---

Background: The invention of central venous catheters (CVC) for hemodialysis (HD), brought about a fundamental change in the treatment of patients who needed HD, from the late 1970’s till the present time. Nowadays the use of CVC is a common medical procedure. Increasing use of these methods necessitates clarification of the exact nature of the effects, and potential complications for surgeons. Objectives: This study attempts to determine the frequency of CVC; complications, survival rates and outcomes in HD patients, treated at the Hasheminejad Kidney Center, Tehran from January 2010 till June 2011. Patients and Methods: In this cross-sectional descriptive study, we collected data (using the census method) from the records of all patients over the age of 18 years, who had been referred, from January 2010 till June 2011, for CVC insertion. Catheter sites, related complications, creatinine (Cr), hemoglobin (Hgb), survival rate of catheters and the patients’ demographic data, were collected and analyzed. Results: In this study, 150 patients were evaluated, 122 participants (81%) were male and 28 (19%) were female. The patients’ average age was 56.2 ± 5 years (19 to 87 years). Regression analysis between the patients, with and without complications, showed that increasing age (P = 0.003, RR = 0.78), decreases in Hgb (P = 0.04, RR = 0.34) and also increased Cr (P = 0.023, RR = 0.45), and BUN (P = 0.014, RR = 0.37) are significantly correlated with catheter-related complications as independent risk factors. The one month survival rate of temporary catheters was 77.3% and their two-month survival was 60%. Conclusions: The overall rate of complications in the present study was no higher than in other similar studies. Anemia rates, however, were much higher in our patients. Most of the complications involved catheter infections, followed by catheter thrombosis. CVC survival rates in Iran have an acceptable outcome and results of this study were similar to those of past studies.

---

Background: Trocar site, incisional hernia is one of the serious complications of laparoscopic surgery. As a result, many surgeons prefer to close the fascia, especially in those sites where a trocar of 10 mm in size or larger has been inserted. On the other hand, suturing the fascia may lead to damage of other tissues, such as the intestines; hence, some surgeons prefer not to close the fascia. Objectives: This study was performed to evaluate the outcome of using fascial non-closure in sites of 10 mm ports and the incidence of subsequent incisional hernia in patients undergoing laparoscopic cholecystectomy. Patients and Methods: The current study was a cohort scheduled for surgery in the General Surgery Ward at the Shariati Hospital of the Tehran University of Medical Sciences. Two hundred and twenty patients were selected in a convenient manner for a cholecystectomy. A 10 mm trocar was inserted in the umbilicus and the other ports were 5 mm. None of the trocar sites was closed. All of the patients were followed up to one year after the operation. Results: The mean age was 43.41 years and 91 patients (41.4%) were male. Five patients (2.3%) developed incisional hernia. The occurrence of hernia was not associated with; age, sex, BMI > 25, smoking or diabetes (P > 0.05). Conclusions: According to the results obtained in this study, it seems that in cases without closure of the fascia site of 10 mm trocars, the incidence of incisional hernia is considerable. Furthermore; age, gender, weight, smoking or diabetes, did not have any relationship with the occurrence of incisional hernia. More comparative studies are required to confirm these results.

---

Background: Small bowel obstruction is one of the most common surgical emergencies and main causes of hospital admissions. Diatrizoate Meglumine Gastrografin, a hyperosmolar water-soluble contrast agent, has been used to triage patients with small bowel obstruction for an operative or a non-operative management. It can also have a therapeutic effect by increasing the pressure gradient across obstructive sites that may result in resolving the obstruction. Objectives: The aim of this study was to test the gastrografin effect in the resolution of small bowel obstruction. Patients and Methods: In this cross sectional–descriptive study, gastrografin was given to patients diagnosed with small bowel obstruction in clinical and radiological grounds . The contrast passage was assessed by serial X-rays. If the contrast remained in the small bowel, a decision was made as to whether proceed to surgical intervention, based on clinical condition. The patients were divided into two groups: A, who finally required surgery, and B, who were resolved by gastrografin administration. Results: Forty six patients were entered into the study. Thirty seven of the patients (80%) received a non-operative course in whom the contrast was observed in the large bowel. They had a mean hospital stay of 4.6 days. Nine patients (20%) required operative intervention. These patients had a mean hospital stay of 8 days. Conclusions: This study has demonstrated that gastrografin was highly effective in the management of adhesive small bowel obstruction resulting in a decreased need for surgery and hospital stay.

---

Background: Hydatid cyst, a zoonosis caused by Echinococcus granulosus, is the only recognized parasitic cysts of the spleen and is known to be at least twice as common as the non-parasitic variety. Case Presentation: A 35 year old woman presented with a one-year history of dull pain and a dragging sensation in her left hypochondrium. Ultrasonography revealed a hydatid cyst in the lower part of the spleen. Laparoscopic splenectomy along with hydatid cyst was done. Her post-operative phase was uneventful. Conclusions: Here, we discuss the pathogenesis of the rare entity of splenic hydatid cysts and the various treatment options available.

---

---

---

Context: Correct timing of diagnostic laparoscopy for unexplained infertility management remains as a debate for clinicians. A cost-effective strategy of diagnostic laparoscopy utilization for unexplained infertile patients is much needed. Evidence Acquisition: Detailed evaluation of the articles extracted from a “Pubmed” and “Cochrane database” search using “unexplained infertility and diagnostic laparoscopy” word group between 1993 and 2012 was the preparation style of this review. Results: Diagnostic laparoscopy should be considered when there are abnormal hysterosalpingography results, a past history of pelvic infection, pelvic surgery and/or unexplained secondary infertility during management of an unexplained infertile couple. Currently, omitting diagnostic laparoscopy following a normal hysterosalpingography in couples suspected to have unexplained infertility and proceeding with ovulation induction for several cycles before referring to assisted reproductive techniques are recommended. The additional value of diagnostic laparoscopy after a normal hysterosalpingography was found to be very low prior several attempts of intrauterine insemination. In the absence of pathological findings precluding fertility during an unexplained infertility evaluation, routine diagnostic laparoscopy for infertility evaluation is not necessary because 77% of these patients become pregnant following ovulation induction and/or assisted reproductive techniques treatment. Conclusions: Omitting diagnostic laparoscopy after a normal hysterosalpingography in infertile patients with unexplained infertility and without risk factors for pelvic pathologies related to infertility is reasonable because the majority became pregnant after several cycles of ovulation induction, and/or assisted reproductive techniques treatment while diagnostic laparoscopy is indicated when pelvic endometriosis and/ or tubal pathology is strongly suspected.

---

Background: Laparoscopic tension-free repair of inguinal hernia was presented in 1990s, promising less pain and shorter recovery period. Objectives: We have presented our experience on laparoscopic inguinal hernia tensionfree repair and comparing it with the open one. Patients and Methods: This is a retrospective study of cases undergone tension-free mesh inguinal hernia repair between July 2008 and October 2011. Cases were divided into two groups. Group I included cases that were repaired by the laparoscopic transabdominal preperitoneal (TAPP) approach and II by the open. Cases were compared regarding the operation time, the postoperative pain (early and long-term), the postoperative scrotal-related and wound complications and the recurrence as well as the cost. Results: The study included 217 cases; 114 in the group I and 103 in the group II. The operation time was significantly longer in the TAPP group (76.5 ± 18 vs. 67.6 ± 20 minutes). However, the overall hospital stay was less (2.6 ±0.79 vs. 2.9 ±0.87 days.) Early postoperative pain scores in the groups I and II were 0.95 ± 1.36 and 1.48 ± 1.47 and long-term pain and numbness were9% and 7.5% respectively, which were not significantly different between the two groups. The postoperative scrotal-related complications occurred more in the laparoscopic group (15% vs. 7.5%). Local wound complications were significantly more in the open technique (1.8% vs. 12%, groups I and II, respectively). Twelve (11%) cases in the group I undergone treatment of an incidentally discovered pathology during laparoscopy including; other side inguinal hernia (7), adhesions (4) and abdominal testis (1). The recurrence rates were 4.3% and 2.4% in the group I and II correspondingly. Conclusions: Laparoscopic TAPP inguinal hernia repair has longer operation time and more cost than the open technique. Local wound complications were more prevalent in the open repair. The postoperative pain, the hospital stay, the scrotal-related complications as well as the recurrence rates were the same in the both groups. The laparoscopy can detect and treat other intra-abdominal pathologies which have not been diagnosed preoperatively.

---

Background: Operating room (OR) planning involves the creation of a “master surgical schedule” in which surgeons are assigned to specific operating rooms (ORs) on specific days of a week. The master schedule is typically one or two weeks long repeatable for several months. Objectives: The purpose of this study was to recommend using a mathematical program to generate a rotation in a way that the limited operating room capacity could be distributed based on smoothing expected demand for in-patient beds. Patients and Methods: This study concentrated on the service-level scheduling at Sunnybrook Health Sciences Centre in Toronto, Canada, to build such a model. We assumed that the number of blocks (days) for each surgeon was given, and that the expected casemix for each surgeon was chosen by random sampling based on historical data. The goal was to assign surgeons to the blocks so tat bed occupancy in the wards would become as stable as possible during the week. The planning problem was first formulated as a stochastic integer programming. Then, an approach with combination of Monte Carlo simulation and Premium Solver provided an approximate solution. Results: The integer program provided scheduled OR number and day of the week for each surgeon, corresponding to the sample. The final result of model, approximated by the proposed method, was the maximum number of beds for each surgical service throughout the week. These were the required bed capacities to handle demands for surgeries. Conclusions: An Integer Programming was presented to schedule OR and day of surgery for each surgeon with restrictions on the available ORs and required number of blocks. The problem was quickly solved using Premium Solver. The reliability of the results was highly dependent on the data. Another fundamental restriction for implementation of the results was to convince surgeons to accept changes in the schedules. The surgeon preferences might be included in the model constraints for more acceptable results.

---

Background: Post-operative nausea and vomiting (PONV) are the most common unpleasant experiences following laparoscopic surgeries. Objectives: In the current research, compared the effect of dexamethasone and ondansetrone combined and separately on preventing nausea and vomiting in the patients undergone elective surgery with general anesthetic using laparoscopic cholecystectomy procedure. Patients and Methods: One hundred fifty patients with ASA class I and II aged between 20-65 years voluntarily participated in this double-blind randomized prospective study. The patients were randomly divided into three groups of 50. All the participants faced general anesthetic procedure whereas each group received different treatment regimen as follow: the O-group, 4 mg ondansetrone, the D-group, 8 mg dexamethasone, and the OD –group, combination of 4 mg of ondansetrone plus 8 mg dexamethasone. Every episode of PONV and the need for antiemetic drug were evaluated 6 hours following the operation and then every 6 hours up to 24 hours after the operation. The complete response was defined as the case with no episode of PONV within the 24 hours and the need for anti-vomiting cases was defined as the failure in prophylaxis. Results: The complete response was observed in 62.2, 68.2 and 89.6 percent of O, D, and OD groups, respectively. The frequency of complete response was significantly lower in OD-group (P = 0.011 vs. the D and P = 0.005 vs. the O group). The need for the antiemetic drug in groups O, D, and OD was 28.3, 22.8, and 6.2, respectively. The incidence of vomiting and failure in prophylaxis was observed in D-group during the first six hrs. The highest need for the anti-vomiting drug within the 6 to 24 hours of post operation was observed in group O compared to the group OD (P = 0.012). Conclusions: Combination of dexamethasone and ondansetrone is more effective than the treatment of PONV by each of these drugs separately following the laparoscopic cholecystectomy .The application of dexamethasone alone in preventing premature PONV is less effective than the application of ondansetrone or the combination of these two drugs. In addition, ondansetrone alone is less effective than the combination of these two drugs in preventing PONV.

---

Background: Large ovarian cysts are rarely seen in the paediatric population and can now be managed by a variety of surgical approaches. Case Presentation: We report a case where a substantial right ovarian cyst in a 13 year old was removed through a single incision in the superior umbilical fold leaving no discernable scar. The placement of a purse string facilitated safe decompression of the cyst allowing delivery into the wound where the lining was stripped before being returned to the abdomen. Conclusions: Subsequent single incision laparoscopic surgery (SILS) port placement through the same wound allowed for a full inspection of the pelvis and abdomen. This approach represents an advance on conventional surgery and is a tenable alternative to an exclusive laparoscopic technique.

---

Background: Myasthenia gravis is a neurological disorder characterized by muscle weakness. The role of thoracoscopic thymectomy in the treatment of this disease is controversial, but has some advantages that include less pain, shorter hospital stays, and better cosmetic results. Objectives: After the introduction of video-assisted thoracoscopic surgery (VATS) thymectomy, there has been increased interest in the use of this technique for myasthenia gravis. We conducted a retrospective study to assess the safety and efficacy of VATS thymectomy in treatment of myasthenia gravis. Patients and Methods: The medical records of 50 patients who underwent VATS thymectomy for the treatment of myasthenia gravis between May 2005 and June 2010 in Afzalipour Hospital, (affiliated to Kerman Medical University of Sciences, Iran) were reviewed. The patients were examined for response to treatment; for patients who were not available for examination, data was obtained through telephone conversations. Results: Forty-three of 50 patients were accessible. Of these, 34 were female and 16 were male, with a mean age of 34.8 years. The treatment responses were remission, 6 (16%); improvement, 30 (70%); and without change, 7 (16%). The total positive response to treatment was 84 percent. Conclusions: VATS thymectomy has been considered as a safe and effective treatment in myasthenia gravis and was associated with low mortality and morbidity. VATS thymectomy is recommended for the treatment of myasthenia gravis.

---

Background: Spontaneous pneumothorax hardly occurs in healthy children. Diagnosing its etiology can be difficult. Chest X ray and Computerized Tomographic scan (CT) are useful investigations but have limitations. CT scan in combination with video assisted thoracoscopic surgery (VATS) improves diagnostic accuracy and facilitates appropriate management of non-resolving spontaneous pneumothorax. Showcased are images demonstrating how effectively CT complements video assisted thoracoscopic surgery (VATS) in managing a recalcitrant case of spontaneous pneumothorax caused by a solitary bulla. Objectives: A 15 year old boy presented to the referring hospital with a right sided spontaneous pneumothorax which occurred whilst playing football Case report: A 15 year old boy presented to the referring hospital with a right sided spontaneous pneumothorax which occurred whilst playing football. His symptoms were shortness of breath and right pleurisy chest pain. His oxygen saturations were more than 95% on air. A needle aspiration was performed yielding 2300mls of air, however the pneumothorax persisted. Conclusions: In cases of pontaneous pneumothorax, Chest X ray and Computerised Tomographic scan have limitations. CT scan in combination with video assisted thoracoscopic surgery improves diagnostic accuracy and facilitates appropriate management of nonresolving spontaneous pneumothorax.

---

Bariatric surgery, as a whole, is the only proven modality to manage the severely obese. The laparoscopic sleeve gastrectomy (LSG) is the most recent tool in the armamentarium of bariatric surgery. Once used as the first-stage in a two-stage procedure for the super-obese patient, it is now used as a primary bariatric procedure. Involving the resection of the greater curvature of the stomach, it has been shown to achieve clinically significant excess weight loss and improvements in obesity-related co-morbidities. Its mechanism of action was originally classified as being a restrictive procedure, similar to laparoscopic gastric banding, but is now known to be far more complex. The pronounced effects of LSG on gut hormones such as ghrelin, PYY and incretins, allow this bariatric intervention to be adequately compared to the more historically classified malabsorptive procedures like the gastric bypass. In this review, we explore the metabolic effects and outcomes of LSG in producing significant weight loss and improving the factors associated with the metabolic syndrome.

---

Background: Inguinal hernia is the most prevalent surgical disease in clinical practice. Endoscopic inguinal hernia repair has been shown to be slightly superior to open approaches. Recent modifications in the minilaparoscopic technique may improve the totally extraperitoneal repair (TEP) results. Objectives: We have performed a prospective study to analyze the feasibility of laparoscopic inguinal hernia repair using mini instruments. Main measured outcomes included postoperative pain, return to work activities and aesthetics. Technical aspects, including operative time and intraoperative and postoperative complications were also analyzed. Patients and Methods: From October, 2009 to May, 2011 consecutive patients undergoing TEP inguinal hernia repair using miniinstruments were included in the study protocol. Exclusion criteria was the same as for standard laparoscopic hernia repair. In all cases, a standardized laparoscopic technique using mini instruments was performed. A study protocol was applied prospectively for data collection, including operative time, hospital stay, need for pain medication, return to work and, patient’s aesthetic evaluation of the scars. Results were expressed in Mean ± SD. Results: Sixty consecutive patients diagnosed with inguinal hernia underwent TEP inguinal hernia repair using mini instruments. Of these, 53 were men and seven were women. The mean age was 50 ± 32 years. In eight cases, the hernias were recurrent and ten were bilateral. A total of 70 hernias were treated. The average operative time was ± 35 min. The mean hospital stay was 18 ± 6 hours. Analgesia was necessary for more than 2 days in 8 patients (13.3 %). There was one conversion to open surgery. Sixteen of the male workers (37 %) had to take 1 week off work. In total, 58 (96 %) of the patients considered the aesthetic outcome to be excellent. Patients were followed for 30 days. No recurrences were noted in this period. Conclusions: Totally extraperitoneal endoscopic inguinal hernia repair using mini instruments is feasible, and applicable to routine surgical practice with good short-term clinical and aesthetic results. Further comparative studies with standard laparoscopic extraperitoneal and open hernia repair are needed to access its long term results.

---

Background: Traditional haemostatic techniques in total thyroidectomy may cause some damages to surrounding tissues. It is believed that these damages can be reduced using ultrasonic dissector devices like Harmonic Scalpel (HS). Objective: In this study, we investigated the efficacy of ultrasonic dissectors (HS) versus conventional techniques (Clamp and Tie). Patients and Methods: A single blinded randomized clinical trial was performed at a referral educational center. Sixty eight eligible participants were enrolled and assigned to conventional group (operated with Clamp and Tie technique) and HS group (operated with Harmonic Scalpel). The following items were recorded in both groups: haemostatic technique, operative blood loss, duration of surgery, length of hospital stay, pathology, thyroid weight, postoperative recurrent laryngeal nerve injury, change in calcemia, pain, drainage volume and hematoma formation. Results: The results demonstrated that application of HS in thyroidectomy significantly reduces operating time (P ≤ 0.0001) and Intra operative bleeding (P ≤ 0.0001). Postoperative drainage (P ≤ 0.0001), pain (P ≤ 0.0001), hypocalcemia (P ≤ 0.0001), and length of hospitalization (P ≤ 0.0001) were significantly lower in HS group. Voice score was significantly lower in HS group (P ≤ 0.0001). Conclusions: HS in total thyroidectomy, reduces operating time, blood loss, postoperative pain, drainage volume, voice changes, and postoperative hypocalcemia, compared to conventional techniques.

---

Background: Postoperative nausea and vomiting (PONV) is an unpleasant, distressing and frequent adverse effect after general anesthesia and surgery which has a high incidence in patients undergoing laparoscopic cholecystectomy. While none of the currently available antiemetic drugs are fully effective in all patients, it has been reported that dexamethasone is effective against emesis in patients undergoing general anesthesia. Objectives: This study evaluates the prophylactic anti-emetic effect of dexamethasone in comparison with metoclopramide and placebo for the prevention of post-operative nausea and vomiting in patients undergoing elective laparoscopic cholecystectomy. Patients and Methods: In Mostafa Khomeini hospital, a teaching hospital of Shahed University, Tehran, Iran, a randomized, double-blind and placebo-controlled study on 161 patients undergoing general anesthesia for elective laparoscopic cholecystectomy was run.One hundred sixty one patients (124 females and 37 males) requiring general anesthesia for laparoscopic cholecystectomy were studied. The dexamethasone group (n = 53) received dexamethasone 8mg IV, the metoclopramide group (n = 55) received metoclopramide 10mg IV and the placebo group (n = 53) received 2ml saline IV at the induction of anesthesia. Results: In the current study, 26.4 %, 32.7 % and 52.8 % of patients reported vomiting in the dexamethasone, metoclopramide and placebo group (P≤ 0.001), respectively. The total incidence of nausea and vomiting also reduced to 30.2 % with dexamethasone in comparison with 49.1 % in metoclopramide group and 58.5 % in placebo group. (P ≤ 0.001) Conclusions: Dexamethasone 8mg is a better anti-emetic agent than metoclopramide for the prevention of post-operative nausea and vomiting after laparoscopic cholecystectomy

---

Background: Hysteroscopy is the gold standard method for diagnosis of intrauterine pathologies. Current study is a review of hysteroscopic findings performed over a period of 5 years in patients with abnormal uterine bleeding (AUB). Objective: The aim of this study was a review of hysteroscopic findings performed over a period of 5 years in patients with abnormal uterine bleeding (AUB). Patients and Materials: This descriptive analytic study was conducted prospectively on patients in reproductive, premenopausal or postmenopausal ages referring to our hospital with complaint of AUB. All patients underwent hysteroscopy (either diagnostic or therapeutic) by the same surgeons. Analysis was performed on the base of the hysteroscopic findings. Results: In our population study (379 patients) major menstrual pattern was menometrorrhagia. The most common diagnoses at operative hysteroscopy were endometrial polyps (17.8%), hyperplastic endometrium (15.2%), and uterine submucosal myoma (9.7%).The most common findings in patients with menometrorrhagia were myoma, and polyp where, the most common finding in patients with menorrhagia, and metrorrhagia was polyp. Our major complications were uterine perforation in 9, thermal injury in 3, and air emboli in one case. Conclusions: In current study the most common pathology was found to be endometrial polyp. Myoma was the most common finding in patients with menometrorrhagic bleeding. Our major complications were uterine perforation, thermal injury, and air emboli.

---

Introduction: Amyand’s hernia – the presence of appendix within an inguinal hernia sac poses a diagnostic and therapeutic challenge in the acute setting. Case Presentation: We report the case of a female patient on long-term corticosteroid therapy that was found at laparoscopy to have an inflamed appendix incarcerated within a right inguinal hernia. A 62-year-old Caucasian female presented with a short history of suddenonset pain in the right groin. Her past medical history included polymyalgia rheumatic for which she had been treated over the past 4 years with oral prednisolone. The studied case was successfully treated through laparoscopic appendectomy and laparoscopic suturing of the deep inguinal ring. Discussion: This totally laparoscopic approach may be of use in cases where definitive treatment with mesh cannot be undertaken and the avoidance of large wounds is desirable.

---