Genel Cerrahi

Background: Laparoscopic cholecystectomy has become the standard operative procedure for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy mainly because of technical difficulty. Our aim was to develop a risk score for prediction of conversion from laparoscopic to open cholecystectomy. Methods: Preoperative clinical, laboratory, and radiologic parameters of 1,000 patients who underwent laparoscopic cholecystectomy were analyzed for their effect on conversion rates. Six parameters (male sex, abdominal tenderness, previous upper abdominal operation, sonographically thickened gallbladder wall, age over 60 years, preoperative diagnosis of acute cholecystitis) were found to have significant effect in multivariate analysis. A constant and coefficients for these variables were calculated and formed the risk score. Results: Overall 48 patients required conversion to open cholecystectomy (4.8%). These patients had significantly higher scores (mean 6.9 versus Ϫ7.2, P Ͻ0.001). Increasing scores resulted with significant increases in conversion rates and probabilities (P Ͻ0.001). Ideal cut-off point for this score was Ϫ3; conversion rate was 1.6% under Ϫ3, but 11.4% over this value (P Ͻ0.001). Conclusions: Conversion risk can be predicted easily by this score. Patients having high risk may be informed and scheduled appropriately. An experienced surgeon has to operate on these patients, and he or she has to make an early decision to convert in case of difficulty.

Background: Laparoscopic cholecystectomy has become the standard operative procedure for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy mainly because of technical difficulty. Our aim was to develop a risk score for prediction of conversion from laparoscopic to open cholecystectomy. Methods: Preoperative clinical, laboratory, and radiologic parameters of 1,000 patients who underwent laparoscopic cholecystectomy were analyzed for their effect on conversion rates. Six parameters (male sex, abdominal tenderness, previous upper abdominal operation, sonographically thickened gallbladder wall, age over 60 years, preoperative diagnosis of acute cholecystitis) were found to have significant effect in multivariate analysis. A constant and coefficients for these variables were calculated and formed the risk score. Results: Overall 48 patients required conversion to open cholecystectomy (4.8%). These patients had significantly higher scores (mean 6.9 versus Ϫ7.2, P Ͻ0.001). Increasing scores resulted with significant increases in conversion rates and probabilities (P Ͻ0.001). Ideal cut-off point for this score was Ϫ3; conversion rate was 1.6% under Ϫ3, but 11.4% over this value (P Ͻ0.001). Conclusions: Conversion risk can be predicted easily by this score. Patients having high risk may be informed and scheduled appropriately. An experienced surgeon has to operate on these patients, and he or she has to make an early decision to convert in case of difficulty.

Objective: To compare primary repair and grafting with one of two materials (one biological human dura mater, and one synthetic polypropylene mesh) or autologous skin, with primary repair alone in abdominal wall hernias in rats. Design: Randomised experiment. Setting: Teaching hospital, Turkey. Animals: 72 male Wistar albino rats randomised into 4 groups of 18 rats each. These were further randomly divided into subgroups of 6 each that were killed on days 15,30,and 45 postoperatively. Interventions: Each test material was sutured to the abdominal wall by an onlay technique. Main outcome measures: Macroscopic and microscopic appearance, and strength of the abdominal wall. Results: Macroscopically, dura mater grafts lost their original shape, but polypropylene and skin did not. When completely incorporated the skin grafts had developed a new fascia. Dura mater and polypropylene induced a pronounced inflammatory reaction at all three times postoperatively, and there were significantly more fibroblasts in the dura mater group on days 15 and 30, and in the skin graft group on day 45, than in the other groups (p < 0.05). Mechanical resistance and mean breaking strength were significantly greater in the skin graft group than in the other groups at all times tested (p < 0.05). Conclusion: Full thickness autologous skin grafts were stronger than both human dura mater and polypropylene mesh when used to reinforce primary repairs of abdominal wall hernias in rats.

S U M M A R Y . Primary or secondary involvement of the breast is a rare form of extranodal lymphoma. In this paper, we present a 36-year-old female patient admitted to the hospital with bilateral breast masses. Histological examination confirmed high-grade malignant lymphoma involving both breasts. r

We investigated the factors affecting recurrence rate in tensionfree hernioplasties in the hope of obtaining better results. Tension-free hernioplasty is an easy procedure with very low reported recurrence rates of o-1.7%. But the causes of failures in open mesh repairs have not been well established. During this prospective study from January 1993 to December 1997 a total of 383 tension free hernioplasties were performed. The influence of some factors including age, sex, type of repaired hernia according to the Nyhus classification, simultaneous bilateral repair, previous hernia operation on the opposite side, chronic constipation, chronic obstructive lung disease, benign prostatic hypertrophy, smoking, previous appendectomy, early postoperative complications and surgical site infection on the recurrence rate were investigated using univariate and multivariate analyses. After a follow-up period of 16 to 62 months (mean 38.2 months) 5 out of 383 repairs failed with a recurrence rate of 1.3%. As a result of logistic regression analysis direct hernia, chronic constipation and surgical site infection were found to be independent risk factors for recurrence. The recurrence rates of tension-free hernioplasties can be reduced by the use of proper surgical techniques, early management of surgical site infection and treatment of chronic constipation.

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

The purpose of the study was to investigate the effective prognostic factors on recurrence and mortality in patients with differential thyroid cancer. Material and Methods: The effects of various parameters of demographic characteristics, the admission symptoms, physical examination, laboratory findings, pathological examination, and surgical method of 184 patients, who underwent surgery due to differential thyroid cancer between January 1986 and December 2009 in 4th General Surgical Clinic of Ankara Numune Training and Research Hospital, on prognosis were examined. The information of the patients was obtained from automation system of the hospital and Thyroid Cancer Information and Follow-Up Form of 4th General Surgical Clinic of Ankara Numune Training and Research Hospital. Results: The sample group consisted of 172 papillary cancer patients and 12 follicular cancer patients. The mean age of the patients was 45.4 years (15-78). There were 159 (86.4%) female patients and 25 (13.6%) male patients. The mean follow-up period of 161 (87.5%) patients, who were followed up regularly, was 73.26 months (1-231). The mean recurrence period was 77.66 months (1-150). Mortality was observed in eight (4.3%) patients during their follow-up period. The mean life expectancy of those who died was 66.87 months (1-150 months). * Single variable analysis revealed that the T stage and pathologic final stage were effective on recurrence. Painful nodules and palpable lymph nodes in the neck and the papillary histological malignant subtype variant, as well as the presence of vascular and adjacent organ invasion, multicentricity, T stage, the lymph nodes, distant metastasis, and the clinical stage during the admission were identified to be effective on mortality. Conclusion: The risk of recurrence is high in DTC patients with high T stage and advanced pathologic stage. The rate of survival of those with multicentric tumors and advanced pathologic stage is low. Therefore, it is important for patients to be followed up closely within a postoperative multidisciplinary context.

Abdominal cerebrospinal pseudocyst (CSF-P) is a rare complication of ventriculoperitoneal shunt (VPS). A 40-year-old man applied to emergency service with the complaints of abdominal pain, headache, nause and vomiting. He had a VPS application history in 16 years ago. A cystic mass lesion which filled at the right subdiaphragmatic and subhepatic area and peritoneal catheter ended in it was detected on the abdominal computed tomography (CT). Part ial cyst excision and shunt revision operation was performed. This case presented for rare incidence and emphasize that the possibility of CSF-P in the patients whom admitted with abdominal complaints, headache and VPS history. Key words : Ventriculoperitoneal shunt; hydrocephalus; abdomen; pseudocyst OZET Abdominal serebrospinal psodokist gelisimi ventrikuloperitoneal sant (VPS) uygulamalarinin nadir gorulen bir komplikasyonudur. 40 yasinda erkek hasta acil servise karin agrisi, basagrisi, bulanti ve kusma sikayetleri ile basvurdu. Hikayesi...

In this study, scald burns in a Turkish population (0-16 years of age) were studied with reference to their occurrence and common causes. Of the burn victims hospitalized at the Burns Unit of Ankara Numune Education and Research Hospital between April 2001 and December 2003, 354 patients were aged 3 months to 16 years and 228 (64.4%) were male. When burn causes were examined, scald burns were the primary type, reported in 77.7% (275) of the patients (p &lt; 0.001). Scalds were the most frequent burn agents in the pediatric population. Tea is a traditional beverage in Turkey. It is consumed especially at breakfast and throughout the day until late at night. Tea in Turkey is steeped and brewed for consumption. As brewing and steeping is a time-consuming process and the tea is served hot, the appropriate level of care regarding the hot tea is neglected. Consequently, tea carries a serious potential to cause burns in this country. Of the scalded children, 93 scald burns (33.8%) were due...

Infectious consequences are still a major problem and leading cause of mortality in burn patients. Among others, aeromonads need special concern because they mimic pseudomonal infections; however, they have a more rapid progression with considerable mortality if undiagnosed promptly. Here, we present a major burn case extinguished with tap water pooled in a tank. With the possibility of aeromonal infection in mind, the patient underwent aggressive debridement with proper antibiotic medication, which resulted in a successful patient management. Aeromonads should always be kept in mind in burn cases that contacted with tanked water or soil after the burn.

BACKGROUND: In the presence of advanced age and comorbidities, patients with gallstones may face gangrenous and perforated cholecystitis during their follow-up. In the literature, dynamic thiol/disulfide homeostasis has been shown to play an important role in detoxification, antioxidant protection, regulation of enzymatic reactions, and apoptosis and cellular signaling mechanisms. In this study, we aimed to evaluate the efficacy of IMA and thiol/disulfide homeostasis in the preoperative diagnosis of patients with cholelithiasis, acute/chronic cholecystitis, and perforated gallbladder. METHODS: Sixty-six patients that presented to the General Surgery Clinic of Ankara City Hospital for a cholecystectomy operation between February 2019 and May 2020 were included in this study. The patients were divided into three groups depending on the condition for which they were scheduled for surgery: cholelithiasis, cholecystitis, and perforated gallbladder. The demographic data, history of cholecystitis, chronic disease, white blood cell (WBC), amylase, lipase and liver function tests (AST and ALT) were recorded before the operation. Gallbladder appearance was evaluated using hepatobiliary ultrasonography. The duration of surgery, pericholecystic adhesions, hospital stay, body mass index (BMI), postoperative complications, and pathology results of specimens were recorded. In addition, thiol/disulfide and IMA values were analyzed in the blood samples taken from the patients preoperatively. RESULTS: The mean native thiol and total thiol values of the patients with an adhesion score of 0 were significantly higher than those with an adhesion score value of 1, 2 or 3. In addition, the disulfide, disulfide/native thiol, native thiol/total thiol and IMA values of the cases with an adhesion score of 2 or 3 were significantly higher than those with an adhesion score of 0. The native thiol and total thiol averages of the patients with normal cholecystectomy were higher than the others. The disulfide, native thiol/total thiol and IMA averages of those who underwent cholecystectomy due to a perforated gallbladder were also higher than the other groups. The mean preoperative WBC of the patients who underwent cholecystectomy due to a perforated gallbladder was also significantly higher than the other groups. Lastly, the native thiol and total thiol values had a statistically significant negative correlation with age, operation time, and hospital stay, and a statistically significant positive relationship with BMI. CONCLUSION: We consider that in the preoperative diagnosis of the perforated gallbladder, the evaluation of thiol/disulfide hemostasis and IMA parameters can be used as an effective and reliable method to predict intraoperative difficulties.

Intravesical foreign objects in bladder are really seen rarely. Most of the time, the reasons of insertions of the foreign body are self-autoerotism to iatrogenic urological procedures, migration from surrounding organs or trauma. It can damage the bladder and may result in several urogenital and bowel complications. Herein, we present a case in a 42year-old female with an eyeliner pencil self-introduced into the urethra with successfully removal of eyeliner from bladder despite to the anamnesis given involuntarily due to embarrassment, guilt and humiliation.

Background: Approximately 10% of patients with symptomatic gallstones may have associated common bile duct stones (CBDS). However, the predictive value of noninvasive tests as well as the preoperative diagnosis and management of CBDS have not been well defined. The aim of this study was to define an accurate and simple model for the prediction and management of CBDS. Methods: A prospective database containing 986 cholecystectomies performed from 1994 through 1999 was evaluated. Univariate analysis using the Pearson chi-square test was performed to determine the factors significantly related to the presence of CBDS. Then logistic regression analysis was performed for multivariate analysis to discover independent predictors. Results: Of the 986 patients in this study, 48 (5%) had CBDS. Of the 48 patients with choledocholithiasis, 22 (46%) were men and 26 (54%) were women. The mean age was 55.3 years (range, 16-87 years). As a result of multivariate analysis, abdominal ultrasonographic findings suggestive of CBDS (common bile duct diameter exceeding 8 mm or visible stones), total bilirubin, and gamma glutamyl transpeptidase levels above normal were the independent predictors of CBDS in patients age 70 or younger. On the other hand, an elevated bilirubin level was found to be the single independent factor related to CBDS in the elderly. Conclusions: For patients with gallstones, suggestive ultrasonographic findings in those younger than 71 years and elevated direct or total bilirubin level in those older than 70 years are the most valuable and practical predictors of CBDS, and thus are the proper indications for preoperative endoscopic retrograde cholangiography.

N ekrotizan fasiit; deri, yüzeyel fasya ve deri altı yağ dokusunun akut başlayıp hızla ilerleyen enfeksiyonudur. 1,2 Nadir görülür, ancak deri invazyonunun derinliğine bağlı olarak lokal doku destrüksiyonundan, doku nekrozu ve septik şokla ölüme kadar ilerleyen bu klinik tabloda acil cerrahi ve antibiyoterapi uygulamalarına rağmen mortalite oranı %6-76 arasında değişmektedir. 3 Nekrotizan fasiit perinede (Fournier Gangreni), karın duvarında ve alt ekstremitelerde görülebilmektedir. Jinekolojik ve obstetrik operasyonlardan sonra nadiren görülmekle birlikte, sezaryen, laparoskopi asiste vajinal histerektomi, vajinal histerektomi, abdominal histerektomi, üriner inkontinans operasyonları ve epizyotomi sonrası gelişen olgular bildirilmiştir. 4

Klinik Nütrisyon Ünitesi (KNÜ) ürün hazırlama protokolü verilerine göre, hastane ortamında, hastaya özel Parenteral Nütrisyon (PN) beslenme ürün hazırlama birim ve toplam maliyetleri, fiili ve maksimum kapasiteye göre hesaplanarak, hazır ticari ürün (HTÜ) satın alma birim ve toplam satın alma fiyatları ile karşılaştırılması amaçlanmıştır. G Ge er re eç ç v ve e Y Yö ön nt te em ml le er r: : Araştırma kapsamında 3 adet periferik (A,B,C) ve 3 adet santral (D,E,F) PN ürünleri fiili ve maksimum kapasite ürün birim ve toplam maliyetleri; 2013 yılı verilerine göre, ANEAH KNÜ ürün hazırlama protokolü temel alınarak, tam ve fiili maliyet hesaplama yöntemleri kullanılarak hesaplanmıştır. B Bu ul lg gu ul la ar r: : Yapılan çalışmaya göre; A ürünü hazırlama birim maliyetinin, A hazır ticari ürün satın alma fiyatından düşük olduğu; ancak bunun dışında kalan diğer (B,C,D,E,F) PN ürünlerinde, HTÜ'lerin satın alma birim fiyatlarının daha düşük gerçekleştiği görülmektedir. Fiili kapasitede günlük ortalama 38 PN ürünü hazırlanırken, ANEAH KNÜ maksimum kapasite PN ürün sayısı 96 olmaktadır. Fiili kapasite hastaya özel PN ürün yıllık toplam maliyetinin 495.257,45 ₺ olduğu; maksimum kapasiteye göre hesaplanan ürün birim maliyetlerinin fiili kapasite sayılarına göre toplam maliyeti 411.258,70 ₺ ve fiili kapasite sayılarına göre HTÜ satın alma toplam maliyetinin de 410.948,43 ₺ olduğu görülmüştür. S So on nu uç ç: : Hastaya özel hazırlanan ürünler, HTÜ'lerden daha maliyetli olarak bulunmuştur. Ancak KNÜ'lerinde PN ürün üretim sayılarının artırılması durumunda hastaya özel PN ürün toplam maliyetleri ile HTÜ toplam maliyetleri arasındaki farkın azalacağı görülmektedir. A An na ah ht ta ar r K Ke el li im me el le er r: : Parenteral beslenme; parenteral beslenme solüsyonları; maliyet kontrolü A AB BS ST TR RA AC CT T O Ob bj je ec ct ti iv ve e: : We aimed to compare unit and total cost of Parenteral Nutrition (PN) products that is tailored to the patient in hospital settings and purchase price and total purchase price of premixed multichamber bags according to 2013 product preparation protocol of Ankara Numune Training and Research Hospital (ANERH) Clinical Nutrition Unit (CNU). M Ma at te er ri ia al l a an nd d M Me et th ho od ds s: : According to 2013 compounded parenteral nutrition preparation protocol of ANERH CNU and data of 2013 actual and maximum capacity and the total cost of production unit, 3 peripheral (A,B,C) and 3 central (D,E,F) PN product is prepared. It is calculated with full and actual cost method. R Re e-s su ul lt ts s: : It is found that the unit cost of compounded parenteral nutrition a preparation is cheaper than a premixed multi chamber bags purchase price. But it seems that other PN compounded parenteral nutrition (B, C, D, E, F) costs are cheaper than premixed multichamber bags unit purchase price. When daily average of 38 PN compounded parenteral nutrition is prepared in actual capacity, maximum capacity of compounded parenteral nutrition is 96 in ANERH CNU. It is shown that the total annual cost of the actual capacity of compounded parenteral nutrition which is tailored to patient (495, 257, 45 ₺) is cheaper than the compounded parenteral nutrition unit costs, calculate according to the maximum capacity with the total cost calculate according to the number of actual capacity (411, 258, 70 ₺) and the total cost of buying premixed multichamber bags calculated based on the number of actual capacity (410, 948, 43 ₺). C Co on nc cl lu us si io on n: : Compounded parenteral nutrition that is tailored to the patient is much more costly than premixed multichamber bags. If the number of compounded parenteral nutrition is increased in CNUs unit, the difference between total cost of compounded parenteral nutrition that is tailored to the patient and premixed multichamber bags seems to be decreased.

Rationale: Nutrition information from food labels provides relevant information when prescribing enteral nutrition formulas (ENF). However, the usefulness of these labels depends on the accuracy of the information provided which has been scarcely researched before this study. Methods: Macronutrient and trace element content of 11 ENF were analyzed. Kjeldahl/Dumas, Soxhlet and Enzymatic-Gravimetric AOAC methods (association of official analytical chemists) were used to determine protein, fat, and total dietary fiber respectively. Mineral content was determined by Flame Atomic Absorption Spectroscopy. Results: When measured content variability did not exceed 20% from the one stated on the labels the sample was considered within range. Accuracy of the labels depended greatly on the micronutrient studied, where the percentage of formulas that did not match the label ranged from 0 to 65%, corresponding to Ca and Mn respectively. Depending on the analytical method used to determine protein, the measured content corresponded to the labels. Regarding fiber, only one of the samples did not underestimate its content. Conclusions: These findings show that protein, fat and manganese were prone to be overestimated, while fiber and cupper were underestimated. More independent analysis are needed to assess this matter in order to see if the nutritional effects expected may not be achieved with many of the formulas tested.

Objective: To compare primary repair and grafting with one of two materials (one biological human dura mater, and one synthetic polypropylene mesh) or autologous skin, with primary repair alone in abdominal wall hernias in rats. Design: Randomised experiment. Setting: Teaching hospital, Turkey. Animals: 72 male Wistar albino rats randomised into 4 groups of 18 rats each. These were further randomly divided into subgroups of 6 each that were killed on days 15,30,and 45 postoperatively. Interventions: Each test material was sutured to the abdominal wall by an onlay technique. Main outcome measures: Macroscopic and microscopic appearance, and strength of the abdominal wall. Results: Macroscopically, dura mater grafts lost their original shape, but polypropylene and skin did not. When completely incorporated the skin grafts had developed a new fascia. Dura mater and polypropylene induced a pronounced inflammatory reaction at all three times postoperatively, and there were significantly more fibroblasts in the dura mater group on days 15 and 30, and in the skin graft group on day 45, than in the other groups (p < 0.05). Mechanical resistance and mean breaking strength were significantly greater in the skin graft group than in the other groups at all times tested (p < 0.05). Conclusion: Full thickness autologous skin grafts were stronger than both human dura mater and polypropylene mesh when used to reinforce primary repairs of abdominal wall hernias in rats.