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.

Multiple synchronous gastrointestinal stromal tumors

Gastrointestinal stromal tumors [GISTs] are rare tumors, even more rare is to find multiple, synchronous GISTs in small bowel. We report a case of multiple synchronous GISTs presented as acute intestinal obstruction. Per operatively four tumors were identified in jejunum and ileum with mesenteric lymph nodes involvement

Is biopsy needed in every gastritis found during endoscopy?

To find out concordance between endoscopic and histological diagnosis of gastritis in dyspeptic patients. All dyspeptic patients who underwent upper gastrointestinal endoscopy with endoscopic diagnosis of gastritis and available biopsy report from July 2006 to June 2008 in Hamdard Medical University Hospital and different private hospitals of Karachi were included in this study. The endoscopist formed a global impression on the presence or otherwise of gastritis according to the Sydney System. Patients with ulcer, growth and any other endoscopic diagnosis apart from gastritis were excluded. With standard biopsy forceps, minimum of two gastric biopsies from inflamed mucosa were taken for histological evidence of gastritis. Total 112 patients [44 males and 68 females] were included in the study with mean age of 41.95 years. Most common symptom experienced by patients was epigastric discomfort in 103 [92%] of patients. In all patients endoscopic diagnosis was gastritis. Biopsy reports showed chronic gastritis in 109 [97.3%] patients. There is good concordance of endoscopic findings of gastritis with histological evidence of gastritis and thus biopsy is not required in every case of gastritis

First port placement for pneumoperitoneum

To find out utility of a modified method of creating pneumoperitoneum for laparoscopic surgery. Quasi-experimental study. Ziauddin Medical University Hospital and Kutiyana Memon Hospital, Karachi from September 2007 to March 2008. The modified method for the creation of pneumoperitoneum for laparoscopic surgeries was applied to all patients. Approximately 1.2 cm vertical incision was made below the umbilicus and subcutaneous fat separated by blunt dissection till the rectus sheath visualized. A small incision approximately 5 mm was made in the full thickness of linea alba without opening the peritoneum. An artery forcep was then introduced in the peritoneum to open it. Rate of success of the procedure, time from sub umbilical incision to insertion of telescope and complication / difficulty encountered during the procedure were recorded in the operative notes and pre designed proforma. Results of the present technique was analyzed and compared with published literature in terms of visceral injury and air leak. A total of 55 patients were included in this study. Scar of previous abdominal surgery was present in 16 patients. Mean time from skin incision to insertion of telescope was 55 seconds [ranging from 35 to 95 seconds]. Trocar insertion into extra-peritoneal space occurred in 6 patients. Withdrawl and re-insertion into peritoneal space was successful in all cases except in 2[3.63%] patients in whom procedure was converted to open technique. No bowel or visceral injury occurred during the procedure. Gas leakage was not encountered during entire surgical procedure in all the patients. This modified technique for the creation of pneumoperitoneum for laparoscopic surgery is safe, quick and without the use of any specialized or disposable instruments

Acute appendicitis in pregnancy; maternal and foetal outcome

To determine the maternal and foetal outcome among the cases of acute appendicitis during pregnancy. Prospective Study. Aga Khan Hospital for Women, Kutyana Memon Hospital and Hamdard University Hospital, where authors work. Period: From June 2004 to May 2008. A total of 21 pregnant females who presented with right sided abdominal pain with clinical diagnosis of acute appendicitis were managed during this study period. All patients were admitted and managed by both surgeon and obstetrician. Detailed 'clinical history and physical examination was performed and all patients were investigated by complete blood picture, urine analysis and ultrasonography of abdomen and pelvis. Appendicectomy was performed through Grid Iron incision. Macroscopic appearance of appendices and other operative findings were recorded and all specimens were sent for histopathology. All the patients were followed up till the out come of pregnancy. Twenty one patients were managed during this study period and out of these 21,13 patients were primigravida and 8 were multigravida. At presentation most of the patients were in their second trimester of pregnancy. Acute appendicitis was confirmed by histopathologically in 16 out of 17 patients with inflamed looking appendices [negative appendicectomy rate was 23.80%]. Foetal loss occurred in 2 patients [9.52%] and both were in their second trimester of pregnancy. One patient gave birth to a baby who had low birth weight [4.76%] and one patient who was operated in third trimester had premature labour [4.76%] three weeks prior to expected date. Remaining 17 patients delivered at term without any consequences. Two patients developed wound infection which responded to wound care and antibiotics. Acute appendicitis is the commonest cause of acute abdomen during pregnancy. A timely decision and a professional liaison among obstetrician and surgeon are key factors for a better outcome

audit of cholecystectomy

To evaluate the results of Cholecystectomy in our practice. Prospective, descriptive study from January 2006 to December 2006. Hamdard University Hospital and private hospitals. A total of 150 patients who underwent cholecystectomy were included in this study. The dats of all the patients who underwent cholecystectomy was entered on a proforma and analyzed. Out of the total 150 patients, 75% were females and 25% males, with an age range of 20 to 76 years. The duration of symptoms was from one day to three years. Laparoscopic Cholecystectomy was attempted in 118 [78.66%] patients and completed in 104 [88.13%] patients; 13 [11.11%] patients required conversion, while in one case the procedure was abandoned due to abdominal tuberculosis. The remaining 32 patients underwent planned open cholecystectomy for various reasons. The comparison of our work with national and international studies showed that Laparoscopic Cholecystectomy in our set up is up to the accepted standard. More emphasis is needed to properly train young surgeons in the field of Laparoscopic surgery

Transhiatal versus ivor-lewis procedure for the treatment of carcinoma oesophagus

To compare the results of Transhiatal and Ivor-Lewis operations for the treatment of Carcinoma Oesophagus. Comparative study conductedfrom 1[st] April 1999 to 30[th] March 2001. Ward 2, Jinnah Postgraduate Medical Centre, Karachi. Thirty patients with resectable carcinoma in the middle and the lower third o[the oesophaglls. The patients were randomly assigned to the two groups. Group-A patients [15] underwent Transhiata/oesophagectomy while Group-B patients [15] were operated by the Ivor-Lewis approach. The data of these patients was collected and analyzed. Student 't' test was applied for statistical significance. Among the thirty cases, 60% were male and 40% female. The average age of the patients was 55 +/- 11.29 years in Group-A and 50.53 +/- 13.83 years in Group-B. In 50% of the patients, the tumour was present in the lower 1/3 of the Oesophagus, in 46.66% in the middle 1/3 and in 3.33% patients both in the middle and the lower 1/3. Histopathology revealed that in 63.33% cases the tumour was squamous cell carcinoma, while in 36.66% it was adenocarcinoma. The mean operative time for Transhiatal Oesophagectomy was 3.75 hours, whereas it was 5.25 hours for the Ivor-Lewis procedure. There was no statistically significant difference in the result of both the procedures. We conclude that Transhiatal and Ivor-Lewis Oesophagectomies are comparable operations for resectable carcinomas of the Oesophagus

Peyronie's disease

Peyronie's disease is an uncommon condition and authors have not seen it in their practice. This is our first experience which is reported here

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

Patient's preference for the route of Postoperative Analgesia

To find out the preferred route [injectable or rectal] for postoperative analgesia in our patients. Cross sectional study conducted on 100 patients.Department of Surgery, Hamdard University Hospital, Karachi.100 patients who underwent the operations of herniorrhaphy, cholecystectomy and appendicectomy. Patients were given the choice of having post-operative analgesia either through injectable [intramuscular, intravenous] or rectal route, and the data analyzed.The results showed that 74% patients preferred injectable, while only 24% preferred rectal route for post-operative analgesia. The reason for rejection of the rectal route was doubt about its efficacy in 45 cases, shyness in 14 and unawareness in 11 patients. Four patients gave no reason or any comment.It is therefore concluded that rectal route should be used cautiously, and if it is necessary a specific consent should be taken pre-operatively to protect against litigation, in case an adverse situation develops