Dr. Tonmoy Baroi Presentation Final.pptx

Dr. Tonmoy Baroi Presentation Final

1. Welcome to Thesis Protocol Presentation 1

2. Proposed Title Open Rives- Stoppa versus Onlay Technique i n The Treatment of Ventral Hernias 2

3. Presented by Dr. Tonmoy Baroi MS Resident (Phase-B) Department of Surgery Sylhet MAG Osmani Medical College Hospital, Sylhet 3

4. Guide Dr. Kazi Zana Alam Associate Professor, Department of Surgery Sylhet MAG Osmani Medical College, Sylhet 4

5. Co-Guide Dr. Azizur Rahman Associate Professor, Department of Surgery Sylhet MAG Osmani Medical College, Sylhet 5

6. Introduction Hernias of the anterior abdominal wall, or ventral hernias, represent defects in the parietal abdominal wall fascia and muscle through which intra-abdominal or preperitoneal contents can protrude . Ventral hernias may be primary or secondary. Primary ventral hernia includes umbilical, paraumbilical , epigastric , spigelian and secondary includes incisional , parastomal hernias. 6

7. Cont… The Incidence and prevalence of ventral hernia increased dramatically in recent years. An estimated one-quarter of all individuals are either born with or will develop a ventral hernia in their lifetimes. Primary ventral hernias occur in approximately one in five adults, and Secondary ventral hernias develop in 10-30 % (Gilles et al., 2023). 7

8. Ventral hernias is more common in females than in males. Overall the male to female ratio was 4:1 and incisional hernias is even more common in females but umbilical hernias is more frequent among males (Gaur & Sharma 2022 ). 8 Cont…

9. Surgery mainly the treatment of all hernias. There are various operative procedure for ventral hernia but the most frequently used methods are the Onlay and Sublay repairs . In Onlay repair mesh is placed between subcutaneous tissues of abdominal wall and anterior rectus sheath. Its advantages include greater technical ease of implementation and shorter operative time. 9 Cont…

10. Its main disadvantages is the higher rates of clinically detectable seroma and surgical site infection. It is worth mentioning that the close contact of the mesh with the skin in very thin patients or in the areas of reduced subcutaneous cellular tissue, can favor its erosion ( Rodrigues et al., 2023). 10 Cont…

11. Rives- S toppa is one of the S ublay mash repair techniques. This procedure was first described by Renestopa , Jean Rives and George Wantz . This technique is considered by many surgeons to be the gold standard for the open repair of abdominal hernias and this technique is an effective repair with favorable outcomes and low morbidity. 11 Cont…

12. The posterior rectus sheath dissection provides release of the rectus muscle and a well- vascularised area for mesh placement. This technique is increasingly becoming the world’s standard approach for the repair of ventral hernias. 12 Cont…

13. Because of its durability and long-term outcomes in addition to the fact that mesh is excluded from the visceral contents and thus does not pose a problem for future abdominal surgery. In open Rives- S toppa , mesh is placed between the rectus muscle and the posterior rectus sheath. 13 Cont…

14. In this technique, mesh lies quite deep so there is less chance of infection transmission, seroma formation and recurrence. However , it has certain drawbacks including greater technical difficulties, longer recovery times and the requirement for experienced surgeons to follow the technical guidelines in order to achieve better outcomes (Kumar et al ., 2023 ). 14 Cont…

15. Operative time depends on anatomical delineation, variation in technical skills, surgeon’s experience and expertise. Study conducted by, Rodrigues et al . ( 2023 ) in Brazil found that mean operative time in Rives- Stoppa is significantly higher than Onlay whereas study conducted by Kumar et al. (2022 ) in India found there is no significant difference in operative time between Onlay and Rives- Stoppa . 15 Cont…

16. In Rives- Stoppa the difference of time can be accounted due to more dissection time needed for creating retromuscular space. Securing reasonable hemostasis is another burden on time. 16 Cont…

17. Seroma is most common early post-operative complications in ventral hernia surgery. Development of seroma after both the procedure is due to broad dissection of subcutaneous tissue during operation and there is tight contact of foreign body (mesh) to the subcutaneous tissue. 17 Cont…

18. Rate of Seroma formation significantly higher in Onlay than Rives- Stoppa (Khawaja, et al., 2023) whereas Studies conducted by Kumar et al. (2013) in India found more chance of seroma formation in Rives- Stoppa . 18 Cont…

19. Hematoma and SSI is an important cause of mesh migration and recurrence. Different study showed that less chance of hematoma and SSI in Rives- stoppa group. High incidence of SSI after using Onlay method due to superficial localization of mesh and facilitated colonization of bacteria in the area. 19 Cont…

20. Studies conducted by Khawaja et al. (2023 ) in Pakistan found more chances of hematoma and SSI in Onlay technique whereas studies conducted by Demetrashvili et al. (2017 ) in Georgia found no significant difference in terms of Hematoma and SSI. 20 Cont…

21. Recurrence is the most important determinant for success in ventral hernia surgery. The anatomic position of the mesh placement has an impact on tissue reaction, tissue incorporation, and tensile strength of the abdominal wall . These are the influencing factors for hernia recurrence. Study conducted by Demetrashvili et al. (2017) in Georgia 21 Cont…

22. found that recurrence in Onlay significantly higher than in Rives- stoppa mesh repair. Whereas studies conducted by Weber et al. (2010) found higher chance of hernia recurrence in Rives- Stoppa than Onlay mesh repair. 22 Cont…

23. From above background knowledge it has been seen that, there is variation of results and controversy still persists between Onlay and Rives- stoppa regarding which one is better procedure to repair ventral hernia. So the present study aims to compare the short term outcome between Onlay and Rives- stoppa . 23 Cont…

24. Rationale Ventral hernias are one of the most common surgical problems. The repair of ventral hernias has always been a big challenge to the surgeons. Onlay and Sublay (Rives- Stoppa ) are two very commonly done procedure. But Both the procedure have some complications such as recurrence rates, SSI and seroma formation. Studies done on this regards has conflicting results and there are some unclarified 24

25. issues remaining regarding the ideal approach for ventral hernia repair. This encourage me to compare the open Rives- Stoppa versus Onlay techniques in ventral hernia repair in our facility for ensure better management of ventral hernia. 25 Cont…

26. Research Question Does Open Rives- Stoppa has better outcome than Onlay Technique in Ventral hernia surgery? 26

27. Hypothesis Open Rives- Stoppa has better outcome than Onlay Technique in ventral hernia surgery. 27

28. Objectives General Objective: To compare the outcomes between Open Rives- Stoppa and Onlay Technique in Ventral hernia repair. 28

29. Specific Objective : To record and compare the following outcomes of Open Rives- Stoppa and Onlay . 1. Operative time 2. Hematoma 3. Seroma 4. SSI 5. Early Recurrence 29

30. Methodology Study design It will be a Quasi- experimental s tudy. Study period Two year (from October 2023 to September 2025). Study place: This study will be carried out in the Department of Surgery at Sylhet MAG Osmani Medical College Hospital, Sylhet . 30

31. Population : All patients with Ventral hernia . Sample: Patients who will undergo Ventral hernia repair surgery during the study period fulfilling the selection criteria in the Department of Surgery, SOMCH. Sampling technique: Convenient sampling. 31

32. Selection criteria Inclusion criteria: 1. Age 18 to 65 years . 2. Both primary and secondary ventral wall hernias . 32

33. Exclusion criteria: 1 . Small ventral wall hernias (defect less than 2 cm ) 2 . Large ventral wall hernias (defect greater than 10 cm ) 3. Morbidly obese patients with BMI > 40 kg\m^2 4. All patients with chronic obstructive pulmonary disease (COPD) like asthma 5. Patients presented as emergency like strangulated hernia with sign of obstruction. 6. Patients who are not fit for general anesthesia (ASA 3 and ASA 4 ). 33

34. Sample size calculation 34 For calculating the sample size for my study, the formula is:

35. Here, n= Desired sample size P1= Anticipated probability of Seroma formation in group A ( Onlay ) = 3 % ( Jameel et al. , 2020) P2= Anticipated probability of Seroma formation in group B(Rives- Stoppa ) = 6.7% ( Jameel et al. , 2020) Zα=Z-value at a definite level of significance, e.g. 1.96 at a 5% level of significance. (95% confidence interval) Zβ=Z-value at a definite power, e.g. 0.84 at 80% power . 35

36. Sample Size calculation : 36 For calculating the sample size for my study, the formula is: = 39.35~40

37. Variable A. Outcome variable- Operative time Hematoma 3. Seroma 4. SSI Early Recurrence B. Demographic variable Age. Sex. 37

38. Data Collection Data will be collected by using structured questionnaire designed for the study by researcher himself. The questionnaire will be prepared by reviewing literature and by consulting with guide, co-guide and experts . 38

39. Study procedure All the patients admitted in surgery department at Sylhet MAG Osmani Medical College Hospital during the study period, who will fulfill the selection criteria, will be enrolled in this study. Patients will be informed in details regarding the procedures of the study and written consent will be obtained. Study population will be allocated into two groups, Group A and Group B. 39

40. Group A ( Onlay Group). Group B (Open Rives- Stoppa Group). Sample will be collected by conveniently. First patient of the sample will be selected by lottery and next patients will be allocated in two groups alternatively. A total of 80 patients will be allocated in two groups (40 patients in each group). 40

41. All patient will be operated after thorough history taking, clinical examination and necessary investigations (complete blood count, liver function tests, renal function tests, coagulation profile, ECG, Chest x-ray, abdominal ultrasound). All patients will receive prophylactic antibiotic ( 3 nd generation cephalosporin) before 60 minutes of surgical incision. 41

42. The selected patients will undergo repair of Ventral hernia by surgeons at level of Assistant Professor and above. In group A ( Onlay ), The Onlay repair will be done under general anaesthesia with skin incision over the bulge or the defect. Using blunt dissection, both the rectus sheath and the defect containing the hernia contents will be identified. 42

43. Then reducing the contents into abdominal cavity, the sac is excised and an epifascial suture line of 5 cm is dissected in all directions. Then with non-absorbable suture, the defect will be closed and adequate size mesh will be placed on the rectus sheath and fixed by double crowning manner with interrupted sutures. Then after proper hemostasis and wound will be closed over a suction drain kept inside and subcutaneous wound approximation and skin closure. 43

44. In group B (Open Rives- Stoppa ), The principles of the preperitoneal or sublay mesh repair included two main steps; mesh placement deep to the rectus muscles and mesh extension well beyond the hernia defect. After the sac was being dissected and delineated, the defect is opened and the preperitoneal plane is created between the posterior rectus sheath and the rectus muscle for the placement of the mesh. 44

45. The posterior rectus sheath along with the peritoneum will be closed with 1-0 prolene suture. A adequate size mesh will be placed in the already created Rives- Stoppa space behind the rectus muscle. A suction drain will be placed in the retrorectus space. The anterior rectus sheath will be closed with continuous 1/0 polypropylene sutures. Another drain is placed in the subcutaneous plane and the skin closed. 45

46. Drains will be removed when drainage was less than 15 ml in 24 hours. Patient will be followed up according to SOAP guideline. In all patients of both groups, single dose of injection of Opioid (1mg/kg/body weight) will be given intramuscularly immediately after recovery from anaesthesia. All the patient will be given 1gm 3rd generation cephalosporin antibiotic preoperatively at the time of induction and will be continued till the 5 th postoperative day twice daily . 46

47. After that non-steroidal anti-inflammatory medicines will be given orally to the patient before they would be sent to home as required. All the patient will be planned to be discharged when drain collection less then 15 ml in 24 hours. Drain collection will be followed up in each post-operative day and surgical site will be checked in 3 rd post-operative day. 47

48. During discharge, a phone number will be provided to contact in case complications (SSI, hematoma, seroma etc) arise. Further follow-up will be advised at end of 1 st week, at 1 month, 3 months and 6 months. Patients will be assessed to see the outcome variables during each follow-up visit . 48

49. Data Processing & Statistical Analysis Data will be processed and analysed with the help of SPSS (Statistical package for social sciences) software, version 25. Quantitative data will be analysed by mean and standard deviation. Qualitative data will be analysed by rate, ratio, percentage. Appropriate test will be applied. A probability value of <0.05 will be considered statistically significant . 49

50. 50 Flow Chart Group B ( 40) Rives- Stoppa Outcome Data collection Selection Criteria Population Study population (n= 80) Group A ( 40) Onlay Outcome Data collection Result Data analysis 50

51. Operational definition Operative time: Operative time will be calculated in minutes from surgical incision to wound closer. Seroma : Seroma is the abnormal accumulation of serous fluid in a dead space containing plasma and lymphatic fluid. Hematoma : Hematoma is a collection of blood within a body tissue in response to injury of a blood vessel. 51

52. SSI: Invasion and multiplication of organisms in any part of the body tissues resulting from any surgery. Recurrence : When hernia reappears near or at the location of a previous repair, they are called recurrent hernia . Onlay : Onlay repair mesh is placed between subcutaneous tissues of abdominal wall and anterior rectus sheath. Sublay (Rives- Stoppa ): Sublay repair mesh placed between the rectus muscle and the posterior rectus sheath. 52

53. Ethical Consideration 1. Ethical approval must be taken from Institutional Ethical Review Board (IERB) of Sylhet MAG Osmani Medical College. Study will be conducted as per the guideline of the ethical board. 2. The nature, purpose and clinical implication of the study as well as benefits and risks will be explained to participating patients in clearly understandable local language and informed written consent will be obtained from them before data collection and/or intervention. 53

54. 3. All information will be collected confidentially with complete respect to the patient wish and without any force or pressure. Patient’s interest would not be compromised anyway to protect their rights to health. 4. No standard treatment protocol will be omitted or obscured for the purpose of the study . 54

55. 5. Patients will be assured of adequate treatment and if any complication arises in relation to the study procedure, it will be managed by the hospital authority. 6. Patients will have the full right to withdraw themselves from the study at any time for any reasons what-so-ever. 55

56. Observation and Result Observation and results will be presented by different tables, graphs, charts, diagrams etc. Discussion Discussion will be made after obtaining the results of the study according to the objectives with references and cross references. 56

57. Conclusion Will be made on the basis of findings. Recommendation Will be done on the basis of finding. 57

58. Internet 2 000 /- Books and literature 3000/- Data analysis and compose 5000/- Pinting and binding 5000/- Investigations 80000/- Suture materials 15000/- Prolene Mesh 160000/- Total 270000 /- Budget 58

59. Time schedule 59 Activity Oct 23 to Dec 23 Jan 24 to May 24 June 24 to June 25 July 25 Aug 25 to Sep 25 Problem definition Literature review Research design Data collection Data analysis Report writing & binding Submission

60. References Alobaidi , M.H. and Alammar , N.R., 2019. Comparative Study between the “ sublay ” versus “ onlay ” techniques of mesh hernioplasty in Ventral hernias. Int J Adv Res Biol Sci , 6 (4), pp.127-138. Dharmendra , B.L. and Vijaykumar , N., 2018. A comparative study of on-lay and sub-lay mesh repair of ventral wall hernias in a tertiary health care centre. International Surgery Journal , 5 (10), pp.3386-3390. Demetrashvili , Z., Pipia , I., Loladze , D., Metreveli , T., Ekaladze , E., Kenchadze , G. and Khutsishvili , K., 2017. Open retromuscular mesh repair versus onlay technique of incisional hernia: a randomized controlled trial. International Journal of Surgery , 37 , pp.65-70. Deherkar , J.A., Borkar , P.E., Kakade , K.R., Kharat , R.S. and Shaikh , S.N., 2022. Comparative study between sublay ( retrorectus ) and onlay mesh placement in ventral hernia repair at a teaching hospital. Formosan Journal of Surgery , 55 (6), pp.215-220. Gaur, S. and Sharma, D.K., 2022. Epidemiology and management of ventral hernia in a tertiary health care centre-a prospective observational study. International Surgery Journal , 9 (2), pp.401-406. Gillies , M., Anthony, L., Al- Roubaie , A., Rockliff , A. and Phong , J., 2023. Trends in incisional and ventral hernia repair: a population analysis from 2001 to 2021. Cureus , 15 (3). 60

61. Jameel , M.K., Saeed , R., Saeed , A.B., Jamal, A., Alam , A. and Hanif , A., 2020. Comparison of onlay versus sublay hernioplasty for ventral hernia. Pak J Med Health Sci , 14 (2), pp.326-8. Kumar, R., Prakash , P., Sinha , S.R., Ahmad, N. and Baitha , K.S., 2023. Short-term outcomes and quality-of-life assessment following rives- stoppa and transversus abdominis release procedures of open ventral hernia repair. Cureus , 15 (7). Kumar, M., Jha , A.K., Arora , A., Sreepriya , P.P., Niroop , B.S. and Ali, M.A., 2022. Comparative analysis of onlay and sublay ( retrorectus ) mesh repair for incisional hernia (width≤ 10 cm) of abdominal wall: A single-center experience. Formosan Journal of Surgery , 55 (1), pp.1-6. Khawaja , F.G., Mahmood , K., Gul , U.J., Aslam , A., Saeed , F. and Nayyar , A., 2023. Comparison of Sublay and Onlay Mesh Repair in Terms of Post-Operative Complications. Pakistan Armed Forces Medical Journal , 73 (3), pp.686-89. Kumar, V., Rodrigues , G., Ravi, C. and Kumar, S., 2013. A comparative analysis on various techniques of incisional hernia repair–experience from a tertiary care teaching hospital in South India. Indian Journal of Surgery , 75 , pp.271-273. Naz , A., Abid , K., Syed , A.A., Baig , N.N., Umer , M.F. and Mehdi , H., 2018. Comparative evaluation of sublay versus onlay mesh repair for ventral hernia. J Pak Med Assoc , 68 (5), p.4. Orgoi , S., Biziya , B.O. and Lamid-Ochir , B., 2016. Schwartz's Principles of Surgery. Central Asian Journal of Medical Sciences , 2 (1), pp.105-106. 61

62. Pereira- Rodrigues , A.K., Maceio- Da - Graça , J.V.S., Ferreira, E.M.L.D.O. and Alves -Almeida, C.C., 2023. Onlay versus rives- stoppa techniques in the treatment of incisional hernias. ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo) , 36 , p.e1766. Saber, A. and Emad , K.B., 2015. Onlay versus sublay mesh repair for ventral hernia. J Surg , 4 (1-1), pp.1-4. Shekhar , H., Jindal , R., Mukherjee , S. and Sharan , J., 2021. Open Onlay versus sublay mesh repair in ventral hernias–a comparative study. International Journal of Contemporary Medicine Surgery and Radiology , 6 (1), pp.A74-A7. Wantz , G.E. and Schumpelick , V. eds., 1995. Inguinal hernia repair . Karger.p.235-245 Wéber G, Baracs J, Horváth OP. [" Onlay " mesh provides significantly better results than " sublay " reconstruction. Prospective randomized multicenter study of abdominal wall reconstruction with sutures only, or with surgical mesh--results of a five-years follow-up]. Magyar Sebeszet . 2010 Oct;63(5):302-311. 62

63. Appendix Appendix-I : Data collection sheet Appendix-II : Informed written consent Appendix-III : ASA score Appendix-IV : ASEPSIS Wound Score Appendix-V : SOAP guideline 63

64. Appendix-I Data collection sheet: Title: Open Rives- Stoppa versus Onlay Technique in The Treatment of Ventral Hernias. Case . No: Date: Particulars of the patient Name: Age: Sex: Occupation: Address: Reg. No: Ward No & Bed No: Date of admission: Contact number: 64

65. Presenting symptoms : Present / Past medical history:   Personal History: Family History: General Examination : Anaemia : Yes/No Jaundice: Yes/No Dehydration : Yes/No Cyanosis: Yes/No Oedema : Yes/No Clubbing : Yes/No Lymph nodes: Thyroid gland: Pulse (beats/minute) (including peripheral pulses): 65

66. Abdominal examination : On Inspection: Shape of abdomen: Scaphoid / Distended Visible cough impulse: Present / Absent Umbilicus: Inverted / Everted Visible peristalsis Scar mark :Present/Absent On Palpation: Temperature: Normal / Raised Tenderness: Present/Absent Muscle guard: Present/Absent Organomegaly : Palpable or not Assess the size of the defect by insinuating the finger through the gap Any palpable swelling .   66

67. On Percussion: Tympanic/Dull all over the abdomen   On Auscultation: Bowel sound: Present / Absent Examination of Inguino -scrotal region: Per Rectal Examination: Other systemic examination 67

68. Investigations: Full Blood Count Random Blood Sugar Serum Creatinine ECG Ultrasonography of Whole Abdomen Chest X-ray 68

69. Operation note: Date of operation Indication of surgery : Type of surgery: Prophylactic Antibiotics- Yes/No Procedure and findings: Total operating time: Per operative complications: Bleeding Visceral Injury Others Conversion : Yes / No 69

70. Post-operative follow up findings: 1st post-operative day Appearance: Pulse: Blood pressure: Temperature: Respiratory rate: Post-operative pain (VAS): At 1 week: 1. SSI . Seroma Hematoma. 70

71. At 1 month:. Early Recurrence At 3 months: 1 .Early Recurrence At 6 months: 1 . Early Recurrence 71

72. Appendix-II Informed Consent Form Getting full information about the purpose, procedure and utility of this study, I give consent to participate in this study. I have not been influenced by anybody or groups or my fundamental human rights have not been violated due to participation in this study. I am assured that confidentiality of all gathered information will be maintained and will be used only for study purpose and my personal information will not be disclosed to others. My participation in this study is entirely voluntary. My decision whether or not to participate will not prejudice my medical care. I have right to withdraw my consent and discontinue participation at any time without prejudice to me or effect on my medical care. I will have got no remuneration or travel expenses due to participation in this study. I am willingly giving signature to this consent form. Signature/ Left thumb impression Signature / Left thumb impression of Of the participant the attendant Signature/ Left thumb impression Signature of the investigator Of the witness 72

73. সম্মতিপত্র     আমি জনাব / জনাবা ............................................. এতদ্বারা ভালভাবে অবগত হয়ে ডাঃ তন্ময় বারই পরিচালিত “Open Rives- Stoppa Onlay Versus Technique in the Treatment of Ventral Hernia ” শীর্ষক গবেষনাকর্মে অংশ গ্রহণের সম্মতি প্রদান করলাম। আমি সম্পূর্ণ ভাবে বুঝতে পারলাম যে , এই গবেষণা কর্মে অংশগ্রহণ ভবিষ্যতে আমার এবং আরও অনেকের জন্য সন্তোষজনক উপকারি ফলাফল বয়ে আনবে। আমি আশ্বস্থ যে , এই গবেষণা ফলাফলে আমি কোনও অপ্রয়োজনীয় শারীরিক , মানসিক , সামাজিক অথবা আইনগত ঝুঁকির সম্মুখীন হব না। আমি আরও বিশ্বাস রাখি যে , আমার ব্যাক্তিগত গোপনীয়তা সর্বতভাবে সংরক্ষিত থাকবে।   স্বাক্ষর / বৃদ্ধাঙ্গুলির ছাপ   নামঃ তারিখঃ ঠিকানাঃ       অংশগ্রহণকারীর স্বাক্ষর / বৃদ্ধাঙ্গুলির ছাপ রোগীর অভিভাবকের স্বাক্ষর / বৃদ্ধাঙ্গুলির ছাপ         স্বাক্ষীর স্বাক্ষর / বৃদ্ধাঙ্গুলির ছাপ গবে ষকের স্বাক্ষর 73

74. Appendix - III ASA Score ASA 1: A normal healthy patient. Fit non obese (BMI under 30), a non-smoking patient with good exercise tolerance. ASA 2: A patient with a mild systemic disease, Example: Patient with no functional limitations and a well-controlled disease (e.g. Treated hypertension, obesity with BMI under 35, frequent social drinker or is a cigarette smoker). ASA3: A patient with severe systemic disease that is not life- threatening. Example: Patient with Some functional limitation as a result of disease (e.g., poorly treated hypertension or diabetes, morbid obesity, chronic renal failure, a bronchospastic disease with intermittent exacerbation, stable angina, and implanted pacemaker). ASA 4 : A patient with severe systemic disease that is a constant threat to life. Patient with functional limitation from severe, life-threatening disease (e.g., unstable angina, poorly treated COPD, symptomatic CHF, recent (less than three months ago) myocardial infarction or stroke. ASA 5: A moribund patient who is not expected to survive without the operation. The patient is not expected to survive beyond the next 24 hours without surgery. Examples: ruptured abdominal aortic aneurysm, massive trauma, and extensive intracranial hemorrhage with mass effect. ASA 6: A brain-dead patient whose organs are being removed with the intension of transplanting them into another patient. The addition of “E” to the ASAPS (e.g., ASA2E) denotes an emergency surgical procedure. The ASA defines an emergency surgical procedure. The ASA defines an emergency as existing “when the delay in treatment of the patient would lead to a significant increase in the threat of life or body part.” 74

75. 75

76. Appendix-v SOAP Note for Post-operative follow up Subjective: Short history of patient (Age, co-morbidity, presenting complaints) Patient’s verbal statement about his/her symptoms. Objective: General condition of patient Vitals Physical examination Cardiovascular examination Respiratory examination Abdominal examination Neurological examination Local examination Laboratory investigations Imaging studies Assessment: Comparison of patient’s condition to previous follow up Diagnosis & differential diagnosis Plan:   Continue same management New orders Referrals Discharge plans 76

77.   THANK YOU 77