Print ISSN: 0027-1446

Online ISSN: 2309-6217

Main Subjects : Genaral Surgery

Surgical Training of Undergraduate Students at Mosul College of Medicine: A Preliminary Evaluation

Mahmood Sulaiman; Khalaf Alluaizy; waleed ahmad; Abdulsalam Almasry

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 2, Pages 115-122
DOI: 10.33899/mmed.2021.130408.1095

Background: There is an idea  that the level of medical college graduates is less than the expected. The improvement of medical training level for the undergraduates in medical schools need a re-evaluation and improvement  for creation of new training programs including a better  surgical training.
Objective: Is to evaluate the clinical surgical training of undergraduates at College of Medicine , University of Mosul .
Participants and methods: The study carried out at College of Medicine , University of Mosul during the year 2019. The study depends on questionnaire  directed to  46  final year students who recently finished their clinical surgical training, 53 resident doctors  graduated from the same college working among surgical wards, and 50 surgical department teachers and expert surgeons interested in medical education. The questionnaire asked about : does the student gain sufficient knowledge and clinical surgical skills during training, does the training provide safe doctor in work, does the training provide  proper communication skills and ability to work properly in teams, and does the graduate able to gain the confidence of patients and other health workers. The participants score freely their answer in grade extend from 1-10, and asked to add any other notes up on surgical training of students including deleting or adding or any  other suggestion.
Results:  Knowledge gaining mean score by medical students, resident doctors, and  expert surgeons  was 6.9 ±1.45 ,  6.68 ± 1.82 &  6.68 ± 1.95  respectively, while mean score for providing  safe doctor to community was 6.04 ± 1.39 ,   6.52 ± 1.40 &   6.17 ± 1.17  respectively. On the other hand the mean score gaining regarding communication skills and ability to work in teams was  6.30 ± 1.44 ,   6.37 ± 1.41  &  6.59 ± 1.13  respectively, while gaining the confidence of patients and other health workers mean score was  6.47 ± 1.18 ,  6.74± 1.45  and   6.66 ± 0.99  respectively.  In all , there was no significant differences. The clinical surgical skills gaining mean score by medical students , resident doctors and expert surgeons was  6.26± 1.61 ,   4.92 ± 1.70 , and  5.8 ± 1.84  respectively. Which reflect the presence of a significant differences between resident doctors in comparison to students and expert surgeons.
Conclusion: There is lower mean score in gaining clinical surgical skills of graduates and  there is a need for more clinical training, improvement, development of clinical training, and a   re-evaluation of clinical training to improve the quality of medical teaching to get competent graduates.

Huge Biloma in a child with unusual presentation

Professor Samir Ibrahim Hasan AlSaffar

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 76-80
DOI: 10.33899/mmed.2021.129534.1077

The term "biloma" describes a well-demarcated, encapsulated or not, intra-abdominal (extrahepatic or intrahepatic) bile collection outside the biliary tree, secondary to iatrogenic, traumatic or spontaneous rupture of the biliary tree. The clinical symptoms of bilomas are usually nonspecific, ranging from no symptoms to abdominal pain, jaundice, and fever. There were only few cases of huge bilomas in the literature but no report of conincidental extrahepatic and intrahepatic biloma in the same patient.
Case report:
We report herein a 12 years boy with huge biloma (20cm in vertical diameter) after blunt abdominal trauma, presented with unique clinical features of marked emaciation and diffuse abdominal distention . To our knowledge this is the largest biloma ever reported in paediatric age group and the first biloma with such unique clinical presentation, and the first case with both extrahepatic and intrahepatic bilomas in single setting.
Although biloma is rare condition but it needs to be considered in differential diagnosis of diffuse abdominal distension in patients following abdominal trauma or surgery.

Implementing a modified intraoperative grading system for a difficult laparoscopic cholecystectomy

Yarub Momtaz Tawfeek Al-Hakeem; Professor Nashwan Qahtan Mahgoob

Annals of the College of Medicine, Mosul, 2021, Volume 43, Issue 1, Pages 91-99
DOI: 10.33899/mmed.2021.128336.1047


Objective: To analyze intraoperative grading findings during elective laparoscopic cholecystectomy by which we can assess the surgical performance regarding its safety, achievability and to determine a safe operative approach and/or time for conversion.

Design: An observational prospective case series study.

Setting: During the period from June 2018 to January 2020, operations were done by 4 qualified consultant surgeons and their teams at 4 hospitals in Mosul and Erbil.

Participants: Two hundred and fifty-five patients.

Patients and Methods: All patients underwent elective laparoscopic cholecystectomy for symptomatic gallbladder disease after full evaluation and taking their informed consents. An intraoperative difficulty calculation score has been implemented that divide the situation into 4 grades: easy, difficult, very difficult and extremely difficult, depending on the appearance of the gall bladder wall color, amount of adhesion, the presence of anatomical abnormalities, and the ability to achieve the critical view of safety. Perforation of the gallbladder, slipped stones, bleeding, using extra instruments, the need for extending the epigastric incision, the use of a drain and conversion to open procedure as well as the duration of surgical intervention had been recorded as predictors for the assessment of the difficulty level during surgery.

Results: The first grade included 168 (66%) patients, the second grade included 62 (24%) patients, while grades 3 and 4 represent 15 (6%) and 10 (4%) of patients respectively. Perforation showed no significance in the grading. Bleeding was more common in grades 3 and 4. Using accessory equipment was mandatory to complete the operation in grade 4 as well as an extension of epigastric port and the need for putting a drain. Conversion to open cholecystectomy was done in 2 operations (0.7%), both belonged to grade 3 and 4. The time needed to accomplish the operation was significantly high in grades 3 and 4.
Conclusion: This modified grading score can provide a tool for reporting operative findings and technical difficulties during laparoscopic cholecystectomy that allow the surgeon to know the seriousness of the situation and taking effective measures to overcome it.


Saad Muawafaq Attash; Nazar Mohammed Jawhar; Mohammed tahseen yahya; Professor Muzahm K. Al-Khyatt

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 2, Pages 199-206
DOI: 10.33899/mmed.2020.128441.1050

Objectives: To assess the methods of preoperative parathyroid adenoma localization and to compare it with operative findings.
Patients and methods: Between June 2017 and June 2019, we had operated 8 cases of parathyroid adenomas. Three patients were males and 5 patients were females. Age ranged from 26 year old to 72 year old with average of 42 year old. Seven cases were sporadic while one case was part of MEN2a. All patients had ultrasonography for preoperative localization, all had CT scan and 4 patients had Sestamibi scan. In all patients, intraoperative measurements of parathyroid hormone was done before and 10 minutes after surgical excision.
Results: Ultrasonography was successful in localizing only one case with certainty. CT scan located the adenoma in another 2 patients. In 4 patients who performed Sestamibi scan, the adenomas were located precisely in all of them including one case of ectopic parathyroid adenoma behind the sternum. In one patient, all the modalities failed in localization which was achieved easily intraoperatively. Single adenoma was found in 6 patients and two adenomas in two patients. The adenomas were located in the neck in 7 patients and in the anterior mediastinum in one patient .Surgical removal was done through neck incision in 7 cases while midline sternotomy in one case. All the patients had resolution of symptoms within the follow up period.
Conclusion: Sestamibi scan is the best investigation in preoperative localization of parathyroid adenoma. Ultrasonography and CT scan can aid in the diagnosis with less sensitivity. Intraoperative localization is possible even in cases of negative investigations.

Comparative study between sharp dissection and electro cautery dissection in incisional hernia surgery.

Omar Saad Mahmood; khalaf rasheed jadoa

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 2, Pages 169-176
DOI: 10.33899/mmed.2020.128390.1048

Background: Incisional hernia is a common problem in our surgical practice and it poses a challenge due to its high incidence of complications like seroma and surgical site infection (SSI).
The objective of this study is to assess the contribution of diathermy to postoperative seroma formation and wound complications in incisional hernia surgery and also to assess other predictors for wound complications including comorbidities, personal and hernia characteristics.
Patients and Methods: This is a prospective case series study comparing two types of flap dissection in cases of open incisional hernia mesh repair. Sixty patients randomized in to two groups of abdominal flap dissection, one group with electro cautery dissection and other group with sharp dissection by scissors and knife. Surgical procedure was the same between the two groups. Primary outcome measures were postoperative seroma, SSI and wound dehiscence.
Results: There was no significant difference in seroma formation (p=0.738), SSI rate (p=0.641) and wound dehiscence rate (p=0.150) between the electro cautery group and the sharp dissection group. The use of cautery leads to reduction in the intraoperative blood loss (p<0.0001) and operative time (p<0.0001). The relation between body mass index (BMI), diabetes mellitus (DM), hernia length, width and postoperative seroma was highly significant (p=0.002, 0.034, 0.002, Conclusions: The use of cautery instead of scissors during flap dissection does not result in increased postoperative wound complications in incisional hernia patients. The use of cautery lead to reduction in the operative time and intraoperative blood loss. The relation between DM, BMI, hernia defect size and increased rate of wound complications was significant.

Incidentally diagnosed papillary carcinoma in a thyroglossal duct cyst. What is the next step? A case report and review of the literature

Professor Nashwan mahgoob

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 2, Pages 184-189
DOI: 10.33899/mmed.2020.127674.1042

Thyroglossal duct cyst is the commonest congenital disorders of the thyroid gland. Rarely, it can be a malignant tumor which is picked up incidentally in postoperative histopathology. Although management is still a controversy, a careful treatment and follow up planning is necessary for the management of such condition. We present a case of a 16-year-old female patient with thyroglossal duct cyst carcinoma.

Wide local excision and sentinel lymph node biopsy in early breast cancer in Duhok city

Sardar Hassan Arif; Ayad Ahmad Mohammed

Annals of the College of Medicine, Mosul, 2020, Volume 42, Issue 1, Pages 19-26
DOI: 10.33899/mmed.2020.126969.1025

Objectives: Breast conservation surgery widely in form of wide local excision and sentinel lymph node biopsy in the management of patients presenting with early breast cancer.
The aim of this study is to analyze the effectiveness of the of the breast conservation surgery and sentinel lymph node biopsy using the methylene blue dye.
Methods: this retrospective cross sectional study conducted at Nov.2014 – Dec.2019 Ninety-six females Patients with stage I and II breast cancer were included in this, patients with stage III and IV, clinically suspicious axillary lymph nodes, and male patients were excluded from this study.
Injection of methylene blue dye done around the breast mass. Resection of the breast tumor done until negative margins achieved, then dissection of the axilla was done and the stained lymph node or nodes were excised and were sent for frozen section examination, when the result was negative no further axillary dissection were done, but when result was positive we did axillary lymph node dissection.
Results: The current study showed a sensitivity of 93%, specificity of 82%, positive predictive value of 85%, negative predictive value of 92%, and the accuracy of the procedure was 88%.
The most frequent complication was seroma formation and wound infection in 12.5% and 7.3 % respectively, some dye related complications were reported including tattooing of the skin in 10.4% of patients, blue urine in 3.1% of patients and mild allergic reactions in 2% of patients.
Conclusions: The technique of wide local excision and SLN biopsy using the methylene blue dye is safe and effective technique for breast conservation surgery especially in the regions were no facilities are available for the radiolabeled colloid.