Introduction

Acharya Sushruta considered, that which is causing pain to body as “Shalya”(1).  Pranashta means that which is not visible. Pranashta Shalya means invisible foreign body hidden inside the body(2). Pranashtashalyaadhyaya(3) is an exquisite piece of work titled by Acharya Suhsruta, which entails about the different dimensions of the Ayurveda science. Acharya Sushruta has mentioned eight types of surgical procedures to fulfil the aim of Ayurveda of Dhatusamyata through Shalyatantra entity(4). Ashtvidha shastra karma- Eight kinds of surgical techniques(5,6,7  are to cure tissue injury and inflammatory conditions. They are Chedana (Excision, amputation, resection), Bhedana (incision, counter incision), Lekhana (scrapping, scooping), Vedhana (Puncturing, penetration), Eshana (Probing), Aharana (extraction and removal), Vistravana (Evacuation, Emptying, drainage) and Seevana (Suturing, Ligation). Foreign body ingestion and impaction remains a common problem both in paediatric and adult populations. In children, the highest incidence of impaction typically occurs between the age of 6 months to 3 years, and the most common ingested foreign bodies include coins, small toys, button batteries and magnets(8). Compared to adults, children in Western populations rarely ingest fish bones. However, previous literature has demonstrated that in countries with a higher fish intake, such as those in Asia, there is an increased incidence of fish bone ingestion and impaction in both children and adults(9).

           Fish bone ingestion possess significant potential hazards regardless of age, including visceral gastrointestinal perforation, secondary deep neck abscesses or mediastinitis and delayed oesophageal stenosis(10). Therefore, regardless of the demographics, fish bone ingestion necessitates accurate diagnosis and appropriate evidence-based management. Pediatric fish bone ingestion presents its own unique challenges. Paediatric fish bone ingestion may provide a diagnostic challenge as a result of difficulties obtained with history-taking from the child, the event frequently unwitnessed by the carers and identification of the exact location of the bone. Although the size of the foreign body has not specifically been assessed in fish bone impactions, it is a well-established predictor for impaction risk in other foreign bodies such as coins(11,12).

Although fish-bone foreign bodies are not frequently associated with severe complications, they can cause several life-threatening complications such as perforation of the esophagus, deep neck infection/abscess, mediastinitis/mediastinal abscess, and aortoesophageal fistula(13,14,15).

Case report: 14 year old Male patient was brought to the surgery OPD of Pakwasa hospital having history of ingestion of fish bone 1 year Ago for this he took home remedies and treatment at private hospital but still had mild pain and difficult during deglutination.  X-ray s/o of no   any abnormalities but patient got no relief. After 6 months of ingestion, abscess   has been formed and had burst externally and there was   pus discharge (on and off) from small opening near hyoid bone at anterior aspect of neck on the left side since 6 months. The discharge was more after taking meal .On local examination, there was small (0.5 X 0.5cm) opening in the lower part of the neck of left side hyoid bone. Some pus discharge was found on pressing near its external opening. X-ray spine and cervical (AP): (24/02/2021) revealed no any significant abnormality. USG REPORT :( 20/02/2021) showed Chronic Hematoma secondary to linear foreign body in neck. CT NECK (plain & contrast) reports revealed: (20/09/2021) Focal small peripherally enhancing hypodense lesion with linear hyper density in middle seen in right infrahyoid region level III .There is small external opening noted – likely abscess with foreign body. Linear abnormal t-2 hyper intense sinus track seen extending superiorly from left parasagittal supraclavicular skin surface to deeper tissue of neck ends blindly in submandibular region. No evidence of any cyst or abscess in underlying soft tissue. ? branchial sinus/fistula.  Patient was planned for exploration and extraction   of   foreign body under general anaesthesia. Under AAP under GA patient in Supine position parts painted, drapped and isolated. .Transverse elliptical incision taken including external opening of sinus .Incision deepened up to platysma muscle. Fibrous   tract was dissected .It was adherent to external Carotid vein which had bleed while dissection. And Rent with prolene (2-0) .Another transverse incision taken superiorly and deepened up to tract. Tract was opened and foreign body removed .Scooping done and sinus cavity closed with vicryl 2-0. Skin Closure done with Vicryl 2-0 (Simple interrupted sutures) .Packed well. Dressing done. All procedure was uneventful. Excised tissues were sent for histopathological examination of tissue. Histopathology confirmed tract lined by chronic inflammation and removed foreign body (fish bone) with confirmation of foreign body (fish bone) obstruction with wound at anterior aspect of neck as final diagnosis. Sutures removed after 10 days. Periodic follow up were taken upto 3 months to rule out any recurrences.

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Discussion

Patient recovered from pain completely after removal of foreign body and   there was disappearance of hyper echoic area Ultra sonographically. Penetrating wounds can damage nerves or blood vessels. Evaluating patient sensation and circulation is essential. Superficial foreign bodies can sometimes be palpated or visualized. Deeper foreign bodies may require additional methods to localize. Sushruta and his commentator Dalhan mentioned a better exposition of aseptic surgery that surgical instruments should be used after Agnitaptena (heated in fire) otherwise risk of suppuration may happen(16). Sushruta made   attention about ideal quality of incision, correct technique of incision, correct shape of incision at particular site, direction of incision, extension of incision, method of suturing, complication of improper incision etc. Sushruta advises the careful haemostasis during any kind of surgical procedure. After incision in surgical procedure or removal of foreign body make sure Nirlohitam vranam kritwa (make blood leakage free) by appropriate measures(17)

Conclusion

In this case an effort has been made to draw a special attention on ancient surgical concepts of Sushruta Samhita practicing today with few refinement. In this present case study, a foreign body in the form of fish bone was successfully excised. A surgeon should come to accurate diagnosis clinically and investigate thoroughly and then plan for the excision of foreign body with all aseptic precautions as soon as possible before it leads to any secondary complications.

Consent of patient: The written consent has been taken from relatives before the procedure  as  well  as  to publish  the  case  report  without  exploring identity of the patient.