Evaluation of Rhomboid Flap Outcome in the Surgical Treatment of Recurrent Sacrococcygeal Pilonidal Sinus vs. Deep Suturing
Conditions: Pilonidal Sinus Infected
Sponsor: Assiut University

Faculty of Medicine 
Institutional Review Board (IRB) 
Assiut Medical School Research Proposal Form 
1 
Research Proposal Form 
This section is for Official Use Only 
Reference Code: 
 
 
Date of application (dd/mm/yyyy):  
10/08/2023 
 
 
 
This section is for the applicant to fill.  
• Use Times New Romans Font, size 11 and adjust line spacing to 1.5 all through the application form 
• Do not CAPITALIZE all words 
Part 1: General 
Master Degree  
 
 
b. MD     
           c. Independent Research/Project 
 
1.1 Applicant Name (responsible for all correspondences and accuracy of data):  
Ahmed Dify Kamal Mohamed 
Department: 
General Surgery 
e-mail address: ahmeddify94@gmail.com 
Mobile Phone:  01022552241 
اﻻﺳﻢ ﺑﺎﻟﻠﻐﺔ اﻟﻌﺮﺑﯿﺔ: أﺣﻤﺪ ﺿﯿﻔﻲ ﻛﻤﺎل ﻣﺤﻤﺪ 
Home Phone:  
.........
 
 
1.2 English Title of research project: 
Evaluation of Rhomboid flap outcome in the surgical treatment of recurrent sacrococcygeal pilonidal sinus 
vs. Deep suturing 
 
1.3 Arabic Title (use the WHO Unified Medical Dictionary): www.emro.who.int/unified-medical -dictionary.html 
ﺗﻘﯿﯿﻢ ﻧﺘﺎﺋﺞ اﻟﺴﺪﯾﻠﺔ اﻟﻤﻌﯿﻨﯿﺔ ﻓﻲ اﻟﻌﻼج اﻟﺠﺮاﺣﻲ ﻟﻠﻨﺎﺳﻮر اﻟﻌﺼﻌﺼﻲ اﻟﻤﺘﻜﺮر ﻣﻘﺎﺑﻞ اﻟﺨﯿﺎطﺔ اﻟﻌﻤﯿﻘﺔ 
 
1.4 Do you need funding from Assiut Medical School Grants Office? 
Yes  
 
 
No  
 
 
Mention other sponsoring agent(s) if any: …………………………………………... 

Faculty of Medicine 
Institutional Review Board (IRB) 
Assiut Medical School Research Proposal Form 
2 
 
Part 2: Research Details 
2.1 Background (Research Question, Available Data from the literature, Current strategy for dealing with the 
problem, Rationale of the research that paves the way to the aim(s) of the work). (200-250 words max.) 
Pilonidal disease derives its name from Latin- pilus meaning “hair,” and nidus meaning “nest” (1). The source of 
pilonidal disease is thought to be a deep intergluteal sulcus. It is widely accepted that the establishment of the pilonidal 
sinus results from the penetration of shed hair shafts through the skin, which ultimately leads to an acute or chronic 
infected site (2).  
Pilonidal disease is largely considered a surgical disease, especially in acute instances with secondary infection and 
abscess. Infection or abscess requires incision and drainage. Definitive treatment is delayed the majority of the time if 
there is an acute infection or abscess until after the infection has been addressed. Surgical options for chronic disease are 
numerous and can include “pit picking,” curettage, aspiration, unroofing, or surgical excision.  Defects can be closed 
primarily, with flaps or grafts, or allowed to heal by secondary intention (3-5).  
The most serious problem of the various surgical approaches proposed is the recurrence rate, ranging from 0% to 40% (6, 
7).  
The surgical treatment of patients with recurrent disease does not differ from the surgical treatment of primary pilonidal 
disease. In case of a recurrence with an abscess, incision and drainage prevail, while in case of chronic recurrent disease, 
a flap based procedure may be indicated following sinus excision with scarring, like the rhomboid flap (8, 9).  
To the best of our knowledge, the existing literature is poor with studies comparing flap-based techniques with deep 
suturing (or primary closure) techniques in the management of recurrent pilonidal disease. 
 
2.2 Aim(s) of the Research (50 words max): 
This prospective clinical trial aims to compare the perioperative outcomes of rhomboid flap versus deep suturing in the 
management of recurrent sacrococcygeal pilonidal disease. 
 
2.3 Research Domain (Faculty Research Plan). 
Evidence-based management of a common surgical problem. 
 
 
2.4. Research Methods and techniques: 
 

Faculty of Medicine 
Institutional Review Board (IRB) 
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2.4.1- Type of the study: A randomized controlled Clinical Trial 
2.4. 2- Study Setting: General Surgery Department, Assiut University Hospitals. 
2.4. 3- Study subjects: 
a. Inclusion criteria:  
b. Adult patients aged between 18 and 60 years;  
c. Patients with one or two small inactive sinuses will be included for easier excisional procedures; 
d. Previous intervention for pilonidal disease whether surgical or non-surgical; 
b. Exclusion criteria:  
1- Patients with an acute abscess. 
2- Patients with mall inactive pilonidal sinus disease. 
3- Age beyond the previous limits.  
4- Patients with primary pilonidal disease. 
5- Refusal to participate in the study. 
6- Unfit for anaesthesia and surgery. 
7- Patients with malignant neoplasms or inflammatory bowel disease. 
c. Sample Size Calculation:  
The required sample size was calculated using the IBMª SPSSª Sample Powerª version 3.0.1 (IBMª Corp., 
Armonk, NY, USA). A previous study conducted by Cihan et al. reported that the incidence of recurrence after 
Rhomboid Flap was 5.71% (9). Thus, it was estimated that a minimal sample size of 32 patients is required to 
achieve a power of 80% to detect expected difference of 14 % in the incidence of recurrence, at a significance 
level of 0.05. An equal number will be recruited in the deep closure group. 
2.4.4 –Study tools (in detail, e.g., lab methods, instruments, steps, chemicals, …): 
All patients will be subjected to complete history taking (focusing on the duration since the primary operation, symptoms 
and its duration), thorough physical examination, and routine preoperative blood tests (CBC, renal function, liver 
function, prothrombin time, random blood glucose). Additionally, conventional or magnetic resonance sinogram will 
ordered when required. 
The rhomboid flap Approach (32 patients) 
The patient will be operated on under spinal anesthesia. The patients will be placed in prone jack-knife position on the 
operating table with the legs slightly abducted and the buttocks strapped apart by adhesive tapes. The anus will be 
excluded from the operative field by surgical drapes. The pathologic area to be excised will be marked. This area will be 

Faculty of Medicine 
Institutional Review Board (IRB) 
Assiut Medical School Research Proposal Form 
4 
enclosed by a rhombus shape with the long axis in the midline (ABCD). Lines AB = BC = CD = DA will be equal to 
each other, with the axis AC being along the natal cleft. Line BD will be extended transversely and then the line EF will 
be drawn equal in length. The rhombus containing the pilonidal sinus will be then excised down to the periosteum in the 
midline and gluteal fascia laterally. Meticulous hemostasis will be done by means of electrocautery. 
The flap will be dissected deep to the gluteal fascia (subfascial level) so as to raise thick a fasciocutaneous flap. This will 
assure good vascularity of the flap without dead space. The rhomboid flap (CDEF) will be mobilized from the gluteal 
fascia and sutured without tension in three layers (gluteal fascia with 2/0 Vicryl, subcutaneous fat with 3/0 Vicryl, and 
the skin with 4/0 Prolene). As all sides will be equal in length, the flap fits in place without tension. A suction drain will 
be left behind and the wound will be dressed as usual. Pressure wound dressing will be applied and removed on the third 
postoperative day. 
The deep suturing approach (32 patients) 
A vertical elliptical incision encompassing all pilonidal pits will be made and excision of the sinus will be carried out 
down to the level of the sacrococcygeal fascia. Tension will be released by a limited sharp dissection above the fascia. 
After haemostasis is ensured using electrocautery, a suction drain will be inserted through a separate incision, then the 
deep fascia will be approximated and the wound will be closed in layers using polyglactin 0 sutures. Finally, the skin will 
be closed with 2/0 polypropylene interrupted mattress sutures. 
 
Postoperative care and follow-up 
Standard postoperative care, including mobilization and return to normal diet as quickly as possible will be 
recommended. Early postoperative complications (bleeding and urine retention) will be noticed and recorded. Pain score 
and early wound infection will be recorded. Post-operative pain will be assessed on the first, fourth postoperative day and 
at stitch removal using a visual analogue scale (VAS) from zero (no pain) to 10 (worst pain imaginable) (10). 
 
Patient will be discharged usually on the next day. Oral antibiotics and analgesics will be prescribed on patient’s 
discharge. All the patients will be advised to shave the area around the operative site at least monthly. 
 
All the patients will be recommended to visit the outpatient clinic twice weekly for two weeks then weekly for another 
two weeks and then every 1 month during the follow-up period (6 months). During each visit, complete patient 
assessment will be done. If any complications are detected (seroma, recurrence, wound dehiscence), it will be recorded as 
well. 
 

Faculty of Medicine 
Institutional Review Board (IRB) 
Assiut Medical School Research Proposal Form 
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Infection will be considered as leakage of purulent secretion through the surgical wound and not only peri-incisional 
hyperaemia. The suction drain will be removed when drainage became less than 20 mL per day (11). Seroma will be 
defined as the formation of non-infected serous fluid collection beneath the flap and diagnosed by clinical examination 
(12).  
 
Duration of incapacity for work will be defined as the date on which patient returned to normal activities including 
employment and leisure activities time from the date of surgery. In addition, patients will be asked to evaluate the 
cosmetic appearance of the wound by looking at its picture using VAS ranging from 0-10 where 0 means the worst 
cosmetic outcome and 10 indicates the best cosmetic outcome. A Turkish study used a 0 to 10 visual analogue scale 
(VAS) scale to assess patient satisfaction with their cosmetic outcome (13). 
 
2.4.5 –Research outcome measures: 
a. Primary (main): 
Postoperative recurrence rate. Recurrence will be defined as the additional outbreak of signs and symptoms of 
pilonidal disease after a disease-free interval following complete wound healing (8). 
      b. Secondary (subsidiary): 
1. Operative time. 
2. Postoperative pain. 
3. The incidence of other complications. 
4. Postoperative cosmetic outcome. 
5. The duration to walk, sit on toilet free from pain. 
6. The duration till complete daily activities. 
 
 
2.5-Data management and analysis (Details needed): 
Data collection 
Data will be collected by the principal investigator from Assiut University Hospital from. 
Computer software 
We will use SPSS version 26 for analyzing the data. 
Statistical tests 
Quantitative data will be presented as means ± SD. Categorical and binary variables will be tested using 
the χ 2 test and Fisher’s exact test. Statistical significance will be assumed when p < 0.05. 
 
2.6-References (max. 15) and written in Vancouver style: 
(1)Esposito C, Cerulo M, Esposito G, Turco A, Borgogni R, Carulli R, et al. Endoscopic Treatment of 
Pilonidal Sinus Disease in Children: A Systematic Review. Journal of Laparoendoscopic & Advanced Surgical 

Faculty of Medicine 
Institutional Review Board (IRB) 
Assiut Medical School Research Proposal Form 
6 
Techniques. 2023;33(5):512-7. 
 (2)Konoplitskyi V, Shavliuk R, Dmytriiev D, Dmytriiev K, Kyrychenko O, Zaletskyi B, et al. Pilonidal 
disease: changes in understanding of etiology, pathogenesis and approach to treatment. Wiadomosci Lekarskie 
(Warsaw, Poland: 1960). 2019;72(8):1559-65. 
 (3)Harries RL, Alqallaf A, Torkington J, Harding KG. Management of sacrococcygeal pilonidal sinus 
disease. International Wound Journal. 2019;16(2):370-8. 
 (4)Grabowski J, Oyetunji TA, Goldin AB, Baird R, Gosain A, Lal DR, et al. The management of pilonidal 
disease: a systematic review. Journal of pediatric surgery. 2019;54(11):2210-21. 
 (5)Saber A, Bayumi EK. Sacrococcygeal Pilonidal Sinus Disease. In: Shiffman MA, Low M, editors. 
Biofilm, Pilonidal Cysts and Sinuses. Cham: Springer International Publishing; 2020. p. 215-30. 
 (6)Monson JRT, Weiser MR, Buie WD, Chang GJ, Rafferty JF, Buie WD, et al. Practice parameters for 
the management of rectal cancer (revised). Diseases of the Colon & Rectum. 2013;56(5):535-50. 
 (7)Manigrasso M, Velotti N, Sosa Fernandez LM, Vertaldi S, Maione F, Gennarelli N, et al. Endoscopic 
approach to recurrent pilonidal sinus: a retrospective analysis. Journal of Laparoendoscopic & Advanced 
Surgical Techniques. 2021;31(1):1-5. 
 (8)Milone M, Basso L, Manigrasso M, Pietroletti R, Bondurri A, La Torre M, et al. Consensus statement 
of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease. 
Techniques in Coloproctology. 2021:1-12. 
 (9)Cihan A, Ucan BH, Comert M, Cesur A, Cakmak GK, Tascilar O. Superiority of asymmetric modified 
Limberg flap for surgical treatment of pilonidal disease. Diseases of the colon & rectum. 2006;49:244-9. 
 (10)Crichton N. Visual analogue scale (VAS). J Clin Nurs. 2001;10(5):706-6. 
 (11)Tavassoli A, Noorshafiee S, Nazarzadeh R. Comparison of excision with primary repair versus Limberg 
flap. International Journal of Surgery. 2011;9(4):343-6. 
 (12)Arnous M, Elgendy H, Thabet W, Emile SH, Elbaz SA, Khafagy W. Excision with primary midline 
closure compared with Limberg flap in the treatment of sacrococcygeal pilonidal disease: a randomised clinical 
trial. The Annals of The Royal College of Surgeons of England. 2019;101(1):21-9. 
 (13)Ertan T, Koc M, Gocmen E, Aslar AK, Keskek M, Kilic M. Does technique alter quality of life after 
pilonidal sinus surgery? The American journal of surgery. 2005;190(3):388-92. 
 
 

Faculty of Medicine 
Institutional Review Board (IRB) 
Assiut Medical School Research Proposal Form 
7 
Part 3: Ethical Considerations (Written in detail taking into consideration the items below): 
 
3.1. Risk – benefit assessment: 
Risk of complications after surgery included infection, wound dehiscence, and recurrence. 
Benefit by removing sinus tracts which will significantly improve patient satisfaction and quality of life. 
3.2. Confidentiality (dealing with data and data dissemination should be confidential). 
Principle investigator should maintain a confidential list of patients included in the study along with their 
national IDs so that patients can be identified at a later date for follow-up and validation if required. This list 
should be stored in line with Assiut university data protection laws. 
3.3. Statement describing the research procedure to be given to the participants. 
two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy. 
single-stage laparoscopic CBD exploration and cholecystectomy. 
3.4. Informed consent. 
Informed consent will be obtained from the participants before the enrollment and after explaining the study. 
3.5. Other ethical concerns: 
- The research should be conducted only by scientifically qualified and trained personnel. 
- The research should be based on relevant pre-clinical investigations in animals. 
- The detailed consent form must be inserted here in the proposal. 
 
ﻣﻮاﻓﻘﺔ ﻟﻼﺷﺘﺮاك ﻓﻲ اﻟﺒﺤﺚ اﻟﻌﻠﻤﻲ:
 
اﺳﻢ اﻟﺒﺎﺣﺚ: أﺣﻤﺪ ﺿﯿﻔﻲ ﻛﻤﺎل ﻣﺤﻤﺪ 
ﻋﻨﻮان اﻟﺒﺤﺚ: ﺗﻘﯿﯿﻢ ﻧﺘﺎﺋﺞ اﻟﺴﺪﯾﻠﺔ اﻟﻤﻌﯿﻨﯿﺔ ﻓﻲ اﻟﻌﻼج اﻟﺠﺮاﺣﻲ ﻟﻠﻨﺎﺳﻮر اﻟﻌﺼﻌﺼﻲ اﻟﻤﺘﻜﺮر ﻣﻘﺎﺑﻞ اﻟﺨﯿﺎطﺔ اﻟﻌﻤﯿﻘﺔ 
ﻧﻮع اﻟﺒﺤﺚ : ﻋﺸﻮاﺋﻲ ﻣﻨﻀﺒﻂ  
ﻣﻜﺎن اﺟﺮاء اﻟﺒﺤﺚ: ﻗﺴﻢ اﻟﺠﺮاﺣﺔ اﻟﻌﺎﻣﺔ – ﻣﺴﺘﺸﻔﯿﺎت ﺟﺎﻣﻌﺔ أﺳﯿﻮط 
أﻧﺖ ﻣﺪﻋﻮ)ة( ﻟﻠﻤﺸﺎرﻛﺔ ﺑﺒﺤﺚ ﻋﻠﻤﻲ ﺳﺮي ﺳﯿﺠﺮى ﻓﻲ ﻗﺴﻢ اﻟﺠﺮاﺣﺔ اﻟﻌﺎﻣﺔ - ﻣﺴﺘﺸﻔﯿﺎت ﺟﺎﻣﻌﺔ اﺳﯿﻮط. اﻟﺮﺟﺎء أن ﺗﺄﺧﺬ)ي( اﻟﻮﻗﺖ اﻟﻜﺎﻓﻲ 
ﻟﻘﺮاءة اﻟﻤﻌﻠﻮﻣﺎت اﻟﺘﺎﻟﯿﺔ ﺑﺘﺎن ﻗﺒﻞ أن ﺗﻘﺮر)ي( أذا ﻛﻨﺖ ﺗﺮﯾﺪ)ﯾﻦ( اﻟﻤﺸﺎرﻛﺔ أم ﻻ. ﺑﺈﻣﻜﺎﻧﻚ طﻠﺐ اﯾﻀﺎﺣﺎت او ﻣﻌﻠﻮﻣﺎت اﺿﺎﻓﯿﺔ ﻋﻦ اي ﺷﻲء 
ﻣﺬﻛﻮر ﻓﻲ ھﺬه اﻻﺳﺘﻤﺎرة او ﻋﻦ ھﺬه اﻟﺪراﺳﺔ ﻛﻜﻞ ﻣﻦ طﺒﯿﺒﻚ.
 
وﯾﺘﻌﮭﺪ اﻟﺒﺎﺣﺚ ﺑﺎﻧﮫ ﻗﺪ ﺗﻢ وﺻﻒ ﻟﻠﻤﺮﯾﺾ اﻟﺒﺤﺚ اﻟﻌﻠﻤﻲ وھﺪﻓﮫ وﺗﻔﺴﯿﺮ ﻣﺠﺮﯾﺎﺗﮫ، اﻟﻔﻮاﺋﺪ اﻟﺘﻲ ﺗﻨﺘﺞ ﻋﻦ ھﺬا اﻟﺒﺤﺚ، اﻟﺘﺄﺛﯿﺮات اﻟﺴﻠﺒﯿﺔ اﻟﺘﻲ 
ﯾﻤﻜﻦ أن ﯾﺴﺒﺒﮭﺎ ھﺬا اﻟﺒﺤﺚ، اﻟﻄﺮق اﻟﺒﺪﯾﻠﺔ ﻟﻠﻮﺻﻮل ﻟﻠﮭﺪف اﻟﻤﺮﺟﻮ.
 
وأﯾﻀﺎ ﻓﻲ ﺣﺎﻟﺔ اﻟﻤﻮاﻓﻘﺔ ﻋﻠﻰ اﻟﻤﺸﺎرﻛﺔ ﻓﻲ ھﺬه اﻟﺪراﺳﺔ ﺳﯿﺒﻘﻰ اﺳﻤﻚ طﻲ اﻟﻜﺘﻤﺎن. ﻟﻦ ﯾﻜﻮن ﻷي ﺷﺨﺺ, ﻣﺎ ﻟﻢ ﯾﻨﺺ اﻟﻘﺎﻧﻮن ﻋﻠﻰ ذﻟﻚ, ﺣﻖ 
اﻻطﻼع ﻋﻠﻰ ﻣﻠﻔﻚ اﻟﻄﺒﻲ ﺑﺎﺳﺘﺜﻨﺎء اﻟﻄﺒﯿﺐ اﻟﻤﺴﺌﻮل ﻋﻦ اﻟﺪراﺳﺔ و ﻣﻌﺎوﻧﯿﮫ وﻟﺠﺎن اﻻﺧﻼق اﻟﻤﮭﻨﯿﺔ اﻟﻤﺴﺘﻘﻠﺔ و ﻣﻔﺘﺸﯿﻦ ﻣﻦ اﻻدارات 
اﻟﺤﻜﻮﻣﯿﺔ اﻟﻤﻨﻈﻤﺔ.
 
اذا ﺣﺼﻞ اي ﻋﺎرض ﺳﻠﺒﻲ ﻣﻦ ﺟﺮاء اﻟﻤﺸﺎرﻛﺔ ﻓﻲ ھﺬه اﻟﺪراﺳﺔ ﻟﻦ ﯾﻜﻮن ھﻨﺎك اي ﺗﻌﻮﯾﻀﺎت ﻣﺎﻟﯿﺔ.
 
أﻗﺮ اﻧﺎ ____________________________ (أﺳﻢ اﻟﻤﺮﯾﺾ او ﻣﻤﺜﻠﮫ اﻟﻘﺎﻧﻮﻧﻲ او وﻟﯿﮫ اﻟﺠﺒﺮي او وﺻﯿﮫ اذا ﻛﺎن اﻟﻤﺮﯾﺾ ﻗﺎﺻﺮا او 
ﻏﯿﺮ ﻗﺎدرا ﻋﻠﻰ اﻟﺘﻮﻗﯿﻊ ) ﺑﺎن اﻟﻄﺒﯿﺐ ﻗﺪ ﺷﺮح اﻟﺒﺤﺚ اﻟﻌﻠﻤﻲ و ھﺪﻓﮫ و ﻓﻮاﺋﺪه واﻟﺘﺄﺛﯿﺮات اﻟﺴﻠﺒﯿﺔ اﻟﺘﻲ ﻗﺪ ﯾﺴﺒﺒﮭﺎ, واﯾﻀﺎ اﻟﻤﻀﺎﻋﻔﺎت اﻟﺘﻲ ﻗﺪ 
ﺗﻨﺘﺞ ﻋﻦ اﻟﺠﺮاﺣﺔ اﺛﻨﺎء وﺑﻌﺪ اﻟﻌﻤﻠﯿﺔ. واﻧﻨﻲ اواﻓﻖ ﻋﻠﻰ اﺟﺮاء اﻟﻌﻤﻠﯿﺔ واﻟﻤﺸﺎرﻛﺔ ﻓﻲ اﻟﺒﺤﺚ اﻟﻌﻠﻤﻲ وﻧﺸﺮ اي ﻣﻌﻠﻮﻣﺎت او ﺑﯿﺎﻧﺎت ﺧﺎﺻﺔ 
ﺑﺎﻟﺠﺮاﺣﺔ.
 
أﺳﻢ اﻟﺒﺎﺣﺚ                                                                       :أﺳﻢ اﻟﻤﺮﯾﺾ:
 
اﻟﺘﻮﻗﯿﻊ                                                                             :اﻟﺘﺎرﯾﺦ: 

Faculty of Medicine 
Institutional Review Board (IRB) 
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Part 4: Funding (Mandatory for those requesting funding from Grant Office) 
4.1. Total funds requested:                                                  LE 
 
4.2. Author responsible for managing the budget/grant (Cannot be a resident): 
Name 
 
Department 
 
e-mail 
 
Mobile 
 
 
4.3. Budget Details 
Cost 
§ Research equipment and accessories 
 
§ Chemicals/Medications 
 
§ Data entry 
 
§ Statistical analysis 
 
 
4.4. All researchers’ International publications in the last 3 years.  
 
Title 
Journal 
Impact 
Factor 
1 
 
 
 
2 
 
 
 
3 
 
 
 
4 
 
 
 
5 
 
 
 
(Add others if required) 
4.5. Details of Previously Obtained Grants (institutional or others): 
 
Title 
Name of 
Applicant for 
grant 
Date 
obtained 
Finished 
Yes/No 
Published 
Yes/No 
1 
 
 
 
 
 
2 
 
 
 
 
 
3 
 
 
 
 
 
4 
 
 
 
 
 
(Add others if required) 

Faculty of Medicine 
Institutional Review Board (IRB) 
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4.6. Research reporting timetable (Mandatory if applying for a fund): 
Activity 
(Other activities may be added) 
Time required (Months) 
2 
4 
6 
8 
10 
12 
14 
16 
18 
20 
22 
24 
Preparation and development of Material 
 
 
 
 
 
 
 
 
 
 
 
 
Training of personnel involved in the research (if 
needed) 
 
 
 
 
 
 
 
 
 
 
 
 
Research work (Clinical, lab work or field work) 
 
 
 
 
 
 
 
 
 
 
 
 
Data entry and analysis 
 
 
 
 
 
 
 
 
 
 
 
 
Research writing 
 
 
 
 
 
 
 
 
 
 
 
 
Publication 
 
 
 
 
 
 
 
 
 
 
 
 
* Numbers indicates the time in months needed to complete each part of the project.  
* Please half squares corresponding to time required for each specific action 
 
ﯾﺘﻌﮭﺪ اﻟﺒﺎﺣﺜﻮن ﺑﻨﺸـﺮ ﻧﺘـﺎﺋﺞ اﻟﺒﺤـﺚ اﻟﻤﻤـﻮل ﻣـﻦ وﺣـﺪة ﺗﻤﻮﯾـﻞ اﻷﺑﺤـﺎث ﻓـﻰ إﺣـﺪى اﻟـﺪورﯾﺎت 
اﻟﻌﻠﻤﯿـﺔ اﻟﻤﺤﻜﻤـﺔ واﻟﻤﺪرﺟـﺔ ﻋﻠـﻰ ﻗﺎﻋـﺪة Scopus أو Web Of Science
 ﻓـﻰ ﺧـﻼل 
اﻟﻔﺘﺮة اﻟﺰﻣﻨﯿﺔ اﻟﻤﺤﺪدة ﻓﻰ اﻟﺒﻨﺪ اﻟﺴﺎﺑﻖ ﻣﻦ ﻗﺒﻠﮭﻢ واﻻ ﯾـﺘﻢ ﺧﺼـﻢ ﻣﺒﻠـﻎ اﻟﺘﻤﻮﯾـﻞ ﻣـﻦ ﻣﺮﺗﺒـﺎﺗﮭﻢ 
ﺑﺎﻟﺘﺴﺎوى ﻓﯿﻤﺎ ﺑﯿـﻨﮭﻢ ﻛﻤـﺎ ﯾﺘﻌﮭـﺪوا ﺑﺎﻹﺷـﺎرة اﻟـﻰ ﻣﺴـﺎھﻤﺔ وﺣـﺪة ﺗﻤﻮﯾـﻞ اﻷﺑﺤـﺎث ﺑﻜﻠﯿـﺔ طـﺐ 
أﺳﯿﻮط ﻋﻨﺪ ﻧﺸﺮ اﻟﺒﺤﺚ. 

Faculty of Medicine 
Institutional Review Board (IRB) 
Assiut Medical School Research Proposal Form 
 
 
 
 
 
 
 
 
10 
Part 5 – Declaration (Name in printed letters): 
I / we (all investigators) certify that, to the best of our knowledge and after reasonable inquiry, the information contained in 
this application, and any supporting documents provided with this application, are correct and complete, and that this 
research has not been conducted or published before. 
ﯾﺘﻌﮭﺪ اﻟﺒﺎﺣﺜﻮن ﺑﻨﺸﺮ ﻧﺘﺎﺋﺞ اﻟﺒﺤﺚ اﻟﻤﻤﻮل ﻣﻦ وﺣﺪة ﺗﻤﻮﯾﻞ اﻷﺑﺤﺎث ﻓﻰ إﺣﺪى اﻟﺪورﯾﺎت اﻟﻌﻠﻤﯿﺔ اﻟﻤﺤﻜﻤﺔ واﻟﻤﺪرﺟﺔ ﻋﻠﻰ ﻗﺎﻋﺪة 
Scopus أو Web Of Science
 ﻓﻰ ﺧﻼل اﻟﻔﺘﺮة اﻟﺰﻣﻨﯿﺔ اﻟﻤﺤﺪدة ﻓﻰ اﻟﺒﻨﺪ اﻟﺴﺎﺑﻖ ﻣﻦ ﻗﺒﻠﮭﻢ واﻻ ﯾﺘﻢ ﺧﺼﻢ ﻣﺒﻠﻎ اﻟﺘﻤﻮﯾﻞ ﻣﻦ 
ﻣﺮﺗﺒﺎﺗﮭﻢ ﺑﺎﻟﺘﺴﺎوى ﻓﯿﻤﺎ ﺑﯿﻨﮭﻢ ﻛﻤﺎ ﯾﺘﻌﮭﺪوا ﺑﺎﻹﺷﺎرة اﻟﻰ ﻣﺴﺎھﻤﺔ وﺣﺪة ﺗﻤﻮﯾﻞ اﻷﺑﺤﺎث ﺑﻜﻠﯿﺔ طﺐ أﺳﯿﻮط ﻋﻨﺪ ﻧﺸﺮ اﻟﺒﺤﺚ. 
Authorship Responsibility (Add more authors if required) 
 
Title Name 
Role** 
e-mail 
Phone 
Department 
Signature 
1 Prof. Abd El-Moniem Ismail Mohamad El-Khateeb 
supervisior Abdelmoneam.elkhateb
@med.au.edu.eg 
01005022533 
General 
surgery 
 
2 Lect. Ahmed Mohamed Ali Abdullah 
supervisior Ahmed.abdallah6@med
.au.edu.eg 
01000363039 
General 
surgery 
 
3 Lect. Moamen shalkamy abdelgawad 
supervisior Moamen.shalkamy@au
n.edu.eg 
01017520093 
General 
surgery 
 
4 G.P. 
Ahmed Dify Kamal Mohamed 
Researcher  Ahmeddify94@gmail.c
om 
01022552241 
General 
surgery  
 
5  
 
 
 
 
 
 
**Choose at least 1 from each of the 3 groups below 
Group 1 
Group 2 
Group 3 
1.1- Conception and design 
1.2- Acquisition of data 
1.3- Analysis and interpretation of data 
2.1- Drafting of the submitted protocol 
2.2-Critical revision of the submitted protocol for important intellectual content 
3.1- Statistical analysis 
3.2- Obtaining funding 
3.3- Administrative, technical, or material support 
3.4- Supervision 
3.5- Other (specify) 
 
After completing the application form, please  
1. Record the completed and revised application form on a CD and present to the Vice Dean Research Office. 

Faculty of Medicine 
Institutional Review Board (IRB) 
Assiut Medical School Research Proposal Form 
 
 
 
 
 
 
 
 
11 
2. All authors should sign a printed copy of the completed application form that should be presented as well to the Vice Dean Research Office. 
3. A copy of the printed and signed research application form should be presented to the Ethical Committee. 
4. It is the applicant responsibility to make sure that the application form is fully and accurately completed and that all other supporting documents or formalities are 
completed in due time.