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Apr07
ALL About to know Fistula
Dr. Samrat Jankar is one of the most expert reliable and ethical fistula specialists in Pune. He is a qualified surgical gastroenterologist and colorectal surgeon and had been awarded a gold medal for fellowship in colorectal surgery by the ACRISI (Association of Colon & Rectal Surgeons of India) board. Furthermore, he has been an international faculty member in this field. Recently, he has been awarded the First Prize for the best video presentation at FISTULACON 2021 for the LASER LIFT procedure in complex fistula in Ano in an international summit organized by ACRSI. He delivered talks on fistula at many national and international conferences and had a live demonstration of fistula surgery at many conferences. He had trained many surgeons for LASER fistula surgery. Dr. Samrat Janakr had been trained for complex fistula in ano surgery under renowned fistula surgeons Dr. Parvez Sheikh (Mumbai) and Dr. Arun Rajunasakul (Bangkok). He is an expert in many surgical procedures for fistula treatment and also pioneered his own surgical technique PILTEC for complex fistula treatment which has the highest success rate. Dr. Samrat Jankar had successfully Performed more than 5000+ successful Anal Fistula Surgeries.

Fistula (Bhagandar) Treatment in Pune
An anal fistula is a tunnel connecting the skin near the anus to the inside of the bowel (usually the rectum). This means that the inside of the bowel is connected to the outside of the body through an additional opening. An anal fistula often results from a previous or current anal abscess. As many as 50% of people with an abscess get a fistula. However, a fistula can also occur without an abscess.


Fistula in Ano treatment options
Surgery is usually necessary to treat an anal fistula as they usually do not heal by themselves or only with medication. The goal of any surgery for a fistula in ano is to balance between getting rid of the fistula and protecting the anal sphincter muscles, which could cause incontinence if damaged. In fistula treatment in Pune what matters most is recurrence and incontinence, the only expert in fistula surgery will have a clear understanding of it. Looking for the best doctor for fistula in ano treatment in Pune, Dr. Samrat Jankar an Internationally recognized surgeon at KAIZEN Gastro care, Wakad Pune offers holistic treatment for complex fistula with the least recurrence rate & almost zero incontinence rate.


Types of Fistual in Ano
Fistulas are classified by their relationship to parts of the anal sphincter complex (the muscles that allow us to control our stool). They are classified as

Intersphincteric
Transsphincteric
Suprasphincteric
Extrasphincteric.
Intersphincteric is the most common and Extrasphincteric is the least common. These classifications are important in helping the surgeon make treatment decisions

What is Complex Fistula?
The Standards Committee for the American Society of Colon and Rectal Surgeons (ASCRS) divided anal fistula into simple and complex types based on the complexity of fistula, risk of recurrence, and risk of incontinence.

Simple fistula:

Simple fistulas are those that are Intersphincteric or low Transsphincteric involving less than 30% of the external sphincter where the risk of incontinence is low.

Complex fistula:

“Complex” fistulas included those with

More than 30% sphincter muscle involvement
Anterior fistulas in female patients
Recurrent fistulas
Fistula associated with preexisting fecal incontinence, inflammatory bowel disease, or prior radiation.
There are several different procedures. The best option for you will depend on the position of your fistula and whether it’s a single channel or branches off in different directions. Surgery aims to heal the fistula while avoiding damage to the sphincter muscles, the ring of muscles that open and close the anus, which could potentially result in loss of bowel control.

The main options are outlined here:
1. Fistulotomy:
The most common type of surgery for anal fistulas is a fistulotomy. This involves cutting along the whole length of the fistula to open it up so it heals as a flat scar. A fistulotomy is the most effective treatment for many anal fistulas, although it’s usually done in simple fistula where the risk of incontinence is less. This procedure is not suitable in complex fistula in ano in cases where the risk of incontinence is considered too high, sphincter preserving procedures are recommended.

At KAIZEN Gastro Care, Dr. Samrat Jankar Fistula Specialist Surgeon in Pune uses a LASER as an adjunct to Fistulectomy to minimize the risk of damage to the sphincter muscle. Thus, with the added advantage of Laser, the chances of post-operative pain will be negligible.


2. Ligation of the intersphincteric Fistula Tract (LIFT):
The ligation of the intersphincteric fistula tract (LIFT) procedure is a best treatment for fistulas that pass through the anal sphincter muscles, where a fistulotomy would be too risky. This is a Highly efficient procedure with almost no recurrences or incontinence. Dr. Samrat Jankar, a well-known colorectal surgeon in Pune, specializes in complex fistula surgery


Moreover, he is adept in LIFT, an advanced procedure for fistula treatment in Pune. Being well-trained with the LIFT procedure under Dr. Arun Rajunasakul (pioneer of the LIFT procedure, to date, Dr. Jankar has performed more than 1000 modified LASER LIFT procedures with excellent results. Had been awarded the best video award at an international conference for the management of complex fistula.

3. FiLaC ( Fistula-tract Laser Closure):
It is a minimally invasive fistula-in-ano surgery that keeps the sphincter intact. This technique attempts to gently remove the anal fistula by using laser energy. The flexible, all-around radiating fiber-optic probe is inserted into the fistula tract from the outside. Then the laser is slowly withdrawn. The inflammatory tissue is destroyed in a controlled manner and the fistula tract contracts. The anal gland that originally caused the fistula is inactivated


4. VAAFT:

Video-assisted anal fistula treatment (VAAFT) is a new minimally invasive and sphincter-saving endoscopic treatment for complex fistulas. The fistula tract and internal fistula are localized using a fistuloscope inserted through the external opening and under direct vision fistula tract is destroyed from the inside and closure of the internal opening is done by stapling or suturing or cutaneous-mucosal flap.

Advantages

No surgical wounds on the buttocks or perianal region.
The internal opening is precisely located which is important in the treatment of any fistula.
Less chance of damage to the sphincter muscle
Potential drawbacks

The biggest argument against VAAFT is its high rate of recurrence (~30%)
Higher cost of treatment
5. FISTULA PLUG
The fistula plug is a 100% synthetic bio-absorbable scaffold. This plug is placed in the fistula tract. Over time cells from the body migrate into the scaffold and new tissue is generated as the body gradually absorbs the plug material, leaving no permanent material in the body.

Advantages of Fistula Plug

No cutting involved and no operation wound. Therefore it is associated with less pain and faster recovery.
No damage to the sphincter muscle.

Potential Drawbacks

Failures can occur due to the dislodgement of the plug from the fistula tract.
The plug can get infected
Failure of treatment can occur in 25-30% of cases
6. PILTEC: a modification of the LIFT procedure
Dr. Samrat Jankar an internationally recognized fistula surgeon pioneered the LASER procedure named PILTEC having the highest cure with zero incontinence rate. He had demonstrated at many surgical conferences and workshops. He had trained many surgeons in fistula treatment using the PILTEC procedure.

Why does the Fistula recur again and again?
Anal fistula treatment remains a challenge for surgeons owing to its persistence or recurrence. Recurrent anal fistulas after surgery are more difficult to treat as there is even more risk of re-recurrence. Now, the challenge is that, even with the availability of so many techniques, there is a high risk of recurrence of the fistula after surgical intervention depending upon the location of the fistula, the kind of procedure performed, the expertise of the surgeon, extent of disturbing anatomy of the perianal region, unexpected findings, the effect of excess fibrosis and scarring after surgery and lack of proper postoperative care in the early and late periods following the surgery. This means that fistulas can keep on coming back even after surgery.

According to Dr. Samrat Jankar, a successful fistula surgery requires proper diagnosis, a perfectly performed and reported MRI, along with the surgeon’s expertise and the method of surgery. Dr. Samrat Jankar, the best fistula surgeon in Pune pioneer of the PILTEC procedure. In almost all cases Dr. Samrat Jankar performs a single-setting surgery with a success rate of more than 98% including fistula with perianal abscess. It is not only about surgery at kaizen gastro care dr Samrat Jankar and their team provide very good postoperative care which is one of the most important components in the complete cure of fistula.

What symptoms does anal fistula surgery address?
The signs and symptoms of an anal fistula include:

Frequent anal abscesses
Pain and swelling around the anus
Bloody or foul-smelling drainage (pus) from an opening around the anus. The pain may decrease after the fistula drains.
Irritation of the skin around the anus from drainage
Pain with bowel movements
Bleeding
Fever, chills, and a general feeling of fatigue
Anal fistula surgery aims to correct an anal fistula and treat all of its associated symptoms. If you have any of the above symptoms or you’re concerned about having an anal infection, abscess or fistula, speak with Kaizen fistula specialist Dr. Samrat Jankar, the best fistula doctor in Pune.

How is an anal fistula diagnosed at Kaizen Gastro Care:
Dr. Samrat Jankar at KAIZEN Gastro Care usually diagnoses an anal fistula by examining the area around the anus. He will look for an opening (the fistula tract) on the skin, then try to determine how deep the tract is, and the direction in which it is going. In many cases, there will be drainage from the external opening. Some fistulas may not be visible on the skin’s surface. Most of the time need further tests to better understand fistula relations with sphincter. An anoscopy is a procedure in which a special instrument is used to see inside your anus and rectum. Also in most cases, he advises an MRI fistulogram of the anal area to get a better view of the fistula tract. Some atypical cases need a colonoscopy to rule out IBD which will be the cause of the recurrence of fistula.

What causes an anal fistula?
The leading causes of an anal fistula are clogged anal glands and anal abscesses. Other, much less common, conditions that can cause an anal fistula to include:

Crohn’s disease (an inflammatory disease of the intestine)
Radiation (treatment for cancer)
Trauma
Sexually transmitted diseases
Tuberculosis
Diverticulitis
Colorectal Cancer
Post-operative care after fistula surgery
Take sitz baths (sit for 15-20 minutes in warm water with antiseptic solution) three times a day and after each bowel movement for the first few days.
If you were given a topical ointment, place this over the anal skin and a little into the anal canal 2-3 times a day.
Don’t worry if you have some bleeding, discharge, or itching during your recovery. This is normal.
Avoid constipation.
Take stool softener before bedtime every day till wound healing.
The use of dry toilet tissue should be avoided. After bowel movements use a jet water cleaning, if possible, followed by taking a warm bath.
If you were given a prescription for an ointment, apply these two or three times a day at the edge of the anal opening and inside by finger (not by applicator).
Eat a regular diet including plenty of fresh fruit and vegetables. Drink 6-8 glasses of water a day.
Connect with your surgeon if your temperature is greater than 101 degrees, significant bleeding, and unbearable pain.

Why Choose Kaizen Gastro Care for Fistula Treatment:
Experienced Fistula Specialist Team: Dr. Samrat Jankar is renowned as the best Fistula Specialist in Pune which is available at Kaizen Gastro Care Pune for treating various Piles, Fistula, and other anal diseases.
Advanced diagnosis and treatment: Kaizen Gastro Care provides a full range of diagnostic tests and innovative treatments which are used for the diagnosis and management of different Piles and Ananl conditions.
Clinic Location: Kaizen Gastro Care Clinic is located at the Pune and PCMC Prime location i.e. Wakad Area. This is the central location of Pune city. The patient can easily come with all public transport.
Leading-edge technology: Kaizen Gastro Care is equipped with leading-edge technology such as Endoscopy tests, Manometry, 24 Hr Ph Monitoring, Biopsy, and biofeedback. Also equipped with Piles Specialists and nutritionists.
A Dedicated Center for Fistula Treatment: Kaizen Gastro Care is the First Dedicated center for Fistula and different Anal Disease treatments in Pune and all over Maharashtra.
We Manage Your Care for the Long Term: We at Kaizen Gastro Care manage Piles, Fistula, and Anal disease for the long term. Kaizen Gastro Care manages the patients for the long term, taking regular follow-ups and long-term care.


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Oct19
Efficacy of surgical techniques and factors affecting residual stone rate in the treatment of kidney stones
Original Research
Efficacy of surgical techniques and factors affecting residual stone rate in
the treatment of kidney stones
Dr. Anil Haripriya


1Associate professor, Department of General Surgery CIMS, Bilaspur (C.G.), India;
2Associate Professor, Department of General Surgery, NSCB Medical College, Jabalpur (M.P.), India
ABSTRACT:
Background: The present study was conducted to assess efficacy of surgical techniques and factors affecting residual stone
rate in the treatment of kidney stones. Materials & Methods: 102 patients of kidney stones of both genders were divided
into 3 groups. Group I patients underwent open stone surgery, group II patients underwent percutaneous nephrolithotomy
(PNL) and group III underwent retrograde intrarenal surgery (RIRS). Surgical techniques complications were evaluated.
Results: In group I mean stone burden was 3.2 cm2

, in group II was 2.5 cm2

and in group III was 1.9 cm2
. The mean
operative time in group I was 84.2 minutes, in group II was 118.4 minutes and in group III was 78.6 minutes. There were 9
cases in group I, 7 in group II and group III was 5 cases. There were 7 cases of fever in group I, 4 in group II and 2 in group
III, infection 2 in group I and 3 in group III, urine leakage 5 in group III and persistent pain 6 in group I and 1 in group II.
The difference was significant (P< 0.05). Conclusion: PNL and RIRS have been seen as safe and effective methods as
compared to open method in case of kidney stones.
Key words: Percutaneous nephrolithotomy, Retrograde intrarenal surgery, Kidney stone.
Received: 13 September, 2020 Accepted: 18 November, 2020
Correspondence: Dr. Arvind Baghel, Associate Professor, Department of General Surgery, NSCB Medical College,
Jabalpur (M.P.), India
This article may be cited as: Haripriya A, Baghel A. Efficacy of surgical techniques and factors affecting residual stone
rate in the treatment of kidney stones. J Adv Med Dent Scie Res 2020;8(12):55-58.
INTRODUCTION
Urinary system stone disease is one of most
frequently encountered diseases in the urology
practice. The stones are frequently observed in the
renal localization, and most of them require
intervention.1 Kidney stone disease, also known as
urolithiasis or renal calculi contributes to one of the
most common health problems in the daily lives of
men and women. It occurs when a solid piece of
material (stone) forms in the urinary tract.2
Approximately 12% of men and 6% of women in the
USA and 10 to 15% of people in Europe and North
America are affected by it. Calcium oxalate (CaOx) is
found to one component of the most common kidney
stones. It has been proposed that the most likely stone
formation mechanism for people with idiopathic
CaOx stones is caused by CaOx overgrowth in renal
papillary Randall’s plaque.
3
Preventive measures such
as dietary therapy and therapeutic treatments such as
drugs and surgical techniques have been verified to be

effective in the treatment of renal calculi. Dietary
modification is a safe and economical preventive
measure for dietary therapy, and in some cases, drugs
are important to reduce the risk of stone formation.
Unfortunately, since the 1980s, there have been no
new drugs developed for the prevention of renal
calculi after the introduction of potassium citrate.4
Some of these methods include percutaneous
nephrolithotomy (PCNL), extracorporeal shockwave
lithotripsy (SWL), retrograde intrarenal surgery
(RIRS), etc. Extracorporeal shock wave lithotripsy
(ESWL) into clinical practice after 1980s, a new era
had begun in the treatment of urinary system stone
disease. In recent years, percutaneous
nephrolithotomy (PNL) has taken increasingly greater
part in the treatment of stone disease with success
rates nearing to 80 percent.5 The present study was
conducted to assess efficacy of surgical techniques
and factors affecting residual stone rate in the
treatment of kidney stones.
Journal of Advanced Medical and Dental Sciences Research
@Society of Scientific Research and Studies NLM ID: 101716117
Journal home page: www.jamdsr.com doi: 10.21276/jamdsr Index Copernicus value = 85.10

(e) ISSN Online: 2321-9599; (p) ISSN Print: 2348-6805

Haripriya A et al. Treatment of kidney stones.

56

Journal of Advanced Medical and Dental Sciences Research |Vol. 8|Issue 12| December 2020
MATERIALS & METHODS
The present study was conducted among 102 patients
who underwent surgical treatment of kidney stones of
both genders in the department of general surgery in a
medical college hospital. All were informed regarding
about the study and their consent was obtained.
Data such as name, age, gender etc. was recorded.
Patients were divided into 3 groups. Group I patients
underwent open stone surgery, group II patients
underwent percutaneous nephrolithotomy (PNL) and

group III underwent retrograde intrarenal surgery
(RIRS).
Endoscopic stone surgery was performed for stone
fragmentation in all patients using pneumatic
lithotriptor or Holmium: YAG laser. Surgical
techniques complications were evaluated. Stones
equal or larger than 4 mm were considered as residual
stones. The dimensions of the stones were calculated
and measured in cm2

. Results thus obtained were
subjected to statistical analysis. P value less than 0.05
was considered significant.

RESULTS
Table I Distribution of patients

Groups Group I Group II Group III
Methods Open stone surgery PNL RIRS
M:F 34 34 34

Table I shows that group I patients underwent open stone surgery, group II patients underwent PNL, and group
III underwent RIRS. Each group had 34 patients.
Table II Assessment of parameters

Parameters Group I Group II Group III P value
Stone burden (cm2

) 3.2 2.5 1.9 0.01
Operative time (mins) 84.2 118.4 78.6 0.001
Length of hospital stay 3.2 3.0 1.4 0.05
Cases with residual stone 9 7 5 0.02
Table II shows that in group I mean stone burden was 3.2 cm2

, in group II was 2.5 cm2

and in group III was 1.9

cm2
. The mean operative timein group I was 84.2 minutes, in group II was 118.4 minutes and in group III was
78.6 minutes. There were 9 cases in group I, 7 in group II and group III was 5 cases. The difference was
significant (P< 0.05).
Table III Assessment of complications in groups

Complications Group I Group II Group III P value
Fever 7 4 2 0.02
Infection 2 0 3 0.05
Urine leakage 0 0 5 0.05
Persistent pain 6 1 0 0.001

Table III, graph I shows that there were 7 cases of fever in group I, 4 in group II and 2 in group III, infection 2
in group I and 3 in group III, urine leakage 5 in group III and persistent pain 6 in group I and 1 in group II. The
difference was significant (P< 0.05).
Graph I: Assessment of complications in groups

0
1
2
3
4
5
6
7

Fever Infection Urine leakage Persistent pain
7

2

0

6

4

0 0

1

2

3

5

0

Group I
Group II
Group III

Haripriya A et al. Treatment of kidney stones.

57

Journal of Advanced Medical and Dental Sciences Research |Vol. 8|Issue 12| December 2020
DISCUSSION
Currently, a diverse range of non-invasive, minimally
invasive and invasive methods have been reported as
treatment approaches for renal calculi. Recent studies
have reported that flexible ureterorenoscopy
(URS)/holmium laser lithotripsy can be an alternative

treatment for patients with renal calculi. The micro-
percutaneous nephrolithotomy (microperc) is a

recently described technique in which percutaneous
renal access and lithotripsy are performed in a single
step. Microperc has been found to be safe and
effective in removing small renal calculi in the adult
and pediatric populations with a high stone-free rate
and lower complication rate.6 Despite all the new
approaches, shock wave lithotripsy (SWL) remains
the first line treatment modality that is widely used for
renal, ureteral and intermediate-size renal calculi. Its
success rates from contemporary series vary from 60
to 90%. However, during an SWL procedure,
physicians should consider the association between
SWL-related pain and patients’ positioning, which
may negatively affect the SWL success rate as well as
its potential complications. PCNL can be divided into
two types: minimally invasive percutaneous
nephrolithotomy (mini-PCNL) and standard
percutaneous nephrolithotomy (standard PCNL).7
Mini-PCNL has a higher efficacy and better safety in
the management of small renal calculi, while standard
PCNL is still regarded as the conventional technique
for the treatment of large renal stones in the upper
urinary tract. However, in the recent years, there has
been a shift in trend to favor a mini-PCNL approach
in order to reduce the morbidities.8The present study
was conducted to assess efficacy of surgical
techniques and factors affecting residual stone rate in
the treatment of kidney stones.
In present study, group I patients underwent open
stone surgery, group II patients underwent PNL, and
group III underwent RIRS. Each group had 34
patients. Ayedemir et al9

included records of 109
cases of kidney stones. Patients were divided into
three groups in terms of surgical treatment; open stone
surgery, percutaneous nephrolithotomy (PNL) and
retrograde intrarenal surgery (RIRS). Patients’ history,
physical examination, biochemical and radiological
images and operative and postoperative data were
recorded.The patients had undergone PNL (n=74;
67.9%), RIRS (n=22;20.2%), and open renal surgery
(n=13; 11.9%). The mean and median ages of the
patients were 46±9, 41 (21–75) and, 42 (23–67) years,
respectively. The mean stone burden was 2.6±0.7 cm2
in the PNL, 1.4±0.1 cm2 in the RIRS, and 3.1±0.9
cm2 in the open surgery groups. The mean operative
times were 126±24 min in the PNL group, 72±12 min
in the RIRS group and 82±22 min in the open surgery
group. The duration of hospitalisation was 3.1±0.2
days, 1.2±0.3 days and 3.4±1.1 days respectively.
While the RIRS group did not need blood transfusion,
in the PNL group blood transfusions were given in the
PNL (n=18), and open surgery (n=2) groups. Residual

stones were detected in the PNL (n=22), open surgery
(n=2), and RIRS (n=5) groups.
We found that in group I mean stone burden was 3.2
cm2
, in group II was 2.5 cm2

and in group III was 1.9

cm2
. The mean operative time in group I was 84.2
minutes, in group II was 118.4 minutes and in group
III was 78.6 minutes. There were 9 cases in group I, 7
in group II and group III was 5 cases. Stone-free rate
in percutaneous nephrolithotomy can vary dependent
on the stone location, and size, as reported in the
literature, it increases up to 90 percent. In the AUA
guideline, this rate has been given as 78 percent. In
our study, in 74 patients, a 70.3% stone-free rate has
been detected. Size, location, composition of the
stone, anatomy of the affected kidney, and experience
of the surgeon are effective on success, and
complications of PNL.10
We found that there were 7 cases of fever in group I, 4
in group II and 2 in group III, infection 2 in group I
and 3 in group III, urine leakage 5 in group III and
persistent pain 6 in group I and 1 in group II.
Lingeman et al11reported 88–91% success rates for
stones with a diameter of 1–3 cm, mean success rate
decreased to 75% in stones larger than 3 cm in
diameter. Still Clayman et al12reported success rates
as 89.2, and 97–100% for stone with a stone burden of
>2, and <2 cm2

, respectively.
CONCLUSION
Authors found that PNL and RIRS have been seen as
safe and effective methods as compared to open
method in case of kidney stones.
REFERENCES
1. Karatag T, Buldu I, Inan R, Istanbulluoglu MO: Is
MicropercutaneousNephrolithotomy Technique Really
Efficacicous for the Treatment of Moderate Size Renal
Calculi? Yes. UrolInt 2015;95:9-14.
2. Kim BS: Recent advancement or less invasive treatment
of percutaneous nephrolithotomy. Korean J Urol
2015;56:614-623.
3. Hyams ES, Munver R, Bird VG, Uberoi J, Shah O:
Flexible ureterorenoscopy and holmium laser lithotripsy
for the management of renal stone burdens that measure
2 to 3 cm: a multi-institutional experience. J Endourol
2010;24:1583-1588.
4. Sabnis RB, Ganesamoni R, Ganpule AP, Mishra S,
Vyas J, Jagtap J, Desai M: Current role of microperc in
the management of small renal calculi. Indian J Urol
2013;29:214-218.
5. Knoll T, Buchholz N, Wendt-Nordahl G: Extracorporeal
shockwave lithotripsy vs. percutaneous nephrolithotomy
vs. flexible ureterorenoscopy for lower-pole stones.
Arab J Urol 2012;10:336-341.
6. Capitanini A, Rosso L, Giannecchini L, Meniconi O,
Cupisti A: Sepsis complicated by brain abscess
following ESWL of a caliceal kidney stone: a case
report. IntBraz J Urol 2016;42:1033-1036.
7. Kim JK, Ha SB, Jeon CH, Oh JJ, Cho SY, Oh SJ, Kim

HH, Jeong CW: Clinical Nomograms to Predict Stone-
Free Rates after Shock-Wave Lithotripsy: Development

and Internal-Validation. PLoS One 2016;11:e0149333.

Haripriya A et al. Treatment of kidney stones.

58

Journal of Advanced Medical and Dental Sciences Research |Vol. 8|Issue 12| December 2020
8. Kang JH, Lee SW, Moon SH, Sung HH, Choo SH, Han
DH: Relationship Between Patient Position and Pain
Severity During Shock Wave Lithotripsy for Renal
Stones With the MODULITH SLX-F2 Lithotripter: A
Matched Case-Control Study. Korean J Urol
2013;54:531-535.
9. Aydemir H, Budak S, Kumsar Ş, Köse O, Sağlam HS,
Adsan Ö. Efficacy of surgical techniques and factors
affecting residual stone rate in the treatment of kidney
stones. Turkish journal of urology. 2014 Sep;40(3):144.
10. Wong C, Leveillee RJ. Single upper-pole percutaneous
access for treatment of > or = 5-cm complex branched

staghorn calculi: is shockwave lithotripsy necessary? J
Endourol. 2002;16:477–81.
11. Lingeman JE, Coury TA, Newman DM, Kahnoski RJ,
Mertz JH, Mosbaugh PG, et al. Comparison of results
and morbidity of percutaneous nephrostolithotomy and
extracorporeal shock wave lithotripsy. J Urol.
1987;138:485–90.
12. Clayman RV, Mcdougall EM, Nakada SY. Endourology
of the upper urinary tract: percutaneous renal and
ureteral procedures. In: Wals PC, Retik AB, Vaughan
EJ, Wein AJ, editors. Campbell’s urology. Philadelphia:
WB Saunders; 1998; 2789–874.


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Oct19
A comparative study of laparoscopic appendectomy versus open appendectomy for the treatment of acute appendicitis
Original Research
A comparative study of laparoscopic appendectomy versus open
appendectomy for the treatment of acute appendicitis
Dr. Anil Haripriya



1Associate professor, Department of General Surgery CIMS, Bilaspur (C.G.), India;
2Associate Professor, Department of General Surgery, NSCB Medical College, Jabalpur (M.P.), India
ABSTRACT:
Background: The present study was conducted to compare open versus laparoscopic appendectomy in acute appendicitis.
Materials & Methods: 68 cases of acute appendicitis were divided into 2 groups. Group I patients were subjected to laparoscopy
appendectomy and Group II patients subjected to open appendectomy. Results: Symptoms were nausea/vomiting seen 28 in
group I and 26 in group II, abdominal pain 32 in group I and 33 in group II and fever in 25 in group I and 21 in group II. The
difference was non- significant (P> 0.05). Oral feed started postoperatively at mean of 5.9 days in group I and 2.6 days in group
II, average hospital stay was 5.6 days in group I and 4.2 days in group II. Wound abscess was seen in 3 days in group I and 4
days in group II and wound infection 2 days in group I and 8 days in group II. The difference was significant (P< 0.05).
Conclusion: Laparoscopic appendectomy is effective method of acute appendicitis as compared to open appendectomy.
Key words: Acute appendicitis, Laparoscopic appendectomy, Oral feed
Received: 11 September, 2020 Accepted: 16 November, 2020
Correspondence: Dr. Arvind Baghel, Associate Professor, Department of General Surgery, NSCB Medical College, Jabalpur
(M.P.), India
This article may be cited as: Haripriya A, Baghel A. A comparative study of laparoscopic appendectomy versus open
appendectomy for the treatment of acute appendicitis. J Adv Med Dent Scie Res 2020;8(12):42-45.
INTRODUCTION
Acute appendicitis is the most common emergent
abdominal condition requiring surgical intervention.
Appendicitis is inflammation of the appendix.
1
Symptoms commonly include right lower abdominal
pain, nausea, vomiting, and decreased appetite.
However, approximately 40% of people do not have
these typical symptoms. Severe complications of a
ruptured appendix include widespread, painful
inflammation of the inner lining of the abdominal wall
and sepsis.
2
Appendicitis is the most common cause of the acute
abdomen in the United States, with an estimated
lifetime risk between 5 and 20%. In fact, appendectomy
is the most common non-elective operation performed
by general surgeons. Although it has been over 115
years since Reginald Heber Fitz first demonstrated the

natural history and pathophysiology of appendicitis and
advocated early appendectomy in his landmark article,
appendicitis continues to present challenges for the
surgeon today.3
Appendectomy is the most commonly performed
operation in the world, 6% of all the surgical procedures
and is done as emergency procedure wherever possible,
the only exception is formation of appendicular mass or
abscess. In these cases, interval appendectomy is
performed as elective procedure.4
Laparoscopic appendectomy gives a better evaluation of
the peritoneal cavity than that obtained by open
approach and also facilitates other differential
diagnosis. Advantages of laparoscopic approach include
less operative time, less postoperative pain, reduced
analgesia, less surgery associated complications, shorter
hospital stay, faster recovery, reduced wound infection

Journal of Advanced Medical and Dental Sciences Research
@Society of Scientific Research and Studies NLM ID: 101716117
Journal home page: www.jamdsr.com doi: 10.21276/jamdsr Index Copernicus value = 85.10

(e) ISSN Online: 2321-9599; (p) ISSN Print: 2348-6805

Haripriya A et al. Laparoscopic appendectomy versus open appendectomy.

43

Journal of Advanced Medical and Dental Sciences Research |Vol. 8|Issue 12| December 2020
and minimal scarring.5 The present study was
conducted to compare open versus laparoscopic
appendectomy in acute appendicitis.
MATERIALS & METHODS
The present study was conducted in the department of
general surgery in a medical college hospital. It
comprised of 68 cases of acute appendicitis. Patients
were informed regarding the study and written consent
was taken.

Patient information such as name, age, gender etc. was
recorded. Patients were diagnosed on the basis of
physical examination, laboratory tests and ultrasound
examination (USG). Patients were divided into 2
groups. Group I patients were subjected to laparoscopy
appendectomy and Group II patients subjected to open
appendectomy. Patients were monitored for pulse rate,
blood pressure, temperature, respiratory rate, bowel
sounds and urinary output. Patients were put on follow
up at 1 week, 2 weeks and 4 weeks after surgery. P
value less than 0.05 was considered significant.

RESULTS
Table I Distribution of patients

Groups Group I Group II
Number Laparoscopy appendectomy Open appendectomy
Number 34 34

Table I shows that group I patients were subjected to laparoscopy appendectomy and group II patients subjected to
open appendectomy.
Table II Assessment of symptoms

Symptoms Group I Group II P value
Nausea/vomiting 28 26 0.97
Abdominal pain 32 33 0.94
Fever 25 21 0.91

Table II shows that symptoms were nausea/vomiting seen 28 in group I and 26 in group II, abdominal pain 32 in
group I and 33 in group II and fever in 25 in group I and 21 in group II. The difference was non- significant (P>
0.05).
Table III Assessment of parameters

Parameters Group I Group II P value
Oral feed started postoperatively 5.9 2.6 0.01
Average hospital stay 5.6 4.2 0.05
Wound abscess 3 4 0.05
Wound infection 2 8 0.01

Table III, graph I shows that oral feed started postoperatively at mean of 5.9 days in group I and 2.6 days in group II,
average hospital stay was 5.6 days in group I and 4.2 days in group II. Wound abscess was seen in 3 days in group I
and 4 days in group II and wound infection 2 days in group I and 8 days in group II. The difference was significant
(P< 0.05).
Graph I Assessment of parameters

0
1
2
3
4
5
6
7
8

Oral feed started
postoperatively

Average hospital
stay

Wound abscess Wound infection

5.9 5.6

3

2

2.6

4.2 4

8

Group I
Group II

Haripriya A et al. Laparoscopic appendectomy versus open appendectomy.

44

Journal of Advanced Medical and Dental Sciences Research |Vol. 8|Issue 12| December 2020
DISCUSSION
The diagnosis of acute appendicitis is often difficult,
and challenging. The most common cause of surgical
abdomen is appendicitis affecting all the age groups.6
The maximum incidence is documented to be about 7-
10 % of the general population in the second and third
decades of life.7 Appendectomy is the operation which
is most commonly performed by the general surgeons.
The Laparoscopic appendectomy was first performed
by Semm K, German Gynaecologist.8

It has gained
acceptance with the technological advances of the past
two to three decades as a diagnostic and treatment
method for acute appendicitis. From that time, this
procedure has been used widely. In spite of its wide
acceptance, there remains a continuing debate in the
literature related to the most appropriate way of
removing the inflamed appendix.9 The present study
was conducted to compare open versus laparoscopic
appendectomy in acute appendicitis.
In present study, group I patients were subjected to
laparoscopy appendectomy and group II patients
subjected to open appendectomy. Burra et al10 in their
study a total 140 patients admitted with clinical
diagnosis of acute or recurrent appendicitis. They were
divided into two groups: open appendectomy (OA)
group with 70 patients in each) and laparoscopic
appendectomy (LA) group (70 patients in each). OA
was performed through standard Mc Burney incision. A
standard 3-port technique was used in this study for the
laparoscopic procedure. It is found that laparoscopic
appendectomy is as safe and effective as the open
procedure. The pain score was reduced in laparoscopic
which is 3.4±1.8 and in open 4.2±1.4. This difference
was found to be statistically significant at p value of
0.05. The duration of analgesics was also reduced in
laparoscopic with mean value of 4.81±3.6 and
10.32±4.2 and this difference was found to be
statistically significant at p value of 0.05.
We found that symptoms were nausea/vomiting seen 28
in group I and 26 in group II, abdominal pain 32 in
group I and 33 in group II and fever in 25 in group I and
21 in group II. Gupta et al11 compared and evaluated the
open and laparoscopic method of appendectomy in
acute appendicitis. The subjects undergoing
appendectomy were evaluated for age, sex, episode
number, duration of pain before presentation in
hospital, operative time, conversion rate, wound
infection, post-operative intra-abdominal abscess
formation, and stay in hospital. It was found that
average operative time in open surgery was 67.5
minutes and 104 minutes in laparoscopic surgery, with
a conversion to open in about 20% of the cases. Oral
feeding in the open group was around the 5th day while
it was around 2nd day in the laparoscopic group.
Average hospital stay was also low in the laparoscopic
group, being only around 5 days in laparoscopic group

and around 8 days in the open group. Overall
complications were also low in the laparoscopic surgery
group.
We observed that oral feed started postoperatively at
mean of 5.9 days in group I and 2.6 days in group II,
average hospital stay was 5.6 days in group I and 4.2
days in group II. Wound abscess was seen in 3 days in
group I and 4 days in group II and wound infection 2
days in group I and 8 days in group II.
Another study by Garg CP12 which studied a total of
110 patients, 61 of whom underwent open
appendectomy and the rest 49 underwent laparoscopic
appendectomy. Operative time was noted to be higher
in laparoscopic surgery, also it was noted that
laparoscopic surgery was associated with less analgesic
use, shorter hospital stay.
The shortcoming of the study is small sample size.
CONCLUSION
Authors found that laparoscopic appendectomy is safer
and effective method for patients of acute appendicitis
as compared to open appendectomy.
REFERENCES
1. Chiarugi M, Buccianti P, Celona G, Decanini L,
Martino MC, Goletti O et al. Laparoscopic compared
with open appendectomy for acute appendicitis: A
prospective study. Eur J Surg 1996; 162(2): 385–390.
2. Garbutt JM, Soper NJ, Shannon W, Botero A,
Littenberg B. Meta-analysis of randomized controlled
trials comparing laparoscopic and open appendectomy.
Surg Laparosc Endosc. 1999; 9(4):17-26.
3. Akshatha Manjunath, Aparajita Mookherjee.
Laparoscopic versus open appendectomy: An analysis
of the surgical outcomes and cost efficiency in a tertiary
care medical college hospital. International Journal of
Contemporary Medical Research 2016; 3(6):1696-
1700.
4. Di Saverio S. Emergency laparoscopy: a new emerging
discipline for treating abdominal emergencies
attempting to minimize costs and invasiveness and
maximize outcomes and patients’ comfort. J Trauma
Acute Care Surg. 2014; 77(1):338–50.
5. Hansen JB, Smithers MB, Schache D, Wall DR, Miller
BJ, Menzies BL. Laparoscopic versus open
appendectomy: prospective randomized trial. World J
Surg 1996; 20(5): 17–21.
6. Klingler A, Henle KP, Beller S, Rechner J, Zerz A,
Wetscher GJ. Laparoscopic appendectomy does not
change the incidence of postoperative infectious
complications. Am J Surg 175(3): 232–35.
7. Kurtz RJ, Heimann TM. Comparison of open and
laparoscopic treatment of acute appendicitis. Am J Surg.
2001; 182(6):211–4.
8. Chung RS, Rowland DY, Li P, Diaz J. A metaanalysis
of randomized controlled trials of laparoscopic versus
conventional appendectomy. Am J Surg. 1999;
177(1):250–6.

Haripriya A et al. Laparoscopic appendectomy versus open appendectomy.

45

Journal of Advanced Medical and Dental Sciences Research |Vol. 8|Issue 12| December 2020
9. Hellberg A, Rudberg C, Kullmann E, et al. Prospective
randomized multicentre study of laparoscopic versus
open appendectomy. Br J Surg. 1999; 86(4):48–53.
10. Burra Viswa Chaitanya, Rama Chandra Mohan
Mallapragada. Comparative evaluation of laparoscopic
with open appendectomy among patients of
appendectomy - A prospective study. International
Journal of Contemporary Medicine Surgery and
Radiology. 2019;4(3):C18-C22.
11. Gupta A, Singh AP. Comparative Evaluation of Open
and Laproscopic Method of Appendectomy in Acute
Appendicitis. Journal: Academia Journal of Surgery.
2020(1):8-11.
12. Garg CP, Vaidya BB, Chengalath MM. Efficacy of
laparoscopyin complicated appendicitis. Int J Surg.


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Jan24
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Book chapter: Spontaneous Bacterial Peritonitis: a Review - (Rajasthan Medical Journal 2006).

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Book chapter: Predicting outcome of Idiopathic Ulcerative colitis - Why and How.


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Sep04
CLOSTRIDIUM DIFFICILE-Antibiotic Diarrhoea,Restrict Use Of ANTIBIOTICS Unnecssarily
CLOSTRIDIUM DIFFICILE often called C-difficile, or C- diff, is a type of bacteria that causes symptoms that can range from diarrhea to life threatening inflammation of the colon.Since the commonest cause of this diarrhea is long term use of antibiotics , it is also called antibiotic diarrhea. In recent years C-diff has become more frequent, more severe and difficult to treat. Your risk is greatest if you are taking or have recently taken antibiotics. The risk is higher if you take multiple antibiotics for a prolonged period. Seen more in older age group, recently hospitalized for an extended period. C-diff infections are seen more in nursing home or longterm care facilities. It is found more among patients with weakened immunity and those who have some underlying medical illnesses. Patients who have had some abdominal surgeries or have colon disease such as inflammatory bowel disease , colorectal cancer or previous C-diff infection are also at risk. The antibiotic that most often leads to C-diff infection include fluroquinolones, cephalosporins, clindamycin and penicillins. These drugs can destroy some of the normal, helpful bacterias in your colon. Once established it produces toxins that attacks the lining of the intestine. The toxin destroys cells and produces plaques of inflammatory cells and decaying cell debris inside the colon. Some new strains of C-diff has emerged that are resistant to certain medications and are deadly. Stool tests like enzyme immune assay and tissue cultures are used to detect this infection.Flexible sigmoidoscopy is sometimes used to confirm the diagnosis. CT scan may be ordered if there is a concern about possible complications like pseudomembranous colitis. Bowel perforation and toxic megacolon are also some of the complication of C-diff.Severe diarrhea may cause dehydration and in some cases kidney function may deteriorate. If not treated promptly this can be fatal.Most common symptoms are, watery diarrhea 10-15 times a day, abdominal cramping, fever, pus or blood in the stool, nausea, dehydration, loss of appetite and weight loss. The first step in treating C-diff is to stop taking the antibiotic that triggered the infection. In an ironic twist, the standard treatment for C-diff is another antibiotic. Usually metronidazole , for mild to moderate and vancomycin, for severe symptoms are the drug of choice. Probiotics are given in conjunction with the antibiotics to restore intestinal flora.For people with severe pain, organ failure or inflammation of the colon , surgery to remove the diseased portion of the colon may be the only option. Would you like to share this with your colleagues? Email Be the first one to share this post


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Jun01
पाचन रहेगा ठीक, यदि माने आयुर्वेद की सीख l
पाचन रहेगा ठीक,
यदि माने आयुर्वेद की सीख l
आज की भागदौड भरी जिन्दगी,अनियमित दिनचर्या एवं खान पान की गलत आदतों के कारण अधिकतर व्यक्ति पेट के रोगों से ग्रस्त हैं, पाचन संस्थान का हमारे पूरे शरीर की सेहत पर प्रभाव पड़ता है खानपान की आदतों में यदि निम्न सुधार कर लिया जाये तो पेट के रोगों के होने की सम्भावना काफी कम हो जाती है-
* रेशे युक्त आहार लें- रेशा युक्त आहार कब्ज,अपचन ,बवासीर,कोलेस्ट्रोल,मोटापा आदि रोगों से बचाता है ,रेशा चोकर युक्त आटा ,सलाद,हरी सब्जियां,फल,चावल,दाल आदि में पाया जाता है l
* संतुलित भोजन करें -भोजन में ,दही ,छाछ ,अंकुरित अन्न ,दूध,दलिया ,खिचड़ी आदि का नियमित सेवन करना चाहिए, छाछ को अमृत तुल्य कहा गया है,मांसाहार ,पूडी ,परांठे ,मिठाई,मिर्च मसाले ,जंक फ़ूड,मैदा आदि का ज्यादा सेवन नहीं करना चाहिए l
* प्रात:काल पानी पीयें - सुबह उठने के बाद चाय के बजाय 2-3 गिलास पानी पीना चाहिए,बैड टी से पेट में एसिड बनता है l
* खाना अच्छी तरह चबा चबा कर खाएं-अच्छी तरह चबा चबा कर खाने से भोजन में लार रस अच्छी तरह मिल जाता है ,जिससे भोजन का पाचन अच्छी तरह से होता है ,जल्दी जल्दी भोजन निगलने से अपचन,गैस,कब्ज,एसिडिटी आदि रोगों की उत्पत्ति होती है l
* शाम को भोजन के बाद घूमें -शाम को खाना सोने से 2-3 घंटे पहले एवं हल्का होना चाहिए ,भोजन के बाद 15-20 मिनट अवश्य घूमें ,इससे बहुत से रोगों से बचाव तो होता ही है साथ ही नींद भी अच्छी आती है,भोजन हमेशा निश्चित समय पर खाने की कोशिश करनी चाहिए l
* नशा न करें -धूम्रपान , तम्बाकू एवं अत्यधिक शराब का सेवन पेट के रोगों के साथ साथ शरीर के अन्य रोगों का भी कारण होता है l
* व्यायाम एवं योगा करें-नियमित रूप से व्यायाम,योगा करने एवं पैदल घूमने से बहुत से रोगों से बचाव होता है ,पाचन शक्ति अच्छी रहती है तथा मानसिक तनाव काफी कम हो जाता है l


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May20
Waited too long
I got a call from emergency that a 32 year old female had come with severe pain in abdomen & vomiting. She had pain since five days and no she was also running fever. I went to examine her. She looked familiar. She had my old case papers. She meet me couple of years back. She had Gallstones but refused to get operated because she said it was hardly causing any symptoms.
Read More : http://drbcshah.com/waited-too-long/


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May17
Emergency Laproscopic Hernia Surgery
Fifty five years old female patient came to me with swelling in Umbilical region since two Years. She had no pain initially hence she Ignored it. As swelling increase, she started getting mild pain and one day she landed up in emergency with severe pain & vomiting. She described that her pain was like delivery pain wave pattern of severe pain due to intestines trapped in the hernia.
Two option of emergency surgery open or Laproscopic (key hole) surgery were given to patient. She choose to undergo Laproscopic Surgery as that is relatively painless during post operative period and also the scar is cosmetic.

Read more :- http://drbcshah.com/laproscopic-hernia-surgery/


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May14
Passing blood in stools
Mr. B______, a 50 year old patient from Saudi Arabia came to me with bleeding while passing stools (also read this interesting case ) since childhood. He was often treated for piles in his country but there was no relief. Ultimately being frustrated with his disease, he came to India. He was skinny and pale. I examined his anal canal but did not see any plies. There appeared some mass in rectum. I posted him for colonoscopy. Almost whole of his colon from rectum to cecum was involved with multiple small grape like growths called polyps. I biopsied few of them and they came benign. The diagnosis of Multiple colonic polyposis was established.
Read More - http://drbcshah.com/passing-blood-in-stools-a-rare-disease/


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May12
Inflammatory bowel disease
Inflammatory bowel disease (IBD) is not a single disease. The term IBD is used mainly to describe two diseases:

Crohns disease
ulcerative colitis

Both Crohns disease and ulcerative colitis are chronic (long-term) diseases that involve inflammation of the gastrointestinal tract (gut). However, there are important differences between the two.

Read more: http://drbcshah.com/inflammatory-bowel-disease/


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