Complications in laparoscopic cholecystectomy

Objective: to list and understand the types and the rate of complications associated with laparoscopic cholecystectomy done by a small group of surgeons over a decade at four military hospitals PNS Shifa Karachi, CMH Rawalpindi, MH Rawalpindi and PNS Hafeez Islamabad

Study Design: observational and descriptive study

Place and Period of study: CMH Rawalpindi from January 2003 to December 2012 [10 years]

Patients and Methods: case records of all patients [both genders and all age groups] undergoing laparoscopic cholecystectomy over a period of ten years were reviewed. Fifteen hundred patients with a clinical follow up record of at least six months were included in the study. Complications were grouped into three main categories, per operative, early post-operative and late post-operative. They were further sub-grouped into major and minor categories. A major complication was regarded as one causing significant morbidity or likely to be potentially fatal if not treated expeditiously. Data analysis included calculation of the number of patients, rate and percentage of different types of complications

Results: complications occurred in 495 [33%] cases. Major complications occurred in 199 [13.27%] cases. In the remaining 296 [19.73%], the complications were labeled as minor. Conversion to open surgery occurred in 147 [9.8%]. Post-cholecystectomy laparoscopic re-intervention within 48 hours was done in 3 [0.2%] cases. There was one mortality due to septicemia following bowel injury

Conclusion: the risk of complications is a possibility in any patient undergoing laparoscopic cholecystectomy despite remarkable advances in instrumentation and video systems. Most common complication is hemorrhage [1.3%] followed by CBD injuries [.13%]. Due attention to risk assessment, patient and family counseling, importance of valid consent and a flexible approach to conversion to open surgery is stressed

Use of harmonic scalpel in laparoscopic cholecystectomy

To determine the effectiveness and safety of the Harmonic Scalpel in laparoscopic cholecystectomy. Quasi Experimental Study. Surgical Unit -1 Combined Military Hospital Rawalpindi. From January to December 2009. A total of 110 consecutive patients undergoing laparoscopic cholecystectomy in which the procedures were performed exclusively with the Harmonic Scalpel were included. Patients were of either sex and of different age groups. Only three patients were operated in emergency and all other under went elective surgery. Ease of dissection and clarity of operative field [as determined by definition of dissection planes, need for using irrigation/suction and need for clearing the smoke by evacuation of gas], haemostasis and control of vascular pedicles, rate of complications, rate of conversion to open surgery and dissection time were analysed. Data was analyzed by SPSS. Frequencies and percentages were calculated. There were 65 females and 40 males. Age range was 24-72 years with mean age 45 years. Irrigation with saline and suction was needed in only 5 cases. There was practically no or minimal whitish smoke and none required evacuation of gas to clear the operative field from it. No patient had hemorrhage of any extent. Cystic artery was clipped in 40 [36.36%] patients and in all others [54.54%] it was secured by harmonic coagulation. None had CBD or bowel injury or post op sepsis. Two [1.82%] cases required conversion to open surgery due to dense adhesions and obscure anatomy. Cystic duct was dissected out with the same device but was clipped in all the cases. Average dissection time was 40 minutes [range, 17-75 minutes].There was no mortality. The Harmonic scalpel is safe and a surgeon friendly instrument for laparoscopic cholecystectomy

Role of strictureplasty in the management of tuberculous strictures of small intestine

To evaluate the outcome and assess the reliability of strictureplasty in the management of small intestinal strictures due to tuberculosis. A retrospective observational and descriptive study. PNS-Shifa, Karachi. Clinical data of cases of intestinal tuberculosis reporting over a period of five years-[Aug 1999-to-Aug 2004] was studied. Thirty patients with small intestinal tuberculosis who underwent strictureplasty alone or in combination with limited resection were selected for the study. In 20 cases [66.67%] the strictureplasty was performed in combination with limited resection. Remaining 10 cases [33.33%] were managed by strictureplasty alone. Anastomotic leakage with fistula formation occurred in 3 cases [10%], Burst abdomen occurred in 2 cases [6.67%]. Sub-diaphragmatic abscess formation occurred in 3 cases [10%]. On prolonged follow-up averaging two years, re-admission was required in 5 cases [16.67%]. Re exploration to relieve obstruction due to adhesions was required in 2 cases [6.67%]. Late incisional hernia was seen in 4 cases [13.33%]. There was no procedure related mortality. Strictureplasty is a simple, quick, and safe operative technique to manage tuberculous small intestinal strictures, in combination with limited resection or as a sole procedure

Role of FNA cytology in the management of carcinoma breast

To evaluate the utility and role of fine needle aspiration cytology [FNAC] in essential surgical management of carcinoma breast. Descriptive study. PNS Shifa, Karachi, Combined Military Hospital [CMH], Pannu Aqil and PNS Rahat from August 1998 to August 2003 [05 years]. Patients and The study included one hundred cases of carcinoma of breast-97 females and 3 males, confirmed on histopathological examination and surgically treated at PNS Shifa, CMH Pano Aqil and PNS Rahat. FNA cytology was the primary tool of investigation in all. The benefit of the procedure was evaluated considering the ease of the procedure, cost, safety, reliability as screening procedure and its effect on sparing the patients from excision or incision biopsy and thus additional anesthesia. Sensitivity of the procedure was 78%, specificity 100%, predictve value 100% and overall diagnostic accuracy 72%. Out of 78 cases, diagnosed as positive for malignancy on FNAC and later confirmed by histopathological examination, 58 underwent frozen section examination followed by definitive surgery [modified radical mastectomy]. Remaining 20 cases underwent additional core biopsy. Out of these, 12 cases underwent definitive surgery without frozen section and 8 patients underwent frozen section examination followed by definitive surgery. A single case required general anesthesia [GA] while the patients undergoing core biopsy required a local anesthesia [LA] as well. Cases remaining undiagnosed by FNA-cytology [22 cases] required either an excision biopsy [17 cases] or incision biopsy [5 cases] under GA followed by definitive surgery, thus requiring general anesthesia twice during the management. FNA-cytology can positively affect the surgical management of carcinoma breast. It can be utilized to select the patients for frozen section examination and can thus spare the patients from additional procedure of excision or incision biopsy under separate anesthesia. It may be adopted as a routine procedure in surgical outpatient