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

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

Management of polypoid lesions of the gall bladder

To analyze the demographic and clinical characteristics of patients diagnosed with polypoidal lesions of gall bladder and to correlate the radiological and histopathological diagnosis. Descriptive study. At Hamdard University Hospital Karachi over a period of 9 years [July 1999- June 2008]. The study included all those patients who were operated for gall bladder polyps. Patients of both sexes above14 years of age diagnosed on the basis of ultrasound and underwent cholecystectomy were included in the study. Twenty eight patients were included in this study with male to female ratio of approximately 1:8. Mean age of patients was 47.5 years. Twenty five patients were having symptomatic gall bladder disease. On the basis of ultrasound 19 patients had solitary polyp while 9 had multiple lesions. All these patients were operated laparoscopically; only one patient had a conversion to open cholecystectomy. Out of total 28 patients 19 were histopathologically proven benign polyps, one patient had severely dysplastic polypoidal lesion while eight patients had chronic cholecystitis with prominent folds with or without gall stones. Of 19 patients with benign disease 15 had cholesterol polyps and remaining 4 had adenomas. Gall bladder polyps are important cause of symptomatic gall bladder disease with peak incidence in 4th to 5th decade. Most of the gall bladder polyps are benign with cholesterol polyps and adenomas being the commonest lesions found on histopathology. Ultrasonography is good diagnostic tool with reasonable accuracy