Background : Antimicrobial prophylaxis in surgical practice is a concept that has been in practice for over 3 decades. The aim is to prevent surgical site infection (SSI), a menace acknowledged as the most common nosocomial infection in surgical patients. Over the years, several international guidelines have been published in the literature to guide the practice. Yet some surgeons still practice outside these guidelines especially in orthopedics and trauma surgical practice. This has led to emergence of resistant strains of bacteria and increased cost of healthcare. The only option left to check this problem therefore lies in the proper use of available antibiotics. The objective of this study was to review the current literature on the guidelines and practice of antibiotic prophylaxis in orthopedics and trauma surgery. Materials and Methods : A review of the literature on this subject was done on Medline, EBSCOhost database, and recent articles from relevant journals and texts. The database was searched using the keywords; antibiotic prophylaxis; orthopedic and trauma surgery. Results: There are several guidelines and protocols that were established from evidence based information. However, compliance to these guidelines amongst surgeons and health institutions is suboptimal for various reasons. This is associated with increased morbidity and cost of treatment. Conclusion : There is a need to be guided by evidence based guidelines in our antimicrobial prophylaxis practice; as surgery is both a science and an art.

Background: Management of colorectal cancer (CRC) in Nigeria is associated with such challenges as operating on locally advanced tumors. We performed a prospective observational study to assess the prevalence of surgical site infection (SSI) following CRC resection in a low resource setting. Materials and Methods: Consecutive patients, who had standard oncologic resection for CRC at Ahmadu Bello University Teaching Hospital, Zaria over a 5-year period from 2008 to 2012, were enrolled into the study. From 2010, patients with locally advanced rectal cancers were given neoadjuvant chemoradiation with concurrent 45 Gy external beam radiation over 5 weeks and fortnightly FOLFOX 4 regimen to downstage tumor followed 6 weeks later by surgery. Surgical resections were performed through open laparotomy. The outcome of interest was the development of SSI within 30 days of surgery. Patient and surgical variables were evaluated for association with SSI. Results: Of 188 patients seen with CRC, 78 (41.5%) had surgical resection and 75 were analyzed for SSI. The prevalence of SSI was 13.7% following transabdominal colectomy, 50% following abdominoperineal resection and 25.3% following overall CRC resection (P < 0.05). There was no SSI in patients whose local tumors were confined to the bowel wall, but 35.2% of patients with locally advanced tumors had SSI (P <0.05). Treatment with neoadjuvant chemoradiation, sex, body mass index, wound classification, surgical procedure duration, use of diverting stoma and perioperative blood transfusion were the significant variables (P < 0.05) for SSI. Conclusion: We observed that the prevalence of SSI in our setting is high and is possibly due to the difficulties of surgical resection of tumors most of which were locally advanced at the time of surgery among other factors.

Background: Association between gallstone disease (GSD) and dyslipidemia has been shown in many studies. The aim of this study was to compare the serum lipid and serum glucose levels in patients with and without gallstone and also to determine changes in same parameters in gallstone patients before and after cholecystectomy. Materials and Methods: A total of 71 patients with gallstone (Group A) and 96 without gallstone (Group B) were studied prospectively. Patients in both groups were investigated for GSD. Total cholesterol (TC), triglycerides (TG), high density lipoprotein cholesterol (HDL-c), low density lipoprotein cholesterol (LDL-c), atherogenic index (AI) and fasting glucose (FG) levels were estimated in both groups pre-operatively. Further, same parameters were studied in Group A post-operatively at 1 week and 1 month intervals. Results: The serum levels of TC, TGs, LDL-c, AI and FG were found to be higher and levels of serum HDL-c were lower in gallstone patients than that of the control group, though not statistically significant. In patients with gallstone, significant decrease in TC, LDL-c, TG, AI and increase in HDL-c levels were observed post-cholecystectomy at both intervals. Post-operatively, rise in serum glucose levels at 1 week interval and decrease at 1 month interval were noticed in patients with GSD. Conclusion: GSD is associated with abnormal lipid profile and serum glucose. Cholecystectomy leads to a significant decrease in these parameters except HDL-c in patients with GSD. The presence of gall stones should be perceived in the context of metabolic disorder, which may be investigated and treated. Asymptomatic gallstone patients may also be treated surgically resulting in improvement of above mentioned biochemical parameters.

Background: Gallstone disease is a common surgical problem requiring cholecystectomy. It is known to produce diverse histopathological changes in the gallbladder ranging from acute or chronic inflammation to metaplasias and even malignancies. The aim of this study was to emphasize the importance of a detailed microscopic examination and to study the diverse range of histopathological lesions in cholecystectomy specimens. Materials and Methods: This is a retrospective study of 360 cholecystectomy specimens received in the Department of Pathology over a period of 2 years from November 2010 to October 2012. Clinical details and histopathological data were retrieved from the records. The variety of morphological changes in the diseased gall bladder were correlated with the clinical findings. Results: Overall, there were 360 cases consisting of 74 (21%) males and 286 (79%) females. Maximum number of patients was between 31 and 40 years (30.2%). Most common pathology noted in our study was chronic cholecystitis seen in 280 cases (77.7%). Other benign lesions were cholesterosis in 36 (10%) and acute cholecystitis in 10 (2.7%). Various other associated lesions and variants of cholecystitis were also encountered. A total of nine malignant lesions of gallbladder were observed, which included eight cases of incidental adenocarcinomas and one case showing lymphomatous involvement. Conclusion: Our study emphasizes that a routine cholecystectomy performed for a common condition like gallstone disease can result in a diverse and wide spectrum of histopathological lesions ranging from benign diagnosis to an unexpected gallbladder malignancy.

Background: Oral cancers are not uncommon. We have analyzed the incidence of nodal metastasis in oral cancer clinically and compared it with the final histopathology examination (HPE) report, correlating the pathologically positive lymph nodes with different parameters such as tumor sites, pathological stage, differentiation, lymphovascular, perivascular extension and perineural invasion. Materials and Methods: This retrospective study was carried out on patients who were evaluated with a histological diagnosis of oral cancer from 2008 to 2012. Lymph node positivity was established by clinical and ultrasound evaluation in 218 patients who underwent neck dissection for oral cancer. This was compared with the histopathology findings. Results: The most common site of oral cancer was buccal mucosa. Histopathologically, majority were squamous cell carcinoma (SCC). Lymph node positivity was observed for different sites as follows: buccal mucosa (26.7%), gingivo-buccal sulcus (20.8%), retromolar trigone (40%), tongue (50%), and floor of mouth (100%). In well-differentiated SCC, node positivity was 25.4%. In moderately differentiated SCC, it was 52.3% and in poorly differentiated SCC, it was 50%. Five cases of verrucous carcinoma did not show any lymph node positivity. According to the pathological staging, the lymph node positivity was as follows: T1 (25.58%), T2 (23.59%), T3 (37%), and T4 (34.78%). Out of 218 patients, 5.5% patients showed positive resected margin, 1.8% patients showed skip metastasis, and 14.6% patients had lymphovascular or perivascular invasion. Univariate analysis showed significant correlation of lymph nodal metastasis with various clinicopathological parameters like tumor site, stage, and differentiation. Conclusion: In our female predominant study group, mostly locally advanced tumors were encountered involving the alveobuccal subsites. Standard neck dissections play an important role in the control of neck disease.

Background: Resin push-out bond between fiber post and root dentin can be achieved in various ways. This study evaluates the bond strength of glass fiber posts cemented into root canal using different luting techniques. The null hypothesis tested was that no difference would be observed among the strategies for post cementation. Materials and Methods: The canals of 50 roots were prepared with the custom drill of glass fiber post and divided into five groups (n = 10), according to the strategy for post cementation: G1- conventional adhesive procedure (single-bottle etch and rinse light-cured adhesive + resin cement (Relyx ARC)); G2- conventional adhesive procedure (single-bottle etch and rinse light-cured adhesive + resin cement (AllCeram); G3- self-adhesive resin cement (Relyx Unicem, 3M/ESPE); G4- self-adhesive resin cement (Relyx Unicem, 3M/ESPE) with previous dentin acid etching; and G5- resin glass ionomer cement (Relyx Luting 2, 3M/ESPE). After post cementation, the specimens were kept for 24 h in 100% humidity. Afterwards, each root was sectioned into 2 mm slices to be pushed-out. The data were submitted to one-way analysis of variance (ANOVA) and Tukey's test (5%). Failure analyses were followed after testing. Results: The self-adhesive resin cement with dentin acid pretreatment (G4: 22.3 ± 2.8) had the highest bond strength values (MPa) (G3: 16.3 ± 4.4 > G1: 7.0 ± 3.9 > G2: 4.9 ± 2.5 > G5: 3.7 ± 2.2) (P < 0.05). This was followed by the same cement without phosphoric acid etching. The other three groups obtained the significantly lowest mean values and were similar to each other. Conclusion: Simplified self-adhesive resin cement promoted the highest bond strength when compared to conventional adhesive cementation and glass ionomer.

Background: The optimum management of penetrating neck injuries (PNIs) is controversial. The initial trend was a mandatory exploration once the platysma is violated. It has changed over time into a selective approach with surgery done to patients with overt clinical features or abnormal investigations. This study aims to test the usefulness and safety of an individualized approach to the management of patients with PNIs. Materials and Methods: The management of PNIs deployed over the period from June 1, 2009 to June 30, 2012 at IBN-Alnafis Hospital, Baghdad, Iraq, was retrospectively reviewed. The demographic features of patients, presenting symptoms and signs, location of injuries in term of neck zones, associated injuries, diagnostic work up and methods of treatment (surgery vs. conservative), morbidity and mortality were determined. Results: Sixty-eight patients (64 males and 4 females) were studied. The peak incidence was in the third decade. The mean age was 29.7 ΁ 12.9 years. Shells were the main causative agents (45.6%). The most frequently injured neck zone was the second (41.7%). Vascular injuries headed the list (8 cases). The majority of patients (56%) were managed surgically while 26.5% were managed conservatively. Other patients were either referred to other hospitals for further treatment or discharged against medical advice. Two patients died in this series (2.9%). Conclusions: In circumstances like ours, a selective approach to management of PNIs seems to be preferable. It can be safely applied if a high index of suspicion is maintained to overcome the known shortcomings of our health system.

Introduction: Hand complications of diabetes mellitus are rare compared to those in the foot. They occur in the ratio of 1:20 in our observations. We managed 36 patients with tropical diabetic hand syndrome and propose a classification for the disease that will allow communication between physicians and prognostication. Materials and Methods: Patients with hand infections and background diabetes mellitus were admitted. Their age, sex and occupations were noted. A clinical diagnosis was made and drained. Wound swab for culture was taken. Wounds were generally serially debrided at bed side with wound being allowed to granulate over time to be subsequently closed by split thickness skin graft. Results: Thirty six patients were studied. Based on their clinical diagnosis, they were classified into three (I,II,III) groups in increasing order of severity. The classification correlated with the type and severity of the disease. It also guided the choice of appropriate treatment. Conclusion: Based on our findings, tropical diabetic hand syndrome was classified and prognosticated based on the degree of soft tissue and bone involvement. The classification allows for communication with other physicians.

Background: Classification of external causes of injury is essential for injury surveillance. The aim of this study was to evaluate the external causes of injury using the international categorization of external causes of injury (ICECI) guidelines. Materials and Methods: Patients 18 years and above with injuries were prospectively selected for the study between 1 ^st July 2009 and 1 ^st December 2009. Written informed consent was obtained from each of patients or their relation if unconscious. Bio-data was obtained from each of patients, the registration and data of the event was recorded according to the ICECI guidelines. Results: A total of 252 patients were studied. Their age ranged from 18 to 72 years. There were 192 ( 76.2%) males and 60 (23.8%) females with a male to female ratio of 3.2:1. Most of the injuries were following road traffic accidents, a third of which were motorcycle related crashes. There was a low utilization of vehicular safety devices and alcohol and psychoactive substances contributed to injury in about 9% of patients. Conclusion: Use of the ICECI guideline in trauma registration could yield relevant data necessary for injury surveillance and we recommend its use for injury registration in our hospitals.

Background: Prostate cancer is an important growing health problem presenting a challenge to urologists, radiologists, pathologists, and oncologists. Many men have incidental microscopic foci of prostate cancer at postmortem that did not manifest during life time. However, some cancers are aggressive with a rapidly worsening course. The objective of this study was to diagnose prostate carcinoma in Tru-Cut biopsy specimens, determine Gleason's grading and correlate clinicopathological findings and prostate specific antigen (PSA) level. Materials and Methods: Tru-Cut biopsies were performed on 100 clinically highly suspicious patients of prostate carcinoma. Eight to 10 cores of prostatic tissue were obtained. The samples were formalin-fixed and paraffin-embedded. The prostatic tumors were diagnosed and assigned Gleason scores using hematoxylin and eosin (H and E) stained sections. Results: Microscopic examination revealed adenocarcinoma in 59, benign prostatic hyperplasia (BPH) in 35, and inadequate biopsy in five cases. The age distribution of these 59 cases with adenocarcinoma revealed that 28 were in the 8 ^th decade, followed by 7 ^th , 6 ^th , and 9 ^th decades, respectively. The mean age was 68.20 years. The Gleason score was 5-7 in 37 patients, 2-4 in 14 cases, and 8-10 in eight cases. The highest PSA level was in Gleason's score of 8-10. Thus, the PSA levels are more in patients with high Gleason grade. Conclusion: Adenocarcinoma is the most common type of prostate carcinoma. The majority of patients had a Gleason score of 5-7, followed by 2-4, and 8-10. The more anaplastic type of cancers were present in the least number of cases.

Small bowel obstruction is a common condition, encountered in the emergency room of the surgery department. Uncommon causes include gallstone ileus, worm infestation, internal hernias, mesentric ischemia, trichobezoars or phytobezoars, Crohn's disease, postoperative strictures, and diverticulosis. Even more uncommon is primary enterolithiasis. Enterolith, the enterogenous foreign bodies, are rare clinical and radiological entities. True enteroliths are formed due to precipitation and deposition of substances from alimentary chime. Primary enterolithiasis is a rare entity, occurring in association with pathological conditions that lead to hypomotility and stasis, like Crohn's disease, small intestine diverticulae, traumatic or postoperative strictures of ileum, ulcerative colitis and blind loops. Primary enterolithiasis may be asymptomatic or may present with sub-acute or acute intestinal obstruction, but specific radiological diagnosis of primary enterolithiasis is uncommon. Definitive treatment of enterolithiasis with small intestinal obstruction is essentially surgical. The options at laparotomy are manual lysis of the calculus without enterotomy or removal by enterotomy. Bowel resection is indicated in cases with definitive bowel pathology. We are presenting five cases of enterolithiasis, which we encountered in the Surgery Department of L.L.R.M. Medical College, Meerut from January 2006 to December 2012. Clinical presentation, diagnosis, investigations and treatment have been discussed along with a review of literature.

Scrotal calcinosis consisting of solitary or multiple deposits of calcium within or outside the dermis of the skin of scrotum are generally very rare and are considered to be idiopathic if it is not of metastatic or dystrophic types. Idiopathic calcinosis of the scrotum (ICS) in children under the age of 9 years is not documented in the literature. We are presenting a 6-month-old infant and a 5-year-old male patient with sub-dermal, intra-scrotal, extra-testicular ICS from children surgical unit of Murtala Muhammad Specialist Hospital, Kano in northern Nigeria. Each patient presented with a scrotal mass that was difficult to diagnose clinically. Following investigations including scrotal ultrasound, and serum calcium, scrotal exploration was carried out and the mass excised. Histological examination revealed features of scrotal calcinosis. The objective of this study was to present the clinical presentation, investigation, and treatment of these children. We shall also under-take a review of the literature.

Spontaneous colocutaneous fistula is a rare clinical entity usually associated with diseases like diverticulitis, crohn's disease and post radiotherapy treated malignancy. This case illustrates the challenges of diagnosis and management of such patients. We present a 60-year old lady who had a lump in left lumbar region which started discharging feculent material ten day prior to presentation. There was history of progressively worsening constipation and weight loss but no rectal bleeding or jaundice. There was a necrotic patch with feculent discharge from left lumbar region with underlying lump that was 5 Χ 4 cm, firm, non-tender and immobile. Following complete evaluation including abdomino-pelvic ultrasound that revealed an ill-defined mass arising from sigmoid colon, a diagnosis of colocutaneous fistula secondary to colonic malignancy was made. After resuscitation, the patient had exploration and Hartmann's procedure. Histopathology confirmed growth as adenocarcinoma and patient was placed on chemotherapy. We present this case to illustrate the challenges of diagnosis and management of such patients.

Primary biliary tuberculosis in the absence of liver involvement is a rare form of hepatobiliary tuberculosis. Barely 20 cases were reported in world literature. We present a 21-year-old man who presented to our hospital with upper abdominal pain and features of obstructive jaundice of 2 months duration. Following clinical evaluation, his radiological imaging revealed common bile duct stricture with proximal dilatation. Clinical diagnosis of cholangiocarcinoma was made and the patient underwent resection and hepaticojejunostomy. Histological examination revealed biliary tuberculosis. The patient was placed on anti-tuberculosis drugs. After one year of follow-up, patient is symptom free. Even though biliary tuberculosis is a rare cause of obstructive jaundice, in endemic areas, it should be considered as a differential diagnosis and investigated, as it can be potentially curable.

Acute dissection of the aorta is one of the most dramatic presentation of cardiovascular emergencies. It has a varying presentation and it is described as deceptive and dangerous. It is reported as rare, and most cases are discovered during autopsies. Prompt recognition and appropriate intervention is crucial. However, not all aortic dissections (AoD) present with classic symptoms of abrupt chest, back, or abdominal pain, and the diagnosis may be missed. We have reported here a 68-year-old man who presented with 18 hours of severe chest pain radiating to the left shoulder and was associated with shortness of breath, palpitations, sweating, and feeling of an impending doom. A diagnosis of inferior myocardial infarction was made based on ST-Segment elevation >2 mm in the Leads II, III and aVF on electrocardiogram (ECG). However, further evaluation with computed tomographic angiogram done revealed DeBakey's type 1 or Stanford type A AoD. He was later referred to a cardiothoracic centre, where he had an aortic root and valve replacement 2 months after the first presentation. He is currently doing fine at 2-year follow-up. Although, AoD is a rare entity and can masquerade in different forms, a high index of suspicion will enhance diagnosis and prompt appropriate intervention.

Lymphangioma is a benign congenital malformation, most commonly diagnosed in infants and children. The vulva is a rare site for the development of lymphangioma. Around 30 cases of lymphangioma circumscriptum (capillary variety) have been reported, only 7 cases of cystic lymphangioma have been reported in the literature so far. We report a case of vulval, multiloculated, cystic lymphangiomas in a 27 year old female, for its rarity and to consider this in the differential diagnosis of a vulval pathology. Viewing vulval lymphangiomas as a differential diagnosis in mind while examining a vulval swelling, will help in proper plan of complete excision.

Empyema thoracis is quite appreciated as a purulent pleural effusion. The basis for open drainage as an option for the treatment of chronic empyema thoracis is that the lung is trapped beneath a thickened and fibrosed visceral peel, which stabilizes and shields the trapped lung from the possible effect of pneumothorax when such a lung is exposed to the atmosphere either deliberately or accidentally. This is often unappreciated by many clinicians especially those with limited experience. From first principles, pus anywhere requires drainage and this applies equally to pleural space pus. Since these patients are often unfit for stressful procedures like decortication or the underlying lung is often unhealthy and will fail to expand or would be seriously violated in an attempt to free it, open drainage provides a safe and suitable option for the treatment of this pathology. We present the successful management of two patients by this approach as well as the review of literature in this respect.

In this era where aesthetics is of prime concern complete root coverage of gingival recession defects with periodontal plastic surgery is a necessity. The present paper describes a case where semilunar coronally repositioned flap procedure was performed with a 2-year follow-up and no relapse. Semilunar coronally repositioned flap commonly referred to as 'Tarnow's technique' is a viable periodontal plastic surgical procedure.

Hirschsprung's disease is commonly diagnosed (up to 90% in developed countries) in the neonatal period and infancy although late presentation into adulthood still occurs albeit uncommon. Adult Hirschsprung's disease (AHD) is defined as the presentation with features of Hirschsprung's disease to the hospital for the 1 ^st time or being diagnosed for the 1 ^st time after the age of 10 years. The standard treatment for AHD is staged: An initial colostomy, a pull-through procedure and a closure of the colostomy. The colostomy is performed to decompress the bowel of the huge fecal load, to allow the proximal megacolon to shrink and thus reduce the coloanal disproportion that will result during anastomosis and also to allow the nutritional rehabilitation of the patient resulting from the chronic constipation. Recent reports suggest that primary pull-through is possible in adults either as an open procedure or laparoscopically assisted. This is a report two cases of AHD managed in our center and who had primary Swenson's pull-through without a stoma. The need for patient selection is emphasized for a good outcome.

Descending necrotizing mediastinitis (DNM) is a rare, severe, life-threatening suppurative infection of the fascial covering of mediastinal cavity. Oropharyngeal cavity is connected to the mediastinum with various fascial planes. The retropharyngeal space is called the "dangerous space" as through this fascial space infection from the mouth and neck rapidly spread to the mediastinum. Gravity and the negative intrathoracic pressure facilitate the spread of infection into the thoracic cavity. Common clinical presentations are fever, odynophagia, dysphonia, dry cough, neck swelling and chest pain. Computerized tomography of neck and chest will diagnose DNM early and it helps in the grading of the disease. Broad spectrum antibiotic therapy and fluid resuscitation with surgical drainage is essential therapeutic aspect. Combination of transcervical and transthoracic drainage is reported to have significantly more survival benefit than the trans-cervical drainage alone. Percutaneous and video-assisted mediastinoscopic drainage has obvious advantages compared with open surgical drainage. We report three cases of DNM, with recurrent laryngeal nerve involvement successfully treated by video-assisted thoracoscopy and percutaneous drainage.

Desmoid fibromatosis is characterized by local aggressive growth without any tendency of metastasis. These very rare tumors can develop in any musculo-aponeurotic structure and they can be found in all regions of the human body. We present a case of a 15-year-old girl who presented with left lower abdominal mass of 4 months duration. The mass was firm, non-tender and fixed to the left lower abdominal wall. Abdominal computed tomography (CT) showed a focal, but non-demarcated mass on the anterior abdominal wall musculature. Following CT guided tru-cut biopsy and histological examination, a diagnosis of desmoid tumor was made. The tumor was completely excised and the 20 cm Χ 16 cm defect closed with a physic mesh. There was no tumor recurrence at 18 months follow-up. Desmoid tumor commonly affects abdominal wall muscles of females. Following proper evaluation and histological diagnosis complete excision of the tumor is attended with good outcome.

The child development from conception through early years of life is marked by many changes. Tooth eruption follows the chronology corresponding to the date, when tooth erupts into the oral cavity. These dates have been established in the literature and are subject to small variations depending upon hereditary, endocrine, and environmental factors. However, the chronology of tooth eruption suffers a more significant alteration in terms of onset and the first tooth or teeth may be present at birth, called as natal teeth. Natal teeth are rare in extremely preterm infants. In this paper we present a rare case regarding the eruption of mandibular natal tooth in a 10-day old, 7-month preterm normally delivered infant.

Adenosquamous carcinoma of the pancreas is a rare subtype of pancreatic cancer. A 55-year-old female patient was admitted in our hospital for evaluation of her epigastric pain of 2 months duration. On physical examination, there was no jaundice. Diffuse tenderness was present over the right upper quadrant and epigastrium. There was a mass located in the epigastrium. Computed tomography scan of the abdomen showed an 8 × 9 cm solid mass with partly cystic areas in the region of body and tail of the pancreas. Other investigations including liver function tests, complete blood count, and urea and electrolytes were normal. A clinical diagnosis of pancreatic tumor was made. Distal pancreatectomy with gastric reconstruction and small bowel anastomosis with splenectomy was done. Histologically, the tumor was diagnosed as adenosquamous carcinoma of the pancreas with infiltration into the wall of duodenum. Adenosquamous carcinoma of the pancreas is an uncommon variant of exocrine pancreatic cancer which demonstrates characteristic immunoprofile and distinct clinical and pathologic features with a worse prognosis than ductal adenocarcinoma.

Myomectomy at the time of cesarean section has traditionally been discouraged due to the risks of hemorrhage and increased postoperative morbidity. However with the new frontiers in surgical practice, successfully performed cesarean myomectomies in selected patients has continuously been reported. Two cases of multiple uterine leiomyoma coexisting with pregnancy were selected, counseled, and had elective cesarean myomectomy. The first patient was a 38-year-old primigravida with 22 years history of subfertility. Her antenatal period was largely uneventful. Her evaluation revealed a singleton pregnancy coexisting with multiple uterine fibroid. At 38 weeks of gestation, she had cesarean section and myomectomy. Thirty-six seedlings were removed. The largest was 12 Χ 8 cm and she lost 1 L of blood. She was discharged home on the 8 ^th postoperative day in good condition. The second case was a 33-year-old primigravida who was diagnosed with uterine fibroid in pregnancy. She also had an uneventful antenatal care and at 38 weeks gestational age, she had the removal of a huge intramural leiomyoma from the lower uterine segment (12 Χ 14 cm) during cesarean section to get access to the baby. She lost 1.2 L of blood and was transfused two pints of blood. Her postoperative condition was satisfactory. She was discharged home on the 7 ^th postoperative day. Cesarean myomectomy can be successfully performed with careful planning, patient selection, and skillful surgery. However, blood transfusion services should be available.

A plethora of pathologies occurs in the cranial base and deep spaces of the neck, the treatment of which poses a surgical challenge owing to the anatomical complexity, difficulty in access, and proximity of vital structures. A multidisciplinary approach is often required in these situations to strike a balance between preventing damage to the vital anatomic structures and complete removal of the lesions. This article describes our experience with three clinical situations that required access osteotomies of maxillofacial region that has facilitated complete to near total removal of the lesions. In the first case, an inferiorly pedicled zygomatic arch osteotomy was done to approach an osteomyelitis of sphenoid bone through the infratemporal fossa. In the second case, paramedian step osteotomy of mandible with mandibular swing was done to remove a lateral pharyngeal wall schwannoma. In the third case, a frontonasoorbital osteotomy was done to approach a lesion at clivus of middle cranial base. All the access osteotomies provided satisfactory exposure of the lesions and were fixed with miniplates, resulting in good restoration of facial skeletal morphology and function. Maxillofacial access osteotomies provide good access to the lesions with minimal surgical morbidity and distortion of facial esthetics.

Dental literature is replete with cases of supernumerary mandibular premolar and unicystic ameloblastoma as separate entities but to our knowledge the present clinical scenario of unicystic ameloblastoma associated with impacted supernumerary premolar was rarely reported. The purpose of this article is to report a patient who presented with pain and swelling of the left mandible of five months' duration. Following clinical evaluation and radiological examination a diagnosis of a rare case of mandibular supernumerary premolar associated with unicystic ameloblastoma was made. The tumor was excised and mandibular reconstruction done.