Gallbladder perforation and stone spillage during laparoscopic cholecystectomy

To determine the frequency of gallbladder perforation and stone spillage during laparoscopic cholecystectomy [LC], and its subsequent complication and management. Descriptive case-series. This is a prospective analysis of laparoscopic cholecystectomies performed at Surgical Unit I, Civil Hospital Karachi, from 1st September 1997 to I5th June 2005. There were 1246 patients in the study, who underwent LC. The inclusion criteria for LC were: patients of all ages and both sexes, symptomatic gallstone disease, recurrent attack while waiting for interval LC, normal levels of blood complete picture and liver function tests, and ultrasound abdomen demonstrating gallstone disease. There were 107 cases of gallbladder perforation, ie a frequency of 8.59%. In 24 of these patients gallstones spillage also occurred, ie a frequency of 1.92%. An effort was made in each case to remove the spilled stones laparoscopically, but in seven patients unretrieved stones were left [ie a frequency of 0.56%]. One patient developed pelvic abscess, presenting with post-operative diarrhea and fever on day 5 and confirmed by ultrasound; it was left to drain in the rectum and treated by broad-spectrum antibiotics. Four patients developed sub-hepatic abscess, presenting with right hypochondria! and shoulder tip pain and fever on day 3; they were confirmed by ultrasound, with subsequent ultrasound guided drainage and broad-spectrum antibiotics. Three patients developed epigastric port site infection; two were treated successfully by daily wound care and appropriate antibiotics after culture and sensitivity. One developed persistent epigastric sinus, and a gallstone was retrieved on exploration. There was no mortality and long-tertn morbidity. Gallbladder perforation and stone spillage are frequent occurrence during laparoscopic cholecystectomy. Active laparoscopic retrieval of spilled stones and thorough irrigation of sub-hepatic area reduces the risk of subsequent complications

Bowel injuries during laparoscopic cholecystectomy

To determine the frequency, site, cause, presentation, management and mortality of the bowel injuries during laparoscopic cholecystectomy [LC]. Descriptive case-series. This is a prospective analysis of laparoscopic cholecystectomies performed at Surgical Unit I, Civil Hospital Karachi. A total of 1246 LCs were performed from 1st September 1997 to 15th June 2005. There were 1246 patients in the study, who underwent LC. The inclusion criteria for LC were: patients of all ages and both sexes, symptomatic gallstone disease, recurrent attack while waiting for interval LC, normal levels of blood complete picture and liver function tests, and ultrasound abdomen demonstrating gallstone disease. There were 2 cases of bowel injury, ie a frequency of 0.16%. One was serosal injury to colon and the other was duodenal perforation. Both were detected peroperatively, and managed by converting the procedure to open and primary closure of injury; duodenal closure was reinforced with omental patch. Postoperatively, the patient with colonic injury recovered well, but the patient with duodenal injury developed duodenal fistula which was managed conservatively. There was no mortality. Both cases of bowel injury were among the first 50 of the 1246 case-series. At 0.16%, the frequency of bowel injuries during laparoscopic cholecystectomy is small; the risk of such injury is more during the learning curve. Timely detection during the operation results in successful outcome, with little or no mortality

Role of ultrasound in predicting conversion from laparoscopic to open cholecystectomy, a surgeon's and radiologist's dilemma!

This prospective study was jointly conducted by the Department of Radiology and Surgical Ward-II, Dow Medical College and Civil Hospital, Karachi from August 2000 to June 2002: 100 patients were selected for this study and all were admitted with complaints of pain in right hypochondrium / epigastrium, dyspepsia, nausea, vomiting and complained of pain in right shoulder. Provisional diagnosis was made on history and clinical examination as cholecystitis. The ages were between 35 to 60 years. 78 patients were female and 22 patients were male. The aim of this study was to assess the role of pre-operative ultrasound findings with operative findings in patients undergoing laparoscopic cholecystectomy. The purpose was to get the proper diagnosis and provide detailed information to the surgeons before operation about the status of liver, Gall Bladder, C.B.D, Biliary Channels, and specially adhesions between the Gall Bladder and the surrounding structures like Omentun, Duodenum etc. In this way, the surgeon was informed about the findings before operation for successful laparoscopic cholecystectomy to avoid the complications of open surgery. Ultrasound is readily available, inexpensive and the modality of choice in the diagnosis of hepato-biliary disease. Out of 100 patients, 74 patients were selected for laparoscopic cholecystectomy [USG findings showed no adhesions]. While 65 patients successfully underwent laparoscopic cholecystectomy, 9 patiems were converted to open cholecystectomy due to unavoidable conditions like inseparable adhesions with surrounding structures [Omentum and Duodenum]. Out of the 26 patients selected for open cholecystectomy [USG showed adhesions] due to cholelithiasis and chronic cholecystitis associated with choledocholithiasis, 3 were found to be without adhesions

unusual cold abscess with a strangulated para-umbilical hernia, in a patient with Stein-Leventhal Syndrome

We report a rare case, in which a massive intra-abdominal tuberculous abscess was a cause of diagnostic confusion, in a young girl previously diagnosed with Stein Leventhal syndrome, when she developed a strangulated para-umbilical hernia