Anatomical Variations Of Cystic Artery: Telescopic Facts

The introduction of laparoscopic cholecystectomy has stimulated a renewed interest in the anatomy of Calot’s triangle 1. This triangle is a focal area of anatomical importance in cholecystectomy and a good knowledge of its anatomy is essential for both open and laparoscopic cholecystectomy 2, 3. This triangle was described by Calot in 1891 as bounded by the cystic duct, the right hepatic duct and lower edge of liver 4. In its present interpretation the upper border is formed by the inferior surface of the liver with the other two boundaries being the cystic duct and the common hepatic duct 2,5. Its contents usually include the right hepatic artery (RHA), the cystic artery, the cystic lymph node (of Lund), connective tissue and lymphatics 5,6. The cystic artery is a branch of the RHA and is usually given off in Calot’s triangle 7. Anatomic variations in Calot’s triangle are common. Variations in cystic artery anatomy, based on its origin, position and number are well described 3, 8 because of its importance in avoiding inadvertent bleeding and its consequences. The reported incidence of these variations is from 25 to 50 % in various studies 3,9 with the magnified laparoscopic view having increased the frequency of recognition of these variations. The methods of retraction used in the laparoscopic procedure gives a different view of the area, thus introducing the term ‘laparoscopic anatomy’7. Accurate knowledge of cystic artery anatomy and its variations can reduce the likelihood of uncontrolled intraoperative bleeding, an important cause of iatrogenic extra hepatic biliary injury and conversion to open cholecystectomy 3, 7, 8. The incidence of conversion to open surgery due to vascular injury is reported to be 0-1.9% and its mortality 0.02% 3, hence these variations should stay in surgical conscience to prevent procedure related morbidity. We aim to present the variations in cystic artery seen in laparoscopic cholecystectomy in our patient population.

Minimal access surgery training of general surgical residents in Karachi, Pakistan; where do we stand?

To evaluate post graduate surgical residents' training in minimal access surgery. This cross sectional survey was based on a 16-item self reporting questionnaire that was provided to 48 third, fourth and fifth year postgraduate general surgical trainees doing residency in seven Karachi institutions accredited by College of Physicians and Surgeons Pakistan for Fellowship training. All 48 trainees completed and returned the given questionnaire. Eleven were 3[rd] year, 33 were 4[th] year and four trainees were 5[th] year residents. Mean age of the trainees was 30.31[SD 2.8] years [range 27 to 43], Males were 35 [72.92%], females were 13 [27.08%]. Forty six [95.83%] answered that laparoscopic surgery was performed in their department, while two [4.17%] replied in negative. Nine [18.75%] said that they had performed Laparoscopic Cholecystectomy under supervision, while 39 [81.25%] responded "no". Regarding "Dry Lab" access 18[37.5%] responded "yes" while 30 [62.5%] said no. Similarly regarding "Wet Lab" none said "yes", all [100%] responded by saying "No" as was the case of Virtual Reality Simulator where 45 [93.75%] said "No" while three [6.25%] did not answer this question and none responded "Yes". Out of the 48 trainees questioned only nine [18.75%] had ever attended a Basic Laparoscopy workshop while 39 [81.25%] had not. Trainees own perception regarding their skills and status in laparoscopic surgery training was such that none said Excellent, 7[14.58%] said Good, eight [16.67%] labelled themselves as Average while nine [18.75%] thought they were below average, 23 [47.92%] said they were Poor in this Skill and one[2.08%] did not respond. Most 41 [85.42%] would prefer to do a One Year Fellowship in Minimal Access Training following FCPS, while one[2.08%] said "No" and six [12.5%] were not sure. Education and training in Minimal Access Surgery within Institutions of Karachi is not standardized and access to training facilities is limited

Feasibility and effectiveness of ESWL for selected vesical calculi

To assess the feasibility and effectiveness of ESWL for selected Urinary Bladder stones. Retrospective quasi experimental study from September 2004 to February 2007. The Stone Center, Taj Medical Complex, Karachi. Twenty six consecutive patients of over 12 years of age with bladder stones of less then 2.5 cm and without symptoms of outflow obstruction. Detailed clinical work-up of all the patients was done. The diagnosis of bladder stone was made either on an IVP or an ultrasound combined with X-ray KUB. Bladder outflow obstruction was excluded on clinical grounds. All patients received shock waves ranging from 14 to 20 kV, up to a maximum of 3000 shocks in a single session. If complete fragmentation was seen before this, the treatment was stopped. Patients were reviewed after 72 hours with a KUB X-ray. Patients with residual stones received a 2nd session at this stage. If no fragmentation was seen after two sessions, the patients were offered alternate modes of treatment. If there was any residual fragment left after two sessions, a third session took place. During the study period, 31 patients presented with bladder stones. Two patients with significant outflow obstructive symptoms, one patient with a stone of 3.5 centimeters and two children [age<12 years] were excluded from the study. Of the 26 remaining patients, 19 were males and seven females. Eighteen patients had complete stone clearance after one session and five after two sessions, while one patient required three sessions for complete stone clearance. Two patients did not have any significant fragmentation and were offered alternate treatment modalities. Overall 24 out of 26 [92.3%] patients had a complete stone clearance. ESWL is a very effective and safe modality for treatment of selected bladder stones. The treatment can be provided on an out-patient basis

Unusual soft tissue tumours of the abdominal wall

To highlight the importance of remembering unusual tumours in the differential diagnosis of Soft Tissue Tumours of the Abdominal wall. Retrospective, decriptive study conducted between June 2000 to June 2003. Hamdard University Hospital and other private hospitals in Karachi. All patients presenting with Unusual Soft Tissue tumours of the Abdominal wall. The biodata, symptoms and signs of these patients were recorded and analyzed. They were extensively investigated; besides routine investigations Ultrasound, CT Scan and MRI were done where indicated. All the tumors were surgically excised and the diagnosis was confirmed on histopathology and immunohistochemical studies. Ten patients, six females and four males, aged 16-59 years, were seen with Unusual Soft tissue Tumours of the Abdominal Wall. Most of them [90%] presented with a swelling, while some had pain [30%] and fever [10%].Surgical excision and histopathology revealed them as desmoid tumour [n-6], rhabdomyosarcoma [n-2], urachal remnant tumour [n-1] and port-site metastatic tumour [n-1]. There was no recurrence in all the patients, except the one with urachal remanant. He died inspite of further excision, radio and chemotherapy. Abdominal wall tumours are rare. They may be innocent like the lipoma, or may show variable behavior like the desmoid tumour, or may be very aggressive like the rhabdomyosarcoma. They need proper clinical workup before embarking upon surgery, which should be wide surgical excision as they show aggressive infiltration in the surrounding tissues. They also require proper follow-up as they are famous for recurrence

Gastric outlet obstruction

To highlight the fact that tuberculosis is a common cause of gastric outlet obstruction in our community.Observational study.This is a three years study of patients with gastric outlet obstruction managed in the Department of Surgery at Hamdard University Hospital Karachi. Twelve patients presented with gastric obstruction. The cause of gastric outlet obstruction was gastric carcinoma in Jive, tuberculosis in five, lymphoma in one and stenotic peptic ulcer disease in one patient. Our results suggest that tuberculosis should be considered as an important cause of gastric outlet obstruction in our community, because tuberculosis is still a prevalent disease in Pakistan and other South Asian countries

Topical application of glyceryl trinitrate 0.2 % for fissure-in-ano

This study was carried out from January 2002 to August 2002 to evaluate the efficacy of glyceryl trinitrate [GTN] 0.2% in healing of fissure in ano Sixteen consecutive patients were recruited with proven fissure in ano of more than 6 week duration. Treatment with topical GTN 0.2% was instituted. Patients were assessed at 1, 3, 6, 12 and 26 weeks. Resolution of symptoms, time taken to heal and occurrence of side effects were recorded. Success rate was 7986 at 12 weeks, reduced to 64% at 26 weeks. Two patients had recurrence of fissure; one was successfully treated with a further treatment with topical GTN while the other opted for lateral internal sphincterotomy

Day surgery: a need for guidelines

Day surgery is being increasingly carried out throughout the world. In our country the concept of day surgery is still in its infancy. In order to practice day surgery safely, we need to have guidelines as to the nature of procedures to be carried out, patient selection, discharge criteria instructions to the patients. We tested our locally devised guidelines on 203 patients admitted as day surgery patients between June 2000 and May 2002. We conclude that day surgery is a safe option with a very high patient satisfaction rate. It should be developed further and for its full utilization we need to have proper guidelines and protocols. Ideally there should be Day Surgery Units in all major hospitals