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

Evaluation of blunt abdominal trauma: the evolving role of ultrasound

To evaluate importance of ultrasonography in the operative management of patients after Blunt Abdominal Trauma. All the suspected cases of Blunt Abdominal Trauma attending the emergency Department of Civil Hospital Karachi from 1999 to 2001 are subjected to the ultrasonography of Abdomen along with other laboratory and radiological investigations apart from those who were hemodynamically unstable. Patients profile consists of a thorough history, physical examination, investigations and diagnosis were registered in the performa. One Hundred Patients of Blunt Abdominal Trauma were assessed by abdominal ultrasound to detect free fluid in abdomen as a result of solid organ injury, to take the decision of laparotomy as an emergency management. 95 patients underwent ultrasound examination. 5 patient left without ultrasound examination. Out of 95 patients, 90 patients did not show any positive findings related to intrabdominal injuries. 2 patients had splenic tear,1 suffered from liver tear and 2 patients had free fluid in the peritoneal cavity. 1 patient turned out to be false negative as he developed fever and peritonitis leading to laparotomy showing small bowel perforation. In our study the sensitivity and specificity of ultrasound examination for detecting intrabdominal injury in clinical stable patients of blunt trauma were 83.33% and 100% respectively. The following conclusions were derived after conducting this study: Majority of the patients suffered from abdominal trauma are seen between 25- 44 years. Unrecognized abdominal injury remains a frequent cause of preventable death following blunt trauma. It can be prevented by the use of ultrasonography as it is cheap, easily repeatable and can be used at bed side. The results are operator dependant so ultrasound training will be incorporated into general surgical residency program

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