cd /home/daytona/workspace/attachments/24010425-d151-4329-b6b1-81632d418c0d && p…

cd /home/daytona/workspace/attachments/24010425-d151-4329-b6b1-81632d418c0d && p…

which tesseract && tesseract --version 2>&1 | head -3; python3 -c "import pytess…

python3 -c " from pdf2image import convert_from_path import pytesseract import o…

cat /home/daytona/workspace/synopsis_ocr.txt

mkdir -p /home/daytona/workspace/synopsis-rewrite && ls /home/daytona/workspace/…

~/synopsis-rewrite/create_synopsis.js

const {
  Document, Packer, Paragraph, TextRun, HeadingLevel,
  AlignmentType, PageNumber, NumberFormat, Footer, Header,
  Table, TableRow, TableCell, WidthType, BorderStyle
} = require('docx');
const fs = require('fs');

const bold = (text, size) => new TextRun({ text, bold: true, size: size || 24 });
const normal = (text, size) => new TextRun({ text, size: size || 24 });
const italic = (text, size) => new TextRun({ text, italics: true, size: size || 24 });

function heading1(text) {
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    children: [bold(text, 26)],
    heading: HeadingLevel.HEADING_1,
    spacing: { before: 300, after: 150 },
  });
}

function heading2(text) {
  return new Paragraph({
    children: [bold(text, 24)],
    heading: HeadingLevel.HEADING_2,
    spacing: { before: 240, after: 120 },
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}

function para(text, spacing) {
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    children: [normal(text, 24)],
    spacing: { before: 80, after: 80, line: 360 },
    alignment: AlignmentType.JUSTIFIED,
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}

function bulletPara(text) {
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  });
}

function emptyLine() {
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}

const doc = new Document({
  sections: [
    {
      properties: {},
      children: [

        // TITLE PAGE
        emptyLine(),
        emptyLine(),
        new Paragraph({
          children: [bold('Comparative Study of Postoperative Outcomes in Preperitoneal versus Retromuscular Mesh Repair in Adult Paraumbilical Hernia: A Quasi-Experimental Study', 28)],
          alignment: AlignmentType.CENTER,
          spacing: { before: 200, after: 300 },
        }),
        new Paragraph({
          children: [bold('Muhammad Shahzeb', 24)],
          alignment: AlignmentType.CENTER,
          spacing: { after: 80 },
        }),
        new Paragraph({
          children: [normal('Post Graduate Resident, MS (General Surgery)', 24)],
          alignment: AlignmentType.CENTER,
          spacing: { after: 200 },
        }),
        new Paragraph({
          children: [normal('Under Supervision of', 24)],
          alignment: AlignmentType.CENTER,
          spacing: { after: 80 },
        }),
        new Paragraph({
          children: [bold('Prof. Dr. Zahid Sattar', 24)],
          alignment: AlignmentType.CENTER,
          spacing: { after: 80 },
        }),
        new Paragraph({
          children: [normal('Associate Professor of Surgery', 24)],
          alignment: AlignmentType.CENTER,
          spacing: { after: 80 },
        }),
        new Paragraph({
          children: [normal('Sahiwal Teaching Hospital, Sahiwal', 24)],
          alignment: AlignmentType.CENTER,
          spacing: { after: 200 },
        }),
        new Paragraph({
          children: [bold('University of Health Sciences, Lahore, Pakistan', 24)],
          alignment: AlignmentType.CENTER,
          spacing: { after: 400 },
        }),

        // PAGE BREAK
        new Paragraph({ children: [new TextRun({ text: '', break: 1 })], pageBreakBefore: true }),

        // LIST OF ABBREVIATIONS
        heading1('List of Abbreviations'),
        emptyLine(),

        new Table({
          width: { size: 100, type: WidthType.PERCENTAGE },
          rows: [
            ['BMI', 'Body Mass Index'],
            ['CDC', 'Centers for Disease Control and Prevention'],
            ['CI', 'Confidence Interval'],
            ['EHS', 'European Hernia Society'],
            ['IRB', 'Institutional Review Board'],
            ['NCCT', 'Non-Contrast Computed Tomography'],
            ['OR', 'Odds Ratio'],
            ['PH', 'Paraumbilical Hernia'],
            ['RR', 'Risk Ratio'],
            ['SD', 'Standard Deviation'],
            ['SPSS', 'Statistical Package for Social Sciences'],
            ['SSI', 'Surgical Site Infection'],
            ['TAR', 'Transversus Abdominis Release'],
            ['UHS', 'University of Health Sciences'],
            ['VAS', 'Visual Analogue Scale'],
            ['WMD', 'Weighted Mean Difference'],
          ].map(([abbr, full]) => new TableRow({
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                children: [new Paragraph({ children: [bold(abbr, 22)] })],
                width: { size: 25, type: WidthType.PERCENTAGE },
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                children: [new Paragraph({ children: [normal(full, 22)] })],
                width: { size: 75, type: WidthType.PERCENTAGE },
              }),
            ],
          })),
        }),

        emptyLine(),

        // PAGE BREAK
        new Paragraph({ pageBreakBefore: true, children: [new TextRun('')] }),

        // PROJECT SUMMARY
        heading1('Project Summary'),

        para('Paraumbilical hernia (PH) ranks among the most prevalent abdominal wall defects encountered in general surgical practice, with a reported lifetime prevalence ranging from 3 to 10 percent in the adult population. The condition predominantly affects individuals with predisposing factors such as obesity, multiparity, and advancing age. When left without intervention, PH carries the risk of irreversible complications including incarceration and strangulation, which justify elective surgical repair in all fit, symptomatic individuals.'),

        para('Two well-established open mesh repair techniques are currently employed for PH: preperitoneal mesh placement (in the potential space between the transversalis fascia and parietal peritoneum) and retromuscular mesh placement (in the retrorectus space, posterior to the posterior rectus sheath). Each technique differs in the extent of dissection required, the biomechanical environment of mesh fixation, and the anticipated profile of wound-related morbidity. Despite both approaches having gained traction in surgical practice, no dedicated prospective comparative study exists specifically for adult PH in the Pakistani surgical context, and published evidence on this specific comparison in an open operative setting remains sparse.'),

        para('This quasi-experimental comparative study is designed to evaluate and directly compare 30-day postoperative outcomes of preperitoneal versus retromuscular open mesh repair among adult patients with primary, reducible paraumbilical hernia at the Department of Surgery, Sahiwal Teaching Hospital, Sahiwal. A sample of 50 adult patients (25 per group) will be enrolled through consecutive non-probability sampling over a 12-month recruitment period. All patients will receive a standardised polypropylene mesh; Group A will undergo open preperitoneal mesh repair, and Group B will undergo open retromuscular (Rives-Stoppa) mesh repair. The primary outcome is the 30-day postoperative complication rate, which encompasses seroma formation, surgical site infection, haematoma, wound dehiscence, and early hernia recurrence. Secondary outcomes include operative time, postoperative pain assessed by Visual Analogue Scale at 24 and 72 hours, length of hospital stay, time to return to normal activity, and patient satisfaction scores. Data will be analysed using SPSS version 26; chi-squared test, independent-sample t-test, and Mann-Whitney U test will be applied as appropriate, with a significance threshold of p < 0.05.'),

        para('The study is anticipated to show that retromuscular mesh placement, by virtue of its wider mesh overlap and biomechanically superior pressure distribution, yields lower seroma and recurrence rates relative to the preperitoneal technique, whereas the preperitoneal approach may demonstrate advantages in operative time and technical simplicity for smaller defects. The findings will furnish locally relevant, evidence-based guidance for surgical decision-making in resource-constrained settings and contribute to standardisation of hernia repair practice across Pakistani surgical institutions.'),

        // PAGE BREAK
        new Paragraph({ pageBreakBefore: true, children: [new TextRun('')] }),

        // INTRODUCTION
        heading1('Introduction'),

        para('Abdominal wall hernias constitute one of the most frequently encountered surgical conditions globally, and among these, paraumbilical hernias account for a substantial proportion of elective general surgery admissions. A paraumbilical hernia is defined as a protrusion of intra-abdominal contents through a fascial defect situated in the linea alba within 2 to 3 cm of the umbilical ring, but not through the umbilical ring itself. Global prevalence estimates range from 3 to 10 percent in the adult population, with a notably higher burden observed in settings where obesity is rising, including urban Pakistan (Sabiston Textbook of Surgery, 22nd ed.; Mulholland and Greenfield\'s Surgery, 2022). Without surgical treatment, PH carries a defined risk of incarceration and strangulation, with associated morbidity and mortality, establishing elective repair as the standard of care for symptomatic patients who are fit for surgery.'),

        para('The historical evolution of hernia surgery has been driven largely by the pursuit of lower recurrence rates. Primary suture closure, though simple to perform, carries an unacceptably high long-term recurrence burden. Meta-analytic evidence from Dias Rasador et al. (Hernia, 2024; PMID 39001938) demonstrated that primary suture repair of umbilical and paraumbilical hernias recurs in up to 54.5 percent of cases at long-term follow-up, compared with approximately 10 percent following mesh-based repair. This body of evidence has established prosthetic mesh repair as the preferred approach for defects larger than 1 cm, as recommended by the European Hernia Society (EHS) guidelines (Muysoms et al., Hernia, 2015). However, consensus on the optimal anatomical plane for mesh placement in adult paraumbilical hernia has not yet been reached.'),

        para('The retromuscular technique, originally described by Rives and Stoppa, involves positioning the mesh in the avascular retrorectus space posterior to the posterior rectus sheath. The underlying principle is biomechanical: rising intra-abdominal pressure acts to press the mesh against the posterior sheath rather than to displace it, thereby conferring inherent stability. In contrast, the preperitoneal approach positions the mesh between the transversalis fascia and the parietal peritoneum. While this requires less posterior sheath dissection and is technically less demanding, it provides a narrower dissection plane and relies on a different fixation mechanism. Both approaches employ polypropylene mesh and are performed through a midline incision, though they differ in the depth and extent of the dissection required.'),

        para('Despite both techniques being in regular use at tertiary surgical centres, the existing literature does not contain a dedicated prospective comparative study focusing specifically on adult paraumbilical hernia treated in an open operative setting within the South Asian context. This study has accordingly been designed to address this gap and generate locally applicable evidence to guide surgical decision-making in Pakistan.'),

        // PAGE BREAK
        new Paragraph({ pageBreakBefore: true, children: [new TextRun('')] }),

        // LITERATURE REVIEW
        heading1('Literature Review'),

        para('Mesh-based repair has attained the status of standard practice for elective primary and recurrent adult paraumbilical hernia repair. The EHS guidelines recommend prosthetic mesh use whenever the defect exceeds 1 cm in diameter, on the grounds that mesh significantly reduces long-term recurrence compared with primary suture closure (Muysoms et al., Hernia, 2015). This recommendation is substantiated by the meta-analysis of Dias Rasador et al., which pooled data from 12 studies involving 2,926 patients and found that mesh repair reduced recurrence risk by 50 percent (RR 0.50; 95% CI 0.31-0.79; p = 0.003). Although the overall analysis identified higher seroma rates with mesh use (RR 1.88; 95% CI 1.07-3.32), this elevation was not statistically significant in the subgroup restricted to randomised controlled trials, an observation with important methodological implications.'),

        para('Among mesh-based techniques, the retromuscular (Rives-Stoppa) repair has accumulated the most robust evidence base, predominantly in the context of ventral and incisional hernias. The Rives-Stoppa retrorectus repair is described in Sabiston\'s Textbook of Surgery (22nd edition) as the reference open technique for ventral hernia repair, on the basis that the biomechanical properties of the retrorectus space allow intra-abdominal pressure to reinforce rather than displace mesh fixation. Published comparative series have reported recurrence rates of 3.5 to 10 percent with the retromuscular technique, substantially lower than those historically documented for non-mesh repair methods (Springer meta-analysis, Updates in Surgery, 2024). The scope of this technique has been extended by the Transversus Abdominis Release (TAR) modification, introduced by Novitsky et al. in 2012, which permits mesh overlap to extend beyond the linea semilunaris for complex abdominal wall reconstruction (Sabiston, 22nd ed.).'),

        para('The preperitoneal approach places the mesh in the potential space between the parietal peritoneum and the transversalis fascia, broadly corresponding to the space of Retzius in the lower abdomen. The most current comparative evidence comes from a systematic review and meta-analysis by Brucchi et al. (Journal of Robotic Surgery, 2025; PMID 41428244), conducted in a robotic surgical context. Across 3,704 patients (2,326 preperitoneal; 1,378 retromuscular), preperitoneal repair was associated with significantly shorter operative time (WMD -39.4 minutes; 95% CI -58.5 to -20.2; p < 0.001), lower overall complication rates (7.2% vs. 15.6%; RR 1.65; 95% CI 1.21-2.26), and reduced wound morbidity (RR 1.81; 95% CI 1.25-2.63). Recurrence rates at follow-up were statistically comparable between groups (1.9% vs. 0.5%; RR 0.95; 95% CI 0.29-3.11), which implies that for small to medium primary defects - the characteristic profile of most paraumbilical hernias - the preperitoneal approach may offer equivalent long-term durability with a lower burden of operative complexity and wound complications. The authors of this review noted, however, that for large or complex defects, retromuscular reconstruction remains the preferred approach, and that the findings may not be directly applicable to open surgical repair.'),

        para('Comparative evidence from open surgical series is limited. A systematic review by Martins et al. (Langenbecks Archives of Surgery, 2024) examined open and laparoscopic approaches for primary ventral hernias and found no statistically significant difference in recurrence rates, although laparoscopy was associated with a reduced risk of surgical site infection. Studies that compare preperitoneal and retromuscular mesh positioning specifically in an open setting for adult paraumbilical hernia are sparse. A prospective study from a peripheral hospital in India by Hanumanthappa et al. (Cureus, 2025; PMID 39958025), using onlay mesh repair, reported wound complication rates of 14 percent and a 6-month recurrence rate of 6 percent - figures broadly comparable to those reported for open preperitoneal repair, though potentially higher than those typical of the retromuscular approach. Collectively, these data affirm that mesh repair clearly outperforms primary closure but that the question of optimal mesh plane for adult paraumbilical hernia in an open surgical setting has yet to be resolved through dedicated prospective investigation.'),

        para('Given the absence of direct comparative evidence for this specific patient population undergoing elective open repair, this study adopts a quasi-experimental design comparing preperitoneal and retromuscular open mesh techniques at a single tertiary-care centre. The choice of a quasi-experimental rather than a fully randomised design is deliberate and reflects the operational constraints of surgical training institutions, where complete allocation concealment and surgeon blinding are not practically achievable. Methodological rigour is maintained through consecutive sampling, standardised operative protocols for both techniques, a uniform polypropylene mesh specification, blinded outcome assessment by an independent research assistant, and prospective follow-up with pre-specified, validated outcome measurement tools. Both techniques are delivered through a midline incision with standardised dissection to the hernia defect.'),

        para('The available evidence confirms that mesh-based ventral hernia repair consistently yields lower recurrence than suture repair, irrespective of technique. The question that remains unanswered - and which this study directly targets - is which mesh plane, preperitoneal or retromuscular, optimises the composite of postoperative morbidity and durability for adult paraumbilical hernia in an open setting at a resource-limited institution.'),

        // PAGE BREAK
        new Paragraph({ pageBreakBefore: true, children: [new TextRun('')] }),

        // HYPOTHESIS
        heading1('Hypothesis'),

        para('Alternative Hypothesis (H1): Retromuscular mesh repair is associated with a statistically significant difference in 30-day postoperative complication rate compared with preperitoneal mesh repair in adult patients with paraumbilical hernia.'),

        para('Null Hypothesis (H0): There is no statistically significant difference in 30-day postoperative complication rate between retromuscular and preperitoneal mesh repair in adult patients with paraumbilical hernia.'),

        // PAGE BREAK
        new Paragraph({ pageBreakBefore: true, children: [new TextRun('')] }),

        // OBJECTIVES
        heading1('Objectives'),

        heading2('Primary Objective'),
        para('To compare the 30-day postoperative complication rate - encompassing seroma formation, surgical site infection, haematoma formation, wound dehiscence, and early hernia recurrence - between open preperitoneal and open retromuscular mesh repair in adult patients with primary paraumbilical hernia.'),

        heading2('Secondary Objectives'),
        bulletPara('To compare operative time (in minutes) between the two repair techniques.'),
        bulletPara('To compare postoperative pain scores using the Visual Analogue Scale (VAS) at 24 hours and 72 hours between the two groups.'),
        bulletPara('To compare duration of hospital stay (in days) between the two study groups.'),
        bulletPara('To compare time to return to normal daily activity (in days) between the two groups.'),
        bulletPara('To compare early hernia recurrence rates at 30 days between the two surgical techniques.'),
        bulletPara('To assess and compare patient satisfaction scores at the 30-day follow-up visit.'),

        // PAGE BREAK
        new Paragraph({ pageBreakBefore: true, children: [new TextRun('')] }),

        // OPERATIONAL DEFINITIONS
        heading1('Operational Definitions'),

        heading2('Paraumbilical Hernia'),
        para('Protrusion of intra-abdominal contents through a fascial defect in the linea alba located within 2 to 3 cm of the umbilical ring, but not through the umbilical ring itself. Diagnosis is based on clinical examination and, where clinically indicated, confirmed by abdominal ultrasound (EHS, 2015).'),

        heading2('Preperitoneal Repair'),
        para('An open surgical technique in which polypropylene mesh is placed in the space between the transversalis fascia and the parietal peritoneum, behind the hernia defect, with a minimum mesh overlap of 3 cm beyond the defect margin in all directions (Mulholland and Greenfield\'s Surgery, 7th ed.).'),

        heading2('Retromuscular (Rives-Stoppa) Repair'),
        para('An open surgical technique in which polypropylene mesh is placed in the retrorectus space, posterior to the posterior rectus sheath and anterior to the rectus abdominis muscle, with a minimum mesh overlap of 5 cm beyond the defect margin in all directions (Sabiston Textbook of Surgery, 22nd ed.).'),

        heading2('Seroma'),
        para('Clinically detectable or radiologically confirmed accumulation of serous fluid in the subcutaneous layer or at the mesh interface, diagnosed by clinical examination or bedside ultrasonography within 30 days of the operative procedure.'),

        heading2('Surgical Site Infection (SSI)'),
        para('Infection involving the skin, subcutaneous tissue, or deeper fascial structures at the operative site, occurring within 30 days of surgery. SSI is classified and diagnosed according to the Centers for Disease Control and Prevention (CDC) criteria (superficial incisional, deep incisional, or organ/space) as defined by Horan et al. (American Journal of Infection Control, 1992).'),

        heading2('Haematoma'),
        para('A collection of blood within the subcutaneous tissue or deeper planes at the operative site, either clinically apparent or confirmed on ultrasonography, occurring within 30 postoperative days.'),

        heading2('Wound Dehiscence'),
        para('Partial or complete separation of the wound edges, with or without exposure of underlying tissue, identified on clinical examination within 30 days of surgery.'),

        heading2('Early Hernia Recurrence'),
        para('Reappearance of a clinically palpable or radiologically confirmed hernia at the index operative site, detected within 30 days of the repair procedure.'),

        heading2('Operative Time'),
        para('Total duration in minutes from initial skin incision to final skin closure, recorded prospectively by the scrub nurse or operating theatre team.'),

        heading2('Length of Hospital Stay'),
        para('Total number of inpatient days from the day of surgery to the day of discharge, inclusive of the day of discharge.'),

        heading2('Time to Return to Normal Activity'),
        para('Number of days from the operative date until the patient reports resumption of pre-illness daily activities, assessed at the 30-day outpatient follow-up visit.'),

        heading2('Patient Satisfaction'),
        para('A standardised 5-point Likert scale score (1 = very dissatisfied to 5 = very satisfied) administered to each patient at the 30-day follow-up visit, assessing overall experience and subjective recovery.'),

        heading2('Visual Analogue Scale (VAS) for Pain'),
        para('A validated 10-cm horizontal scale (0 = no pain; 10 = worst imaginable pain) administered at 24 hours and 72 hours postoperatively to quantify pain intensity in each study group.'),

        // PAGE BREAK
        new Paragraph({ pageBreakBefore: true, children: [new TextRun('')] }),

        // REFERENCES NOTE
        heading1('References'),
        bulletPara('Dias Rasador AC et al. Umbilical and paraumbilical hernia repair: systematic review and meta-analysis. Hernia. 2024. PMID: 39001938.'),
        bulletPara('Muysoms FE et al. EHS Clinical Guidelines: The role of mesh repair for small umbilical and epigastric hernias. Hernia. 2015; 19(1):1-9.'),
        bulletPara('Sabiston DC. Sabiston Textbook of Surgery. 22nd ed. Philadelphia: Elsevier; 2022.'),
        bulletPara('Mulholland MW, Greenfield LJ. Surgery: Scientific Principles and Practice. 7th ed. Philadelphia: Wolters Kluwer; 2022.'),
        bulletPara('Brucchi C et al. Robotic preperitoneal versus retromuscular hernia repair: systematic review and meta-analysis. J Robot Surg. 2025. PMID: 41428244.'),
        bulletPara('Martins C et al. Open versus laparoscopic repair of primary ventral hernia. Langenbecks Arch Surg. 2024.'),
        bulletPara('Hanumanthappa MB et al. Onlay mesh repair for paraumbilical hernia at a peripheral hospital. Cureus. 2025. PMID: 39958025.'),
        bulletPara('Novitsky YW et al. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012; 204(5):709-16.'),
        bulletPara('Horan TC et al. CDC definitions of nosocomial surgical site infections: a modification of CDC definitions of surgical wound infections. Am J Infect Control. 1992; 20(5):271-4.'),

      ],
    },
  ],
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync('/home/daytona/workspace/synopsis-rewrite/Shahzeb_Synopsis_Rewritten.docx', buffer);
  console.log('Done: Shahzeb_Synopsis_Rewritten.docx created');
});

cd /home/daytona/workspace/synopsis-rewrite && node create_synopsis.js 2>&1

python3 /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/works…

# Validate by checking the file size and that it can be opened with python-docx …

# Verify it's a valid ZIP/docx by inspecting its structure python3 -c " import z…