Background: Hemorrhoids are a common human disease for which the best option available for the surgical management has remained conventional open hemorrhoidectomy. The most common complication of open hemorrhoidectomy is postoperative pain caused by spasm of the internal sphincter. Lateral sphincterotomy is a commonly performed procedure for relieving spasm and pain. Hence, we decided to evaluate whether addition of lateral sphincterotomy along with hemorrhoidectomy can help in the postoperative pain relief. Aim: Comparison of postoperative pain after hemorrhoidectomy with and without lateral internal sphincterotomy. Settings and Design: This was a prospective study conducted between November 2013 and December 2015 on 102 consenting patients who chose conventional open hemorrhoidectomy after obtaining an ethical clearance for the study. Subjects and Methods: The patients were randomized into two groups using the lottery method. Group A in addition to conventional open hemorrhoidectomy received lateral internal sphincterotomy. In Group B, only conventional open hemorrhoidectomy was performed. Pain assessment was done on the day - 0, 1, 2, and 7, respectively, by visual analog scale. Statistical analysis was done using  Chi-squared test (two-tailed) and a P < 0.005 was considered statistically significant. Results: On assessment of pain on the day - 0, 1, 2, and 7, respectively, by visual analog scale; we found statistically significant pain relief in the group whom lateral sphincterotomy was added. Conclusions: In this study, we conclude that in conventional open hemorrhoidectomy for 2 ^nd degree hemorrhoids addition of lateral sphincterotomy is an effective, convenient, and simple way to reduce the postoperative pain.

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Arteriovenous malformations (AVMs) that bleed may be a common occurrence in the human body, however, when they present at such a site, as the distalmost part of the penile urethra, they become, commonly "uncommon." In addition, the distal site also makes them liable to be missed both via imaging as well as cystoscopy. Moreover, those reported are mainly congenital or post-traumatic. Thus spontaneous bleeding AVMs are an even rarer entity, and to the best of our knowledge, this may be an index case in this regard. Thus, our case highlights the need for astute clinical skills as well as a high index of the vigil, during imaging and during introduction or removal of the cystoscope, to avoid overlooking this elusive entity.

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Purpose: Perforated viscus is one of the most series conditions that need to be evaluated and studied, especially if it associated with systemic inflammatory response syndrome (SIRS). There are some studies carried out in the same subject that do not exactly clarify the predictive role of SIRS in the evaluating patients with perforated viscus, and they lack of a strong result foundation of the subject. Objective: The main purpose of this study is to evaluate the role of SIRS criteria in patients with perforated viscus and to see if SIRS have important value in predicting the surgical intervention, complications, Intensive Care Unit (ICU) admission, mortality, the outcome, and its effect on them later on. Methods: A retrospective study was carried out which included sixty patients with perforated viscus presented to Al-Noor Hospital Emergency Department in Makkah during 1435H. Certain variables including SIRS criteria were collected using a data collecting sheet. These variables are comorbidities, vital sign on presentation, the result of certain investigation), intervention which had done, presence of postoperative complication, ICU length stay, and outcome. Results: The role of SIRS criteria in patients with perforated viscus was found to be statistically significant as regards the patient's gender, the type of surgical intervention (either laparoscopic or open), and the duration of ICU admission, with P < 0.05. No statistical significance role was found between SIRS criteria and complications; mortality, status of ICU admission, and the outcome of perforated viscus patients, with P > 0.05. Conclusion: SIRS criteria in patients with Perforated visus (PV) can be used clinically to predict the need for surgical intervention and ICU admission.

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Introduction: The surgical transversus abdominis plane (TAP) block is a novel approach for postoperative analgesia after abdominal surgeries. The block was given intraperitoneally during the intraoperative period. We evaluated its analgesic efficacy in patients during the first 48 h of the postoperative period after abdominal surgery, in a randomized, controlled, double-blind clinical trial. Materials and Methods: Thirty adult patients undergoing surgery requiring midline abdominal incision were randomized and divided into two groups. Group-T received TAP block with 20 ml of 0.5% bupivacaine intraperitoneally, and Group-P received TAP block with normal saline (placebo). Each patient was evaluated by a blinded investigator in the postanesthesia care unit and at 1, 2, 4, 6, 12, 24, 36, and 48 h. Results: Diclofenac consumption was almost reduced by 50% in TAP group in comparison to placebo group (mean diclofenac requirement of the TAP group vs. placebo group was 110 ± 25 mg and 225 ± 28 mg, respectively; P < 0.0001). Mean time to first request of analgesic was significantly prolonged in TAP block (210 min) as compared to placebo (90 min). Postoperative verbal analog scores at rest and at movement were significantly reduced in TAP block group from 4 to 24 h postoperatively as compared to placebo group. All TAP block patients were quite satisfied with the postoperative analgesic regimen. Conclusion: Postoperative analgesic consumption of diclofenac was almost reduced to half in TAP block group as compared to placebo group, and also, time to first request of analgesic was significantly prolonged in TAP block group. The surgical TAP block is a novel approach for providing postoperative analgesia which is easy to perform, safe and has no adverse effects.

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Background: Perforation peritonitis is the common surgical emergency. Despite advances in surgical techniques, antimicrobial therapy, and intensive care support, management of peritonitis continues to be highly demanding due to associated morbidity and mortality. Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is the best available method for risk stratification in critically ill patients. Materials and Methods : This study was conducted in the 60 patients, who were admitted from causality and surgical outpatient department with a proven diagnosis of ileal perforation peritonitis. The patients were scored using by APACHE II into either of the two groups, Group A: <10 score. Group B: ≥10 score. Patients were operated for primary closure or ileostomy formation and were divided into two groups of 30 each depending on the surgical management. Group I (n = 30): These patients were managed by primary repair of the perforation with or without resection-anastomosis. Group II (n = 30): These patients were managed by ileostomy formation with closure/resection of the perforation. The outcome was assessed by postoperative complications and duration of hospital stay as related to APACHE II score. Results : Typhoid accounted for 38.3% of ileal perforations, Tuberculosis 15%, trauma 5% and nonspecific 41.6%. The majority of the perforations were single (90%), of size <1 cm (81.66%), and located within 60 cm of terminal ileum (95%). Simple closure of perforation with or without resection anastomosis was statistically significantly (P < 0.005) more done in patients with APACHE II score <10 whereas frequency of ileostomy was statistically significantly (P < 0.005) more done in patients with APACHE II score ≥10. As the APACHE II score increases the percentage of complication rate and hence hospital stay also increases, 12.97 ± 3.50 days in patients with APACHE II <10 score and 20.96 ± 5.09 days in patients with APACHE II ≥10 score (P < 0.001). Conclusion: Enteric fever is the most common cause of perforation peritonitis. Higher APACHE II scores in secondary peritonitis correlated significantly with the higher mortality and morbidity of the patients.

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Background: Most major hepatocellular carcinoma (HCC) staging systems recommend hepatic resection only for patients with early-stage of HCC. Still there is controversial about resection of patients with large HCC (defined as >5 cm). The aim of this retrospective study is to investigate the clinicopathological features that impacted the long-term outcomes of 1 year after hepatectomy of large HCC >5 cm in cirrhotic patients. Materials and Methods: From February 2012 to December 2015, a total of 92 patients with resection of large HCC on liver cirrhosis were reviewed retrospectively and considered for clinicopathological features that impacted the long-term outcomes. Time to recurrence (recurrence-free survival) and overall survival (OS) were determined by Kaplan-Meier analysis. Results: Twenty-nine (31.5%) patients developed tumor recurrence. The mean time until tumor recurrence was 12.4 ± 6.6 months. The cumulative 1-, 2-, and 3-year disease-free survival rates were 73%, 28%, and 18%, respectively. On multivariate analysis, male gender, α-fetoprotein >400, bilobed tumors, patients with portal hypertension, plasma transfusion, and absence of tumor capsule remained independent predictors for recurrence of HCC. The OS rates at 1, 2, and 3 years were 73%, 31%, and 16%, respectively. On multivariate analysis, α-fetoprotein >400 and plasma transfusion remained independent predictors for death. Conclusions: Liver resection is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. Identification of risk factors and close postresection follow-up with early detection are mandatory measures for prompt treatment of tumor recurrence which is reflected by a beneficial survival rate for this group of patients.

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Left-sided gall bladder (GB) without situs inversus is albeit recognized clinical entity. We report our experience of one case of left-sided GB in a 39-year-old male who underwent laparoscopic cholecystectomy for cholelithiasis. Left-sided GB may provide an unusual surprise to the surgeons during laparoscopy as routine preoperative studies may not always detect this anomaly. Awareness of the unpredictable confluence of the cystic duct to common bile duct and selective use of intraoperative cholangiography aids in the safe laparoscopic management of this unusual entity.

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A 24-year-old male presented to us with complaints of dyspnea on exertion and cyanosis. On examination, he had systolic murmur over pulmonary area. X-ray and contrast-enhanced computed tomography chest confirmed a large cystic pleuropericardial mass compressing the pulmonary artery which was excised successfully by midline sternotomy. Microscopic examination of purulent content of cyst revealed acid-fast Mycobacterium bacilli. This report is unusual on account that symptomatic and clinically evident pulmonary stenosis from pleuropericardial cyst is rare. Second, it is one of the rare presentations of tuberculosis.

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