Risk of bowel resection in patients with hernia Abdulmalik Altaf, Wafaa Ali Algethmi Saudi Surgical Journal 2019 7(2):43-46 Introduction: Repair of hernia is one of the most common general surgery operations. Strangulation of the hernia contents requiring bowel resection is one of the serious complications of hernias. The aim of the present study is to evaluate the risk factors of bowel resection in patients undergoing emergency surgical repair of hernia. Methods: A retrospective study reviewed the medical records of all patients who underwent emergency surgery for hernia from January 2014 to December 2017 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients were stratified into two groups: bowel resection was required (Group 1) or not (Group 2). Extracted patients' data for each group included four different fields: (1) personal data and patients' characteristics, (2) preoperative assessment, (3) intraoperative assessment, and (4) postoperative length of hospitalization and complications. The data were analyzed to determine the risk factors for bowel resection. Results: A total of 83 patients underwent emergency surgery hernia repair during the study. A univariate multiple logistic regression model identified three variables that were independent risk factors for bowel resection: duration of symptoms >24 h (odds ratio = 6.093), previous abdominal surgery (odds ratio = 4.531), and high American Society of Anesthesiologists (ASA) classification score (odds ratio = 8.273). Conclusion: Risk factors for bowel resection in emergency hernia repair include high ASA score, previous abdominal surgery, and prolonged the duration of symptoms. Further prospective studies are recommended to confirm the findings of this study.

Flipped classroom as an effective educational tool in teaching surgery for undergraduate students Ramula Durai, Mukuntharajan Mohanraj Saudi Surgical Journal 2019 7(2):47-50 Background: In recent years, the flipped classroom (FC) method of teaching has received much attention in health sciences education. The concept of FC has been present in medical education since the 1990s with the introduction of team-based learning. Flipping the classroom is the practice of providing learners with study materials, traditionally covered in lectures, to be learned before class while the teacher becomes the facilitator of classroom discussion. The successful flipped class requires well-planned learning design, interesting study materials, effective plan for formative assessment, to identify gaps in learning, and suitable innovative teaching tools to close the gaps. Although it has been introduced few years back, this concept is new in our institute and we studied this as a pilot project for surgery students. Flipped classroom teaching method elaborated to the students ,before starting this new teaching learning method. Objective: The objective of the study is to assess the effectiveness of FC teaching in surgery for undergraduate students. Collation of students perception of this new TE-Learning compared to traditional teaching methods. Methodology: One hundred students of final-year MBBS were included in this study for the surgery subject. Randomly chosen by computer, they were divided into two groups (n = 50). One group followed FC and the other group followed traditional teaching method handled by two different faculties. This study is undertaken to find the effectiveness of FC. Five module were prepared on the topic Groin Hernia “ for this “flipped group” learning. Students in flip group were provided with study materials, videos, and before classroom discussion, while the other group followed didactic lecture. Effectiveness of this new method was assessed by pretest, posttest at the end of the topic, and feedback on perception of flipped class obtained by a questionnaire. Results: FL group students felt that learning surgery is more interesting and brings in motivation and better understanding of the topic taught. Videos and surgical anatomy were found easy to understand. Eighty-two percent used lecture notes, 62% found PPT easy to follow, while 78% found animation more interesting. In posttest also, flipped group performed better than didactic lecture method. Success depends on the topic chosen, especially in surgery. Conclusion: Flipped class not only brings motivation but also improves their understanding of the course materials and enhanced their communication skill and clinical thinking. Students in the Flipped Class, showed a preference for this method of teaching and found this more interesting.

Results of urethral plate preservation and use of vascular dartos flap in hypospadias repair Rajendran Ramaswamy, Samir Morsy Hegab, Rayan Ahmed Baz, Saif Saeed Galib, Ghazi Mukattash Saudi Surgical Journal 2019 7(2):51-56 Background: Lower complication rates are observed if urethral plate (UP) is preserved and utilized for reparative surgery of hypospadias. Aim: This study aims to analyze our results of hypospadias repair by UP preservation, and using vascular dartos flap as interposition flap. Materials and Methods: prospective, cohort study of operated cases of hypospadias over 4.5 years' period. Data including age, diagnosis, preoperative testosterone administration, operation, postoperative complications, and assessment of outcome using hypospadias objective scoring evaluation (HOSE) system were collected. We preserved UP as far as possible, for urethral tube construction. We applied meatal advancement and glanuloplasty incorporated (MAGPI) for glanular/coronal hypospadias and tubularized incised plate urethroplasty (TIPU) (Snodgrass) for most other cases. Single dorsal vascular dartos-flap was transposed ventrally as interposition flap in TIPU. Single transurethral catheter 6F/8F size was employed as urethral stent as well as for bladder drainage. At the first review at 2 weeks after getting discharged, all patients underwent urethral calibration and first HOSE-score assessment. Maximum HOSE-score was 16 points and minimum 5. Results: A total of 111 patients with mean (range) age of 34.69 m (11 m– 123 m) were studied. TIPU (n = 49), MAGPI (n = 44), and others (n = 18) were the operations. There were 10 permanent complications; 9 following TIPU (7 (14.3%) single urethrocutaneous fistula (UCF), 1 torsion penis, 1 glans-dehiscence), and 1 following MAGPI (glans-dehiscence). Mean follow-up period was 15 m (range = 3–36 m). HOSE score ≥14 was achieved in 106 (95.5%) cases. Conclusion: The excellent result of MAGPI in our series is due to strict case selection and technical precision. UCF rate of 14.3% in TIPU can be due to the unselected nature of our cases which included small glans diameter and unfavorable UP characteristics.

Current trends in the management of hydatid disease: Surgeons' perspective M Ezzedien Rabie, Khaled ElShaar, Mohammad Al Skaini, Hussein Ageely, AbdelNasser Zaid, Ismail El Hakeem, Saad Al Qahtani Saudi Surgical Journal 2019 7(2):57-62 Background: Surgery was the only known curative treatment for hydatid disease. Currently, this is being changed. Aims: The aim of this study was to explore the evolution of our management policy for hydatid disease. Patients and Methods: We retrieved records of patients with hydatid disease, treated in our unit in the period from January 1998 to February 2012. Results: Twenty-seven patients were identified. For comparison and driven by the appearance of nonsurgical means in the series, patients were divided into two groups: the first group included the first 12 patients and the second group included the last 15 patients. In the first group, all patients received surgery and only two (16.7%) received postoperative albendazole therapy. In the second group, only four patients (26.7%) received surgery with perioperative pharmacotherapy, eight patients (53.3%) received pharmacotherapy alone, and three patients (20%) received puncture-aspiration-injection-reaspiration (PAIR) with periprocedural pharmacotherapy. In those who received surgery with adjuvant pharmacotherapy, one patient died and the cyst disappeared in the remaining three. In those who received PAIR, the cyst disappeared in one case and regressed in the other two. In those who received pharmacotherapy alone, two patients showed disappearance of the cyst, one showed partial response, and five are under follow-up. Conclusions: Surgery is no longer the first-line treatment for hydatid disease. It should be reserved for complicated cases and those presenting as an emergency. When applied, surgery should be backed by pharmacotherapy which has a pivotal role, both as a sole agent and as an adjunctive to therapy.

Outcome of combined complete excision of the caudate lobe with partial hepatectomy for treatment of resectable Klatskin tumors Bilal O Al-Jiffry, Mohamed Al Saeed, Majed Al-Mourgi, Alaa E Younes, Samir Badr, Tamer Abdel-Rahman, Ayman Attalla, Abdullah Al-Sawat, Mohamed Hatem, Mahmoud El-Meteini, Ali B Al-Jiffry Saudi Surgical Journal 2019 7(2):63-68 Background and Aim of the Work: Combination of partial hepatectomy with complete excision of the caudate lobe was found to improve the outcome of resectable Klatskin tumors. In this prospective multicenter study, the outcome of these combined resections would be evaluated. Patients and Methods: This prospective study enrolled 72 patients with resectable Klatskin tumors. The study was conducted in Taif tertiary hospital and Ain Shams University Hospitals from January 2008 to December 2014. All patients underwent partial hepatectomy with complete excision of the caudate lobe after preoperative biliary drainage. The primary outcome was the resection margin (positive or negative), postoperative complications, and patient survival. Other outcomes included; the mean operative time, mean amount of blood loss, and prognostic factors correlated with survival. Results: The number of patients underwent combined resection were 72 patients, 49 males and 23 females with mean age of 58.3 ± 14.2 years. Mean operative time was 243 ± 57 min and the mean blood loss was 896 ± 211 ml. The recorded postoperative complications included; bile leak in 16.7%, wound infection in 15.3%, pleural effusion in 12.5%, liver failure in 4.2%, and liver abscess in 4.2%. Recorded hospital mortality was 5.6%. The resection margin was negative (R0) in 51/72 patients (70.8%). The overall mean survival during the follow-up was 48 ± 10.2 months. The estimated overall 5-year survival rate was 37.5% increased to 50.1% in R0 patients, and it was 4.8% when the margin was positive. There was a significant positive correlation between the patient survival and the negativity of the resection margin, and a negative significant correlation with the pretreatment level of carcinoembryonic antigen. Age, gender, Bismuth classification, and pretreatment level of carbohydrate antigen 19.9 had insignificant correlation with the survival. Conclusion: The excision of the caudate lobe with extended hepatic resection by the experienced hepatobiliary surgeon in properly selected patients survival has been proved to be safe and effective.

Patients' attitudes and knowledge toward clinical trial participation Abdulmalik Altaf, Rakan Bokhari, Ghada Enani, Sami Judeeba, Alyaa Hemdi, Ashraf A Maghrabi, Hanaa Tashkandi, Murad Aljiffry Saudi Surgical Journal 2019 7(2):69-74 Objective: The study objective was to investigate patients' attitudes toward clinical trial participation and the barriers to participation. We also aimed to estimate the proportion of patients willing to participate in clinical trials. Methods: We conducted a survey on patients who were scheduled to have minor or major surgery at King Abdulaziz University Hospital between May 2018 and December 2018. We used a questionnaire that comprised 27 multiple-choice questions to assess patients' attitudes and knowledge toward trial participation. Data were analyzed using the Statistical Package for the Social Sciences software. Results: We recruited 200 patients, of whom 123 (61.5%) were male; 129 patients (64.5%) agreed that they were knowledgeable about the importance of clinical researches, whereas 34 (17.0) reported that they had no knowledge about its importance. One-hundred and thirty-eight patients (69.0%) were positive about clinical trial participation, 30 patients (15.0%) were negative, and 32 (16.0%) had no opinion. There was no statistically significant association between patients' attitudes toward trial participation and age (P = 0.422) or gender (P = 0.066). Conversely, there was a statistically significant association between the level of education and patients' willingness to participate in clinical trials (P = 0.05). We found a statistically significant association between patients' perception of clinical trials in their community and age (P = 0.001) as well as educational level (P = 0.003). Conclusion: The findings suggest general support of clinical trials, with 69% of the patients willing to consider enrolling in a clinical trial.

Peritoneal encapsulation: A puzzling encounter during open and laparoscopic surgery M Ezzedien Rabie, Asim Elyas, Mohammad Bazeed, Mohammad Osama, Hana Ahmed Alhashemy Saudi Surgical Journal 2019 7(2):75-78 The presence of an intraperitoneal membrane, encasing parts of the bowel, is a bizarre and rare condition. Three categories are recognized, peritoneal encapsulation, primary sclerosing encapsulating peritonitis (SEP), and secondary SEP, each with different etiology. Symptomatic cases may present with bowel obstruction while asymptomatic cases may only be discovered at surgery for an unrelated reason. In this report, we describe the clinical course of two patients, in whom the condition was discovered only during surgery. The first patient had peritoneal encapsulation and the condition was discovered during laparoscopic cholecystectomy. Due to a bizarre laparoscopic view, in which access to the general peritoneal cavity was hindered by the membrane, conversion to open surgery was necessitated. The second patient had idiopathic encapsulating sclerosing peritonitis, which was discovered at laparotomy for bowel obstruction. Both patients convalesced well after surgery and had an unremarkable postoperative course. In this report, we aim to highlight the existence of this rare entity, which can cause difficulty, particularly during laparoscopic surgery.

Forgotten retrosternal goiter Abdulmalik M Ismail, Mohammed S AlFehaid, Hussam Binyousef Saudi Surgical Journal 2019 7(2):79-81 The presence of thyroid tissue in the mediastinum after total thyroidectomy is commonly known as “forgotten goiter,” which is considered as an extremely rare condition with controversy regarding the etiological causes. We report a 57-year-old female who has had a total thyroidectomy. Postoperatively, she underwent a computed tomography scan which revealed a retrosternal goiter. A reexploration was performed utilizing the previous collar incision. The mass was totally below the thoracic inlet separated from the central neck compartment. Forgotten goiter, though a rare pathology, can be prevented by meticulous preoperative imaging and can be managed during the first operation; however, surgical treatment for forgotten goiter, when performed in specialized centers, can be achieved through cervical approach and is associated with low morbidity.

Chewing gum and postoperative ileus: How to solve a multifactorial problem? Yasser Ali Kamal Saudi Surgical Journal 2019 7(2):82-82