Differential diagnosis of groin swellings

•

48 gefällt mir•38,900 views

Groin swelling is one of the commonest problem in general surgical practice. A groin swelling is always considered to be synonymous with a hernia. However this does not always hold true. there are a variety of other causes which present as an groin swelling.Awareness of the diferential diagnosis is therefore essential for aproper diagnosis thus preventing mismanagement. The presentation gives abroad outline of the various conditions depending upon the various areas of the groin from which the swelling arises.

Gesundheit & Medizin Technologie

Differential diagnosis of groin swellings
by

Dr. Ketan Vagholkar
MS, DNB, MRCS, FACS.
Consultant General Surgeon

DD of scrotal swellings
 Skin: boils,sebaceous cysts,
papilomas,warts
 Subcut tissues: lymph scrotum, filariasis
 Tunica vaginalis:
hydrocele,pyocele,haematocele,chylocele.
 Testis: orchitis (acute or
chronic),neoplasms.
 Epididymis: cysts, acute or chronic
infections.
 Spermatic cord: varicocele, lymph varix.

DD of inguinal swellings
 Inguinal hernia
 Lymph nodes
 Encysted hydrocele of the cord
 Undescended testis

DD of inguinoscrotal swellings
 Inguinal hernia
 Hydrocele: encysted hydrocele of the
cord,infantile hydrocele,hydrocele of the
hernial sac.
 Spermatic cord: varicocele,funiculitis,lyph
varix,diffuse lipoma of the
cord,haematoma of the cord.
 Testis: undescended,ectopic testis.

DD of femoral swellings
 Femoral hernia
 Lymph nodes
 Saphena varix
 Ectopic testis
 Psoas abscess

DD of inguinofemoral swellings
 Inguinal lymph nodes
 Distended psoas bursa
 Effusion in the hip joint

Weitere ähnliche Inhalte

Was ist angesagt?

ANDI & benign breast disorders

dileep hoysal

sebaceous cyst

Simply Medics

Inguinal hernia repair

Inguinal hernia

Varicocele

Buerger’s disease

Hydrocele ppt by Dr. Ashok Kumar , LHMC

varicose veins

Dermoid cyst

SCROTAL SWELLING

Breast lumps

Dr. Darayus P. Gazder

FOURNIER'S GANGRENE

Hydrocele

compartment syndrome

NECROTIZING FASCITIS

Ganglion cyst

Abdominal mass

Babylon Medical College

Management of varicose veins RRT

Ranjith Thampi

Obstructive jaundice

Silah Aysha

varicose vein surgery

Yazhini Thamaraiselvan

Was ist angesagt? (20)

ANDI & benign breast disorders

sebaceous cyst

Inguinal hernia repair

Inguinal hernia

Varicocele

Buerger’s disease

Hydrocele ppt by Dr. Ashok Kumar , LHMC

varicose veins

Dermoid cyst

SCROTAL SWELLING

Breast lumps

FOURNIER'S GANGRENE

Hydrocele

compartment syndrome

NECROTIZING FASCITIS

Ganglion cyst

Abdominal mass

Management of varicose veins RRT

Obstructive jaundice

varicose vein surgery

Ähnlich wie Differential diagnosis of groin swellings

Lymphadenopathy

Dr Ndayisaba Corneille

lymphadenopathy-190913090658.pdf

Pratyush Gautam

Sexually transmitted infections

Dr Subodh Shah

OPERATIVES #02 eversion of sac & circumcision.pptx

masoom parwez

Viral keratitis

Dr. Gaurav Shukla

DIAGNOSIS OF A CERVICAL TUMEFACTION - F HERAN

JFIM - Journées Francophones d'Imagerie Médicale

Cervicofacial infection

Arul Lakshmanaperumal

EWMA 2013 - Ep516 - Dermoscopy diagnostic method of microangiopathy in chroni...

EWMA

EWMA 2013 - Ep516 - Dermoscopy diagnostic method of microangiopathy in chroni...

EWMAConference

Scrotal swelling

Alia Syarmila

abdomen wall defects in neonate,exomphalos.ppt

chowhan67

Hydrocele Seminar - A comprehensive review of literature

Harmandeep Jabbal

PSORIASIS

saurav Poudel

03 infectious disease DNA viruses 2

med_students0

Cervical lymphadenitis in the pediatric age group

Erasmus Hospital, ULB

Diseases of the female genital tract

Dr. Varughese George

viral.ppt

Paramesh Gundi

imaging of scrotum [Repaired] [Repaired].pptx

dypradio

8 neck examination

Lama K Banna

03 vascular pathology

med_students0

Ähnlich wie Differential diagnosis of groin swellings (20)

Lymphadenopathy

lymphadenopathy-190913090658.pdf

Sexually transmitted infections

OPERATIVES #02 eversion of sac & circumcision.pptx

Viral keratitis

DIAGNOSIS OF A CERVICAL TUMEFACTION - F HERAN

Cervicofacial infection

EWMA 2013 - Ep516 - Dermoscopy diagnostic method of microangiopathy in chroni...

Scrotal swelling

abdomen wall defects in neonate,exomphalos.ppt

Hydrocele Seminar - A comprehensive review of literature

PSORIASIS

03 infectious disease DNA viruses 2

Cervical lymphadenitis in the pediatric age group

Diseases of the female genital tract

viral.ppt

imaging of scrotum [Repaired] [Repaired].pptx

8 neck examination

03 vascular pathology

Mehr von KETAN VAGHOLKAR

Meckel’s diverticulum in a hernia sac is designated as a Littre’s hernia. It is an uncommon type of hernia. The diagnosis is invariably made at the time of surgery. Resection anastomosis of the adjacent segment of the small bowel with the diverticulum is a contentious issue. A case of Littre’s hernia is reported. A case of Littre’s hernia in a 17-year-old boy is reported to highlight the diagnostic and therapeutic issues confronting the attending surgeon. A short segment resection anastomosis of the small bowel along with the Meckel’s diverticulum was done. A herniorrhaphy was done with no complications. The diagnostic challenges, the dilemma of selecting the best option for removing Meckel’s diverticulum, and the choice of hernia repair are discussed. Littre’s hernia is invariably diagnosed intraoperatively. A short segment resection anastomosis of the adjacent small bowel and Meckel’s diverticulum prevents complications arising due to the diverticulum. A herniorrhaphy for a young patient and the use of an absorbable mesh for other age groups is advisable.

LITTRE’S HERNIA: A SURGICAL DILEMMA

KETAN VAGHOLKAR

Post-traumatic wounds especially after run over accidents are difficult to manage. The vascularity and regenerative potential of the tissues is severely compromised. Surgical intervention is of limited value. A conservative approach with concomitant hyperbaric oxygen therapy (HBOT) serves as a great salvage in such cases. A case of post-traumatic forefoot gangrene in a 27-year-old laborer is presented to highlight and create an awareness of the potential benefit of HBOT in salvage of distal parts of the lower extremity where the blood supply is severely compromised.

Hyperbaric oxygen therapy a boon for complex post traumatic wounds

KETAN VAGHOLKAR

Deep vein thrombosis (DVT) usually affects the deep vein of the legs, though it may also occur in the veins of the arms, mesenteric and cerebral veins. Venous thromboembolism can cause sudden pulmonary embolism with instantaneous death. In patients who have developed deep vein thrombosis there is likelihood of recurrent thrombosis and post thrombotic syndrome. Deep venous thrombosis is preventable in majority of the cases. Understanding the etiopathogenesis, clinical presentation, evaluation and management is essential for both prevention and management thereby reducing the morbidity and mortality associated with the disease.

Deep Vein Thrombosis

KETAN VAGHOLKAR

Background: Fluid collection in a femoral hernia sac designated as a femorocele is an extremely uncommon surgical condition. Till date 9 cases of unilateral femorocele and one case of bilateral femorocele have been reported in English literature. Objective: Thus making the case presented the second case of bilateral femorocele in English literature. Case report: A case of bilateral femorocele in a patient suffering from rheumatic heat disease who had undergone dual valvular replacement with ascites due to cardiac cirrhosis is presented to highlight the surgical challenges in management of such a rare case. Discussion: Pathophysiology, clinical features, investigations and managemeny of femorocele are discussed. Conclusion: Contrast enhanced CT scan of the abdomen and scrotum is diagnostic. Open surgery in the form of dissection of sac with high ligation followed by obliteration of femoral ring is therapeutic. There is no scope of laparoscopy in such a case.

Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis ...

KETAN VAGHOLKAR

Sliding inguinal hernia continues to be the most challenging hernia to treat. Both diagnosis and treatment pose a dilemma to the attending surgeon. Understanding the pathological anatomy of the sliding inguinal hernia is essential for optimal choice of surgical procedure without causing damage to the involved viscera. A case of sliding inguinal hernia is presented to highlight the diagnostic and technical challenges for repair of sliding hernia. Majority of sliding hernias are diagnosed at the time of surgery. Sigmoid colon is a commonest content in a left sided sliding hernia. Bevan’s technique is best suited to deal with the sac followed by Lichtenstein tension-free mesh repair.

Sliding hernia.pdf

KETAN VAGHOLKAR

Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.

Carcinoma of the gall bladder.pdf

KETAN VAGHOLKAR

Fournier’s gangrene is a severe necrotizing fasciitis affecting the scrotum, perianal and perineal region. Development of this condition after inguinal hernia repair is extremely rare. A 54-year-old diabetic male patient who had undergone right inguinal hernia repair in a private clinic presented with severe necrotizing infection of the scrotum, predominantly of the right side. He was referred to our surgical unit. Initial resuscitation followed by broad spectrum antibiotic therapy and aggressive debridement of necrotic tissue followed by closure of scrotum was performed with excellent outcome. The purpose of presenting this case is to create awareness about this complication after hernia repair surgery especially in cases with comorbidities like diabetes mellitus.

Fournier’s gangrene of the scrotum after inguinal hernia repair: case report

KETAN VAGHOLKAR

Hydrocele of the Canal of Nuck (HCN) is a rare condition seen in adult females. Diagnosis of HCN poses a great challenge to the attending surgeon. There are various variants of embryological abnormality of the processes vaginalis manifesting in different forms. Understanding the embryological development of the processes vaginalis and the gubernaculum in female is therefore essential for determining the best surgical option for treating these rare cases.

Hydrocele of Canal of Nuck.pdf

KETAN VAGHOLKAR

Carbuncle is a confluent folliculitis that is infection affecting multiple hair follicles leading to multiple sinuses discharging pus. It is commonly seen on the back of immuno-compromised patients. Admission to hospital with aggressive treatment, both systemic and locally is necessary. Optimisation of co-morbidities such as diabetes, adequate hydration, and antibiotics and are mainstay of initial treatment. Surgical intervention in the form of debridement and desloughing followed by wound care is the next line of management. Patient education at the time of discharge is necessary for prevention of recurrence.

Carbuncle: A challenging infective lesion

KETAN VAGHOLKAR

Cases of self-inserted foreign bodies into the lower urinary tract are uncommon. They are associated with a mental illness called polyembolokoilomania. The site, size and nature of the foreign body determines both the symptomatology and complications. A case of self-inserted needle into the penile urethra by a 15-year-old boy is presented. A plain X-ray of the pelvis revealed the needle. The needle was successfully removed by cystoscopy. Plane X-ray imaging and CT scan are essential to locate the site, size, and nature of the foreign body. Endoscopic approach is preferred in majority cases. Psychiatric counselling in the post-operative period is required to prevent further episodes of reinsertion of such foreign bodies.

Foreign body in the male urethra: case report

KETAN VAGHOLKAR

Introduction: Morel-Lavalleé lesion is an uncommon closed degloving injury usually affecting the lower extremity. Although these lesions have been documented in literature, yet there is no standard treatment algorithm for the same. A case of Morel-Lavallée lesion following blunt injury to the thigh is therefore presented to highlight the diagnostic and therapeutic challenges in managing such lesions. The aim of presenting the case is to create awareness of clinical presentation, diagnosis, and management of Morel-Lavallée lesions, especially in the setting of polytrauma patients. Case Report: A case of Morel-Lavallée lesion in a 32-year-old male with history of a blunt injury to the right thigh caused by a partial run over accident is presented. A magnetic resonance imaging (MRI) was done to confirm the diagnosis. A limited open approach for evacuating the fluid in the lesion was performed followed by irrigation of the cavity with a combination of 3% hypertonic saline and hydrogen peroxide in order to induce fibrosis to obliterate the dead space. This was followed by continuous negative suction accompanied with a pressure bandage. Conclusion: A high index of suspicion is necessary especially in cases of severe blunt injuries to the extremities. MRI is essential for early diagnosis of Morel-Lavallée lesions. A limited open approach is a safe and effective option for treatment. The use of 3% hypertonic saline along with hydrogen peroxide irrigation of the cavity to induce sclerosis is a novel method for treating the condition.

Morel-Lavallée Lesion: Uncommon Injury often Missed

KETAN VAGHOLKAR

Background: The development of a pseudocyst after mesh repair of an incisional hernia is a rare complication. Both diagnosis and management pose a great challenge to the attending surgeon. Therefore, the need to report such an uncommon complication and its management in order to create awareness of this distinct though rare entity. Case report: A pseudocyst formation following an onlay mesh repair of an incisional hernia is reported. Contrast-enhanced CT scan was diagnostic. It revealed a well-formed cyst with no communication with the peritoneal cavity. Complete excision of the cyst was curative. Conclusion: Pseudocyst formation is a rare complication following mesh repair. Contrast-enhanced CT scan is essential for confirming the diagnosis. Complete surgical resection of the cyst is the mainstay of surgical treatment.

ABDOMINAL WALL PSEUDOCYST COMPLICATING INCISIONAL HERNIA REPAIR

KETAN VAGHOLKAR

Background: Traumatic lumbar hernia is due to shearing of bony insertions of the muscle in the lumbar region. In recurrent cases, there is more attenuation of muscles. This makes fixation of the mesh extremely difficult. Hence, the need to develop a new technique. Case report: A 27-year-old male presented with a recurrent post-traumatic right- sided lumbar hernia. He had a severe two wheeler accident. Following the accident he had undergone various surgical interventions for a fractured pelvis with a deglowing injury involving the right gluteal region and upper thigh. He had also developed a post-traumatic lumbar hernia for which he had undergone open mesh repair. Subsequently he developed recurrence of the post traumatic right-sided lumbar hernia. After complete investigation he underwent open mesh repair for the recurrent post traumatic lumbar hernia. The defect was wide and was devoid of healthy surrounding muscles. The mesh was fixed to the ileal bone with bone anchors and to the twelfth rib with trans-osseous fiber sutures passed through holes drilled in the twelfth rib. Flaps were created from the remnant surrounding attenuated muscles. They were double-breasted to cover the mesh. Postoperative outcome was excellent with no recurrence for the last six months. Discussion: The various anatomical and technical considerations of bone fixation of the mesh for hernia repair are discussed. Conclusion: Bone fixation of the mesh with bone anchors is a viable option especially in cases where there is severe attenuation of adjacent muscles for mesh fixation.

Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lum...

KETAN VAGHOLKAR

Background: Acute calculous cholecystitis is one of the commonest biliary tract emergencies. The advent of laparoscopic cholecystectomy has changed the treatment approach from conservative to emergency surgical intervention. As a result, emergency laparoscopic cholecystectomy is emerging as the standard of care. Therefore, the needs to evaluate the various factors that determine the procedure’s safety. Aims: The study aims to evaluate the efficacy and safety of laparoscopic cholecystectomy in acute calculous cholecystitis. Materials and methods: Consecutive patients who underwent laparoscopic cholecystectomy for acute calculous cholecystitis over a 2-year-old period were studied prospectively. Results: 75 patients were evaluated. The mean age was 49.48 years. Majority presented with right hypochondriac pain. 22 patients had hypertension. 26 had diabetes and 6 patients had both hypertension and diabetes. In 61 patients the mean duration of surgery was less than 60 minutes. 5 patients needed conversion to an open procedure. 10 patients developed complications. Mean hospital stay was 4.34 days. Conclusion: Early emergency laparoscopic cholecystectomy is a safe and viable option for treating acute calculous cholecystitis

LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS (STUDY OF 75 CA...

KETAN VAGHOLKAR

Lipoma is one of the most common soft tissue tumor arising from the mesenchyme. It is slow growing, encapsulated, and usually benign in nature. Tumors over the back, shoulder, and neck region have a high propensity to assume large size thereby getting redefined as a giant lipoma when they exceed 10 cm in width or weigh more than 1000 grams. MRI is the investigation of choice for evaluating giant lipomas. Fine needle aspiration cytology (FNAC) or frozen section may be pertinent in suspected cases of liposarcoma. Complete surgical incision is the treatment of choice. A case of a giant lipoma on the back of a 64-year-old lady is presented with a view to revisit conceptual understanding of the clinical evaluation, investigation, and management of giant lipomas.

Giant lipoma over the back

KETAN VAGHOLKAR

Background: Appendicectomy is one of the common procedures performed by a general surgeon. However, the advent of laparoscopic appendicectomy has reduced the number of open appendicectomies performed. Therefore there is a need to study the advantages of the laparoscopic approach over the traditional open approach. Aims: The study aimed to compare laparoscopic appendicectomy with open appendicectomy based on various intraoperative and postoperative parameters Materials and methods: 50 patients undergoing interval appendicectomy were randomised into two groups. Group A comprised 25 patients who underwent laparoscopic appendicectomy and group B comprised 25 patients who underwent open appendicectomy. Results: Confirmation of diagnosis and evaluation of intraoperative findings was easier in group A patients. In addition, early commencement of feeds with early bowel movements, reduced need for postoperative analgesia due to less pain, lesser complications and shorter duration of hospital stay was observed in group A patients. Conclusion: Laparoscopic appendicectomy has better outcomes rendering it a preferable procedure for appendicectomy.

LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)

KETAN VAGHOLKAR

Background: The incidence of abdominal tuberculosis is increasing. Preoperative diagnosis continues to be the biggest challenge. Diagnosis is established only after histopathological examination. The modes of presentation and therapeutic options need to be assessed. Objectives: To study the patterns of presentations, the extent of organ involvement and therapeutic options. Materials and methods: Fifty histopathologically proven cases of abdominal tuberculosis were studied. In addition, epidemiologic data, clinical patterns of presentation, diagnostic and various surgical options, including outcomes, were studied. Results: The mortality in the study was 8%. The disease was commonly seen in 21 to 40 years old and commonly seen in females. HIV positivity, anaemia and hypoproteinaemia were associated with poor outcomes. Four types of presentations were observed. Diagnostic laparoscopy enabled early histopathological diagnosis of biopsy specimens. Chemotherapy is the mainstay of treatment Surgery is a significant adjunct in diagnosing and managing complications. Patients presenting with perforative peritonitis had a poor prognosis Conclusion: Critical evaluation of chronic abdominal pain is essential. Supportive evidence such as the history of TB or contact with a patient suffering from TB is highly suggestive of abdominal tuberculosis. Radiological tests are highly suggestive but not diagnostic. Diagnostic laparoscopy enables tissue diagnosis. Chemotherapy accompanied by surgical intervention for complications is the mainstay of treatment.

ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)

KETAN VAGHOLKAR

Background: Perforative peritonitis poses a significant diagnostic and therapeutic challenge to the attending surgeon. Delay in diagnosis followed by sub-optimal treatment may lead to many complications, thereby increasing both morbidity and mortality. This is by virtue of various factors which affect the prognosis. Hence the need arises to identify these prognostic factors. Aims and Objectives: To study the various etiological factors of perforative peritonitis and to identify prognostic factors and comorbid conditions which influence the outcome in perforative peritonitis. Materials and Methods: 50 patients with an established diagnosis of perforative peritonitis due to various aetiologies confirmed by clinical and radiological investigations were included in the study and studied prospectively. On admission to the hospital, various haematological and radiological investigations were conducted to confirm the diagnosis. Patients subsequently underwent surgical intervention. Postoperative recovery and outcomes assessed. Results were tabulated and statistically analysed. Results: The mean age of patients in the study was 36.5 ±5 years. Patients who presented in an advanced stage developed complications. The majority of patients were males. The interval between the onset of symptoms and operative intervention was directly related to postoperative complications. Pneumoperitoneum was the most common x-ray finding, followed by dilated bowel loops with free fluid in the peritoneal cavity as the most common ultrasonography finding. Tachycardia and oliguria, which were markers of the severity of the disease process, were associated with an increased rate of complications. Peptic ulcer perforation was the most common, followed by perforations caused by infective aetiology. Perforations caused by infective aetiology had a higher rate of complication. Primary closure of the perforation was the most commonly performed procedure. Significant abdominal contamination found intraoperatively contributed to a negative outcome, as were comorbid conditions, which also increased the complication rate significantly. Conclusion: Delayed intervention after the onset of symptoms, tachycardia, oliguria and comorbidities are associated with a higher complication rate. Radiological investigations help in confirming the diagnosis. Infective aetiology of the perforation and extensive peritoneal contamination was associated with higher complication rates. Prompt and aggressive resuscitation on admission, optimum antibiotic administration, and early meticulous surgical intervention can reduce morbidity and mortality to a bare minimum.

PERFORATIVE PERITONITIS: CONTINUING SURGICAL CHALLENGE.(PROSPECTIVE STUDY OF ...

KETAN VAGHOLKAR

Background: Skin approximation is a very important step in a surgical operation. The quality of skin approximation affects the quality of the scar. Traditional skin suturing is associated with quite a few wound complications. Staple approximation is an innovative alternative with good results. Aim: The aim of the study is to compare traditional suturing of skin edges versus staple approximation and to evaluate the impact of these techniques on wound complications such as pain, surgical site infections, scarring and patient satisfaction. Materials and methods: 150 patients are included in the study and divided into two groups. Group A (skin suturing) and group B (staple approximation). The effect of the technique on wound healing is evaluated. Results: Patients belonging to group B (staple approximation) had less pain, shorter skin closure duration, no wound complications, fine scarring and greater patient satisfaction. Conclusion: Staple approximation of skin edges during the closure of laparotomy incisions is recommended.

COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...

KETAN VAGHOLKAR

Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively. Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60 years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B. The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic requirement, early commencement of oral feeds, and shorter duration of hospitalization

COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...

KETAN VAGHOLKAR

Mehr von KETAN VAGHOLKAR (20)

LITTRE’S HERNIA: A SURGICAL DILEMMA

Hyperbaric oxygen therapy a boon for complex post traumatic wounds

Deep Vein Thrombosis

Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis ...

Sliding hernia.pdf

Carcinoma of the gall bladder.pdf

Fournier’s gangrene of the scrotum after inguinal hernia repair: case report

Hydrocele of Canal of Nuck.pdf

Carbuncle: A challenging infective lesion

Foreign body in the male urethra: case report

Morel-Lavallée Lesion: Uncommon Injury often Missed

ABDOMINAL WALL PSEUDOCYST COMPLICATING INCISIONAL HERNIA REPAIR

Novel Technique for Mesh Fixation to the Bone in Recurrent Post Traumatic Lum...

LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CALCULOUS CHOLECYSTITIS (STUDY OF 75 CA...

Giant lipoma over the back

LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY IN ADULTS. (STUDY OF 50 CASES)

ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)

PERFORATIVE PERITONITIS: CONTINUING SURGICAL CHALLENGE.(PROSPECTIVE STUDY OF ...

COMPARISON BETWEEN SUTURING AND STAPLE APPROXIMATION OF SKIN IN ABDOMINAL INC...

COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...

Kürzlich hochgeladen

Call Girls Bareilly Just Call 8250077686 Top Class Call Girl Service Available Easy & Fast Booking Procedure Of Bareilly Escorts Call girls are ready and waiting to provide the quality essentialness that will help ease away life's tensions Bareilly Escorts are regular companions of elite gentlemen and can take them places they could only dream of visiting. These ladies take great care in maintaining themselves to look appealing; visiting salons and spas regularly keeps them looking their best; their portfolios can be found online via an escort’s agency website. EXCITING OPTIONS AVAILABLE AT OUR INDEPENDENT ESCORTS Candlelight dinner Evening date Night clubs or parties Hotels or your flats Business trip Business party Stripping party Bareilly Escort Service are adept at performing wild anal sex, deep throat sex and cum eating - perfect for satisfying all your sexual needs and playing any game imaginable. Affordable professional assistants are readily available and ready to assist with any situation - be it romantic date or solo night. Their beautiful appearances and striking personalities will leave you speechless, while they can accompany you to restaurants or bars where their presence will surely leave an impression.

Call Girls Bareilly Just Call 8250077686 Top Class Call Girl Service Available

Dipal Arora

Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine Sex Service At Affordable Rate Booking Contact Details WhatsApp Chat: +91-6297143586 Hyderabad Escort Service includes providing maximum physical satisfaction to their clients as well as engaging conversation that keeps your time enjoyable and entertaining. Plus they look fabulously elegant; making an impressionable Independent Escorts Hyderabad understands the value of confidentiality and discretion - they will go the extra mile to meet your needs. Simply contact them via text messaging or through their online profiles; they'd be more than delighted to accommodate any request or arrange a romantic date or fun-filled night together. We provide - Flexibility Choices and options Lists of many beauty fantasies Turn your dream into reality Perfect companionship Cheap and convenient In-call and Out-call services And many more. 02-May(Ast)

Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...

chandars293

Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available Easy & Fast Booking Procedure Of Coimbatore Escorts Call girls are ready and waiting to provide the quality essentialness that will help ease away life's tensions Coimbatore Escorts are regular companions of elite gentlemen and can take them places they could only dream of visiting. These ladies take great care in maintaining themselves to look appealing; visiting salons and spas regularly keeps them looking their best; their portfolios can be found online via an escort’s agency website. EXCITING OPTIONS AVAILABLE AT OUR INDEPENDENT ESCORTS Candlelight dinner Evening date Night clubs or parties Hotels or your flats Business trip Business party Stripping party Coimbatore Escort Service are adept at performing wild anal sex, deep throat sex and cum eating - perfect for satisfying all your sexual needs and playing any game imaginable. Affordable professional assistants are readily available and ready to assist with any situation - be it romantic date or solo night. Their beautiful appearances and striking personalities will leave you speechless, while they can accompany you to restaurants or bars where their presence will surely leave an impression.

Call Girls Coimbatore Just Call 9907093804 Top Class Call Girl Service Available

Dipal Arora

Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl In 5 Star Hotel Service Available Booking Contact Details WhatsApp Chat: +91-8617370543 Guwahati Escort Service includes providing maximum physical satisfaction to their clients as well as engaging conversation that keeps your time enjoyable and entertaining. Plus they look fabulously elegant; making an impressionable Independent Escorts Guwahati understands the value of confidentiality and discretion - they will go the extra mile to meet your needs. Simply contact them via text messaging or through their online profiles; they'd be more than delighted to accommodate any request or arrange a romantic date or fun-filled night together. We provide - Flexibility Choices and options Lists of many beauty fantasies Turn your dream into reality Perfect companionship Cheap and convenient In-call and Out-call services And many more.

Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...

Dipal Arora

Bangalore Call Girls Nelamangala Number 9332606886 Meetin With Bangalore Escorts Booking Contact Details Whatsapp Chat :+91-9332606886 These professional and Call girls in Bangalore can satisfy your every desire - be it sensual massage or an erotic shower, they are always more than willing to meet them. Furthermore, they pay close attention to body language cues to ensure you enjoy every minute spent in their company - both in-call and outcall services are offered. Is an excellent choice for anyone seeking an exciting and thrilling night of fun and excitement The Oberoi, Bengaluru Taj West End The Leela Palace Bengaluru JW Marriott Hotel Bengaluru The Ritz-Carlton, Bangalore Sheraton Grand Bangalore Hotel at Brigade Gateway Conrad Bengaluru ITC Gardenia, Bengaluru Renaissance Bengaluru Race Course Hotel The Lalit Ashok Bangalore 27 apr 24 (LK)

Bangalore Call Girls Nelamangala Number 9332606886 Meetin With Bangalore Esc...

narwatsonia7

Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night girls hear seeking Navi Mumbai Escorts I’m sweet , warm , beautiful and friendly, independent escort girl. My body is sexy and natural. All my pictures are recent and real. InCall and outcalls as well offer class and good service. Don’t hesitate to contact me, message me on whatssap. I’m waitting for you We Are Provide Escorts Service All OYO Hotels ,3*,4*,5* Star Hotel And Home Flat, Apartment. Guest-House. Services In -Call And Out – Call Both Are Services Available. 24Hrs. Any Time Any Where Call Whatsapp, +91-◖9833363713 ◗ Our Services and Rates: – – In call Shot 1500 Out Call Short 2000 : – In call Night 6000 Out Call Night 7000 Minimum To Maximum Range Available Only Serious And Genuine Persons Can Contact Us : +91-◖9833363713 ◗ More Information And Contact Profile Real Pic Visit Our Website City Wise Escorts Service Agency. Good Looking Cheap And Best Models Girls U Can Get Best Click On Link

Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...

aartirawatdelhi

The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Miss This Chance Of Getting Into My Sexy Boobs? Booking Contact Details WhatsApp Chat: +91-6297143586 Hyderabad Escort Service includes providing maximum physical satisfaction to their clients as well as engaging conversation that keeps your time enjoyable and entertaining. Plus they look fabulously elegant; making an impressionable Independent Escorts Hyderabad understands the value of confidentiality and discretion - they will go the extra mile to meet your needs. Simply contact them via text messaging or through their online profiles; they'd be more than delighted to accommodate any request or arrange a romantic date or fun-filled night together. We provide - Flexibility Choices and options Lists of many beauty fantasies Turn your dream into reality Perfect companionship Cheap and convenient In-call and Out-call services And many more. 01-May(Ast)

The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...

chandars293

EXPLORE THE BEST ESCORT SERVICE IN HARIDWAR These days people are very engaged with their hectic life timetable. Some are busy with the stress and hectic schedule in the office, while others have a partner but don't feel the same excitement as before. But don't worry; our sexy escort service in Haridwar is here to bring excitement back to your life. Luxury Escort Service is the best place to get some busty, sizzling, hot escorts who can help you relish all the moments and make the night unforgettable. We are one of the faithful escort agencies in Haridwar that provide escort services in Haridwar to the customers in the best practices. We apprehend that you need somebody who can listen to you and share some quality time with you, not being judgemental. Your privacy and hesitation are understandable while booking the Escort, but you can trust us as we have many clients who reach out to us repeatedly. You are at the right place if you are searching for a trustworthy and cheap escort service in Haridwar. Luxury Escort Service in Haridwar is the best place to get some seductive and hot escort girls service who can help you enjoy all the moments and make the night even more special. Vast numbers of independent escorts are working across Haridwar all day and night to make their clients happy as never before. If you feel so alone or get disheartened from the hectic life schedules, then nothing is better than having a mate who can give you a token of new love. Don't Worry, Guys; we are here for you. We are a highly demanded Luxury Escort Service in Haridwar that provides all types of escort services. We have top Haridwar models in Haridwar, highly sexy housewives in Haridwar, hot college girls in Haridwar, and beautiful independent escort girls in Haridwar to serve you with a sensual time that is matchless to all your unique experiences in life. Many escort agencies in Haridwar provide escort services in the market, but we have been operating in the industry for eight years to till date. We served Our Independent Escort Service to approximately 10000+ satisfied clients in Haridwar. Unlike other escort service companies in Haridwar, we give the client to mention their requirements and desires to cater to them with the best escort service in Haridwar.

College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...

perfect solution

Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine Sex Service At Affordable Rate Booking Contact Details Whatsapp Chat :+91- 9332606886 These professional and Call girls in Bangalore can satisfy your every desire - be it sensual massage or an erotic shower, they are always more than willing to meet them. Furthermore, they pay close attention to body language cues to ensure you enjoy every minute spent in their company - both in-call and outcall services are offered. Is an excellent choice for anyone seeking an exciting and thrilling night of fun and excitement The Oberoi, Bengaluru Taj West End The Leela Palace Bengaluru JW Marriott Hotel Bengaluru The Ritz-Carlton, Bangalore Sheraton Grand Bangalore Hotel at Brigade Gateway Conrad Bengaluru ITC Gardenia, Bengaluru Renaissance Bengaluru Race Course Hotel The Lalit Ashok Bangalore 30 apr 24 (LK)

Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...

narwatsonia7

💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Available ) Full Fun With Sex Booking Contact Details WhatsApp Chat: +91-7001035870 Escort Service in Kolkata | 369+ call girls book @₹6k-₹18k/full night cash Hi, I am Taniya Sharma. My age is 25 year old , an independent call girl in Kolkata. I love sex and I'm the only girl in your city that can satisfy you completely. I also provide this service at a very low rate.No Advance Payment Genuine Low Price Kolkata Cash Payment Fully Medically Fit & Competent Girl I am. Book Your GF | FOR BOOKING CALL Our All Services 1 ) ★ (Oral to consummation) bjnonCovered 2 ) ★ Special Massage 3 ) ★ O-Level (Oral sex) 4 ) ★ Blow Job; 5 ) ★ COB (Come On Body) 6 ) ★. Extraball (Have sex ordinarily) 7 ) ★ A-Level (5 star escort) 8 ) ★ Strip-bother 9 ) ★ BBBJ (Bareback Blowjob) 10 ) ★ Spending time in my rooms 11 ) ★ BJ (Blowjob Without a Condom) 12 ) ★ COF (Come On Face) 13 ) ★ Completion

💎VVIP Kolkata Call Girls Parganas🩱7001035870🩱Independent Girl ( Ac Rooms Avai...

Taniya Sharma

Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 Star Hotel Service Available Booking Contact Details WhatsApp Chat: +91-8617370543 Patna Escort Service includes providing maximum physical satisfaction to their clients as well as engaging conversation that keeps your time enjoyable and entertaining. Plus they look fabulously elegant; making an impressionable Independent Escorts Patna understands the value of confidentiality and discretion - they will go the extra mile to meet your needs. Simply contact them via text messaging or through their online profiles; they'd be more than delighted to accommodate any request or arrange a romantic date or fun-filled night together. We provide - Flexibility Choices and options Lists of many beauty fantasies Turn your dream into reality Perfect companionship Cheap and convenient In-call and Out-call services And many more.

Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...

Dipal Arora

Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service Booking Contact Details Whatsapp Chat :+91-7001035870 These professional and Call girls in Bangalore can satisfy your every desire - be it sensual massage or an erotic shower, they are always more than willing to meet them. Furthermore, they pay close attention to body language cues to ensure you enjoy every minute spent in their company - both in-call and outcall services are offered. Is an excellent choice for anyone seeking an exciting and thrilling night of fun and excitement The Oberoi, Bengaluru Taj West End The Leela Palace Bengaluru JW Marriott Hotel Bengaluru The Ritz-Carlton, Bangalore Sheraton Grand Bangalore Hotel at Brigade Gateway Conrad Bengaluru ITC Gardenia, Bengaluru Renaissance Bengaluru Race Course Hotel The Lalit Ashok Bangalore 29 apr 24 (LK)

Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service

vidya singh

Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl In 5 Star Hotel Service Available Booking Contact Details WhatsApp Chat: +91-8250192130 Hyderabad Escort Service includes providing maximum physical satisfaction to their clients as well as engaging conversation that keeps your time enjoyable and entertaining. Plus they look fabulously elegant; making an impressionable Independent Escorts Hyderabad understands the value of confidentiality and discretion - they will go the extra mile to meet your needs. Simply contact them via text messaging or through their online profiles; they'd be more than delighted to accommodate any request or arrange a romantic date or fun-filled night together. We provide - Flexibility Choices and options Lists of many beauty fantasies Turn your dream into reality Perfect companionship Cheap and convenient In-call and Out-call services And many more. 29-Apr(Ast)

Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...

astropune

Call Girls Ooty Just Call 8250077686 Top Class Call Girl Service Available Easy & Fast Booking Procedure Of Ooty Escorts Call girls are ready and waiting to provide the quality essentialness that will help ease away life's tensions Ooty Escorts are regular companions of elite gentlemen and can take them places they could only dream of visiting. These ladies take great care in maintaining themselves to look appealing; visiting salons and spas regularly keeps them looking their best; their portfolios can be found online via an escort’s agency website. EXCITING OPTIONS AVAILABLE AT OUR INDEPENDENT ESCORTS Candlelight dinner Evening date Night clubs or parties Hotels or your flats Business trip Business party Stripping party Ooty Escort Service are adept at performing wild anal sex, deep throat sex and cum eating - perfect for satisfying all your sexual needs and playing any game imaginable. Affordable professional assistants are readily available and ready to assist with any situation - be it romantic date or solo night. Their beautiful appearances and striking personalities will leave you speechless, while they can accompany you to restaurants or bars where their presence will surely leave an impression.

Call Girls Ooty Just Call 8250077686 Top Class Call Girl Service Available

Dipal Arora

(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Celebrity for 5* Hotels Booking Details Are here 05-May-2024( Mj) Click On WhatsApp Chat +91-8445551418 Jaipur Escorts Make You Feel Like Royalty Jaipur Escorts catering to high profile clients are available 24-7 to meet their clients' needs and are also available for dinner dates, business conferences, foreign travel trips and clubbing activities. Their customers are contacted directly through in order to prevent risky situations from developing.is home to some of India's most beautiful women. These girls come highly educated with great backgrounds; furthermore they are extremely beautiful and will make you feel like royalty if hired for hours or days! Siya Khan | FOR BOOKING CALL Our All Services :- 1 )★ (Oral to consummation) bjnonCovered 2 )★ Special Massage 3 )★ O-Level (Oral sex) 4 )★ Blow Job; 5 )★ COB (Come On Body) 6 )★. Extraball (Have sex ordinarily) 7 )★ A-Level (5 star escort) 8 )★ Strip-bother 9 )★ BBBJ (Bareback Blowjob) 10 )★ Spending time in my rooms 11 )★ BJ (Blowjob Without a Condom) 12 )★ COF (Come On Face) 13 )★ Completion

(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...

parulsinha

Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Available Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Available Easy & Fast Booking Procedure Of Bhubaneswar Escorts Call girls are ready and waiting to provide the quality essentialness that will help ease away life's tensions Bhubaneswar Escorts are regular companions of elite gentlemen and can take them places they could only dream of visiting. These ladies take great care in maintaining themselves to look appealing; visiting salons and spas regularly keeps them looking their best; their portfolios can be found online via an escort’s agency website. EXCITING OPTIONS AVAILABLE AT OUR INDEPENDENT ESCORTS Candlelight dinner Evening date Night clubs or parties Hotels or your flats Business trip Business party Stripping party Bhubaneswar Escort Service are adept at performing wild anal sex, deep throat sex and cum eating - perfect for satisfying all your sexual needs and playing any game imaginable. Affordable professional assistants are readily available and ready to assist with any situation - be it romantic date or solo night. Their beautiful appearances and striking personalities will leave you speechless, while they can accompany you to restaurants or bars where their presence will surely leave an impression.

Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...

Dipal Arora

Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi { J R P} 27-04-2024 Delhi Call Girls Service provide for both you and your partner.📞📞 🔝9711199012 You will be offered varied sex positions and techniques. Your location call girl will fulfil all your sexual fantasies. She will also accommodate other erotic requests, including sex-related ones. The result will be an unforgettable experience. You should always remember that it takes time to master new erotic pleasure. But perseverance pays off! OUR SERVICES RATE: – let you know the our Call girls price in Delhi are very affordable and Best rate in genuine market of Call girls. But as all you knows that Quality has comes with its own Price tag. We provide -Anal Sex,Sex without Condom, Girlfriend tour, Oral sex, Exciting body massage Anal, Blowjob, Handjob, Kissing ,(French kiss also) Flexibility, Choices and options, Lists of many beauty fantasies, Turn your dream into reality, Perfect companionship, Cheap and convenient, In-call and Out-call services, And many more., One Shot — 5000/in call (time 1 hour), 6000/out call Two shot with one girl — 8000/in call (time 2 hour), 10000/out call Body to body massage with sex- 8000/in call (time 1 hour) Full night Service for one person– 12000/in call, 13000/out call (shot limit 3-4 shots) "T" Vip Call Girls {[ Delhi ]}✌️Independent Escort Models 💕 Hot Model's ➡️ Parul Desai 📞📞 "Delhi"Call Girls In India's Finest Models Rate 9999/- "B" Call Girls Delhi ✌️Independent Escort Service 💕 Hot Model's ➡️ High Profile Call Girls Dhaula Kuan Delhi Maya ➡️ 💋Independent Escort📞 🌍Hot Fantasy🌍 Hot Models Call Girls Shankar Vihar Delhi" 🚀 Delhi Escorts ꧁❤ ❤꧂ ☎️ Hard And Sexy Vip Call Dolly ➡️ Vip Call Girls In CGO Complex Delhi ❤️ No Advance Payments ➡️ ❤️ 😘 DATY (Dinner At The Y)

Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi

AlinaDevecerski

VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts 🔝 9256729539🔝✔️✔️ One shot: ₹2000/in-call, ₹5000/out-call Two shots with one girl: ₹3500 /in-call, ₱6000/out-call Body to body massage with sex: ₱3000/in-call Full night for one person: ₱7000/in-call, ₱10000/out-call Full night for more than 1 person : Contact us at 9256729539. for details Operating 24/7, we serve various locations in Indore. For premium call girl services in Indore 9256729539. Thank you for considering us !

VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts

aditipandeya

Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available Easy & Fast Booking Procedure Of Gwalior Escorts Call girls are ready and waiting to provide the quality essentialness that will help ease away life's tensions Gwalior Escorts are regular companions of elite gentlemen and can take them places they could only dream of visiting. These ladies take great care in maintaining themselves to look appealing; visiting salons and spas regularly keeps them looking their best; their portfolios can be found online via an escort’s agency website. EXCITING OPTIONS AVAILABLE AT OUR INDEPENDENT ESCORTS Candlelight dinner Evening date Night clubs or parties Hotels or your flats Business trip Business party Stripping party Gwalior Escort Service are adept at performing wild anal sex, deep throat sex and cum eating - perfect for satisfying all your sexual needs and playing any game imaginable. Affordable professional assistants are readily available and ready to assist with any situation - be it romantic date or solo night. Their beautiful appearances and striking personalities will leave you speechless, while they can accompany you to restaurants or bars where their presence will surely leave an impression.

Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available

Dipal Arora

♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl 100% Genuine Please Contact Me Booking Contact Details WhatsApp Chat: +91-7001035870 Hyderabad Escort Service includes providing maximum physical satisfaction to their clients as well as engaging conversation that keeps your time enjoyable and entertaining. Plus they look fabulously elegant; making an impressionable Independent Escorts Hyderabad understands the value of confidentiality and discretion - they will go the extra mile to meet your needs. Simply contact them via text messaging or through their online profiles; they'd be more than delighted to accommodate any request or arrange a romantic date or fun-filled night together. We provide - Flexibility Choices and options Lists of many beauty fantasies Turn your dream into reality Perfect companionship Cheap and convenient In-call and Out-call services And many more. 29-Apr(Ast)

♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...

astropune

Kürzlich hochgeladen (20)