collected include demographics such as age, gender, etiological factor, and pattern of bone fracture involved in the panfacial fracture. Data were stored and analyzed using IBM SPSS Statistics for IOS Version 25 (Armonk, NY, USA: IBM Corp.). Results were presented as simple frequencies and descriptive statistics. Statistical significance was set at P ≤ 0.05. Results: A total of 1057 patients presented with maxillofacial injuries, of which 43 male patients suffered from panfacial fractures during the study period giving a prevalence rate of 4.1%. The age ranged from 16 to 45 years with mean ± standard deviation (26.6 ± 8.3) years. The age group of 21–30 years had the highest frequency of panfacial fracture, whereas the age group of 41–50 years had the least occurrence with a statistically significant difference. Most of the mandibular fractures involved the symphysis and parasymphysis (27.9% and 23.3%), respectively. In the midface, Le Fort I and II were the most common maxillary fractures. Conclusion: Inquiry into the prevalence, sociodemographics, and pattern of panfacial fractures is essential in decision-making by the attending clinicians for the patients' overall management. This study has reported a prevalence rate of 4.1% with only male preponderance.

Context: Systemic inflammatory response syndrome (SIRS) can be a result of ischemia, inflammation, trauma, infection, or a combination of several “insults.” Aims: The present study aims to estimate the relationship between SIRS and different predictive factors including sex, renal disease, diabetes (DM), comorbidities ultrasound, computed tomography (CT) abdomen, operative intervention, and other operational findings of inflamed appendicitis, gangrenous and perforated appendicitis, and postoperative complications. Settings and Design: Retrospective cohort study was conducted at Al-Noor Hospital Emergency Department in Makkah. Materials and Methods: Data were collected from 259 patients with acute appendicitis presented to the Al-Noor Hospital Emergency Department in Makkah during 1435H. Variables such as comorbidities, vital sign on presentation, the result of certain investigation (white blood cell count, arterial blood gas, ultrasound, and CT abdomen), interventions provided, postoperative complication, intensive care unit length stay, and outcome along with SIRS criteria were followed to collect the data. Statistical Analysis Used: A secondary logistic analysis was also performed (SPSS version 19.0) on key risk factors, in order to exclude confounding covariates. Results: The findings of the study indicate a significant relation between SIRS criteria and the operation findings of perforation with collection with a significant P = 0.001. The presence of gangrenous appendicitis intraoperatively provided almost significant relationship with SIRS criteria (0.065). Conclusion: The present study concluded that SIRS has a significant predictive value with the presence of complicated appendicitis in the form of perforation and gangrene.

Background: The relation between the resected stomach volume (RSV) and the weight loss after laparoscopic sleeve gastrectomy (LSG) appears conflicting in the literature. The aim of the present research was to find the correlation of RSV after LSG, the percentage of excess weight loss (%EWL) at 6-month and 1-year follow-up, and the initial body mass index (BMI). Materials and Methods: Sixty patients aged between 18 and 60 years who underwent LSG were included. Preoperatively, the baseline data of patients such as BMI and presence of Type 2 diabetes mellitus were noted. LSG was performed under general anesthesia. The resected stomach was punctured with Veress needle and insufflated with CO₂. The maximum volume was recorded as RSV. The sleeve volume was measured by the amount of methylene blue used to distend the stomach during the leak test. %EWL was calculated at 6 months and 12 months. The primary outcome measures were to find the correlation of RSV with %EWL and BMI, whereas the secondary outcome measure was to find the correlation of vertical length of staple line with %EWL. Comparison of categorical and continuous variables was done using Chi-square test/Fisher's exact test and unpaired t-test, respectively. Correlation analysis was done using Pearson's correlation technique. Results: The RSV positively correlated with initial BMI (r = 0.456). There was no significant correlation of RSV, sleeve volume, and vertical length of staple line with %EWL at 6-month and 12-month postoperative intervals. Conclusion: RSV positively correlated with baseline BMI, but not correlated with %EWL.

Background: The reported incidence of bacteria in bile is extremely variable from 8% to 42%. Several authors have been able to correlate the bacteria cultured from bile at pancreatico-duodenectomy (PD) with those subsequently causing wound infections and septicemia in the postoperative period. In addition, preoperative biliary intervention increases the risk of bactibilia that can translate into increased postoperative morbidity. Materials and Methods: This study was a prospective study conducted at the Department of Surgical Gastroenterology in Sher-I-Kashmir Institute of Medical Sciences from January 2015 to July 2020. A total of 71 patients who underwent PD were included in the study. Results: All patients had intraoperative bile culture (IBC). IBC was positive in forty (56.3%) patients. IBC was more likely to be positive in patients with preoperative intervention as compared to those with no intervention (86.11% vs. 13.89%). IBC was polymicrobial in 28/40 (70%) patients, with Escherichia coli and Klebsiella Pneumoniae both cultured together in 40% of patients. The monomicrobial infection was mainly due to E. coli in 22.5% of patients. Six/40 (15%) patients with bactibilia had wound infection and 4/40 (10%) patients had intra-abdominal collection. Patients with intervention had more of bactibilia (31/36 [86.11%]) compared to that of noninterventional group (9/35 [25.71%]), showing that the intervention was associated with an increased risk of biliary infection. The percentage of multidrug-resistant strains in our study was 97.7%. Conclusion: Positive IBC can determine the cohort of patients who are at risk of postoperative morbidity. Patients with preoperative intervention should be considered potentially infected who deserve careful operative technique to avoid spillage of bile to minimize wound infection and other morbidity. IBC also allows for early appropriate antibiotic use.

Background: Traumatic diaphragmatic injury (TDI) is one of the injuries that can occur after blunt and penetrating trauma and can be neglected or missed due to the masking of accompanying organ injuries. In this study, we delved into the difficulties in the diagnostic and treatment approaches for TDI patients. Methods: We retrospectively examined 22 TDI cases who were urgently operated following blunt (n = 14) and penetrating (n = 8) traumas in thoracic and general surgery clinics between January 2004 and 2019. We recorded information such as trauma type, diagnostic techniques, concomitant organ injuries, the location of diaphragmatic injury and its stage, the herniated organs toward the chest cavity, and surgical method. Results: The average mean age of the cases in the study was 41.5 years (22–66 years), and all of them were male. Among these, the percentage of pericardial rupture was significant (23%). In abdominal approaches, thorax was examined with an optical camera through the diaphragmatic rupture. TDI was classified into five groups based on the severity of the injury. Additionally, diaphragmatic ruptures in the central tendon or subpericardial area were examined. The entire central diaphragmatic injury was found as blunt trauma. This group was diagnosed with a high rate of multiple organ injuries (100%) and pericardial rupture (30%). Morbidity was 36%, and mortality was 14%. Conclusion: TDI should be taken into consideration in thoracoabdominal traumas. The frequency of organ injury in high-level TDI is also high. Therefore, laparoscopic and thoracoscopic evaluations should be needed. A good preoperative and peroperative strategy diminishes mortality and morbidity. We suggest that laparoscopy and thoracoscopy will be a lifesaving method in high-grade TDIs.

Introduction: Pain management is a vital part of postoperative treatment. Pain management in the postoperative period is based on a number of factors such as the extent of surgery, patient profile and surgeon experience, etc. The numbers of subjective scoring system were proposed to scale the severity of pain. Materials and Methods: This prospective audit was performed between November 2015 to January 2016. Pain scores were recorded in all patients underwent surgery for initial three days by numerical rating scale (NRS). Results: A total of 92 patients were included in this audit. The patients were broadly divided into the two groups: non-malignancy group and malignancy group. Pain scores were found higher in adult patients, in malignancy patients, and in patients who require wide excision. The scores were found on the lower side in the ear and throat surgery group in comparison to the nose surgery group. Discussion: Postoperative pain is an individual multi-factorial experience. Poor management is likely to increases the chances of local and systemic complications and delays in the recovery of the patients. Appropriate selection of analgesics would reduce hospital financial burden to a great extent but the side effect profile of each drug should be kept in mind.

Currently, bariatric surgery procedures has witnessed an upsurge in its utilization to control obesity and its allied morbidities. However, gastric or anastomotic leak, though rare, is its most dreadful complication. In this report we describe the clinical course of a 41 year-old-male, with a body mass index of 41.6, who underwent open mini gastric bypass which was followed by leak. A second laparotomy was performed in which intraperitoneal drains were inserted and a feeding jejunostomy was constructed. This was followed by the insertion of a mega stent, along with the application of over the scope clip at the site of the leak. Few days later, he appeared in our hospital with manifestations of sepsis. Computerized tomography scan showed persistence of leak with a perisplenic collection. A third laparotomy was performed and after tedious dissection, the stent was found eroding through the site of gastrojejunostomy. The defect was closed over a T tube and the perisplenic collection was drained. The patient tolerated surgery well, but he developed wound infection with disruption. Conservative treatment was followed to create a controlled incisional hernia, to be dealt with later. After a lengthy hospital stay, radioloic studies showed cessation of the leak with no collection. T tube, drains and jejunostomy tube were removed in time and the patient was discharged in good condition for OPD follow-up.

We report a case of diaphragmatic hernia of Morgagni with a unique clinical presentation. It is important to know all the possible complications and acute presentations of Morgagni hernia. Before the innovation of laparoscopy in the treatment of diaphragmatic hernia, it is used to be treated either through abdominal approach or, in most cases, thoracic approach.