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

Embolectomy for acute limb ischemia: experience in 84 cases in a tertiary care hospital

To highlight the presentation, outcome and the role of embolectomy in the management of acute limb ischemia. A descriptive study. Department of Vascular Surgery, CMH Rawalpindi from Oct 2008 to Dec 2010. All patients with acute limb ischemia presenting at CMH Rawalpindi during study period and managed by embolectomy were included. Embolectomy was performed through transfemoral or transbrachial approach, depending upon the limb involved under local anesthesia with Fogarty catheter. Eight four patients of acute limb ischemia were managed by embolectomy during study period. Lower limb was affected more frequently 51 [60.7%] than upper limb 33 [39.3%]. Male to female ratio was 1.4: 1. Forty eight [57.1%] patients reported 12 hours after the onset of symptoms. Embolism was the most common cause present in 53 [63%] and most frequent site of obstruction was femoral bifurcation 23 [45%]. Presence of paralysis and skin changes were bad prognostic signs. Eight patients [9.5%] had fasciotomy at the time of embolectomy. Nine major amputations were carried out in 8 patients [10.7%]. Eleven patients [13.0%] died within 30 days. Limb salvage rate was 83.3%. In the scenario of multiple new therapeutic techniques, embolectomy is still a simple, safe and effective surgical option for treatment of acute limb ischemia

Extrahepatic biliary obstruction; postoperative morbidity and mortality

The objectives of this study are to evaluate the surgical management, both definitive and palliative, in selected patients with biliary obstruction and to find out the postoperative morbidity and mortality in these patients. A descriptive study. Duration of the study is two years conducted from June 2002 to May 2004. The study was carried out at the surgical unit 4 of the Combined Military Hospital and surgical department of the Military Hospital. Thirty eight cases of biliary obstruction were included. A convenient sampling technique was followed. Data analyzed by using SPSS version 10.0 for windows on computer. Descriptive statistics like frequency, percentage, average etc were computed for data presentation. Any inferential test was not found to be applicable for this descriptive type case series. We selected 38 patients with features of extrahepatic biliary obstruction. Out of these [n38] 15 patients [39.5%] suffered from benign diseases while those having malignant diseases were 23 [60.5%]. 19 [50%] patients died within two years of follow up while 19 [50%] were the survivors. Mortality was maximum for the malignant cases. In benign cases only one patient died. Maximum deaths 6 [31.6%] occurred in the period of up to one month of operation. 20 patients had one or another complication of operation and hence the morbidity came out to be 52%. According to our results the mortality and morbidity related to extrahepatic biliary obstruction in our patients was higher compared to other studies which can only be reduced by early detection and treatment

Peripheral vascular injuries; epidemiology and management

Peripheral vascular injuries constitute 4-6% major trauma. Although uncommon the complication of hemorrhage and Ischemia can be limb threatening and life threatening. Rapid diagnosis and appropriate treatment is therefore essential. Delay allows irreversible Ischemic injury to take place and encourages propagation of intravascular thrombosis, which results in eventual loss of function or even limb itself. [I] To collect data about different aspect of epidemiology and management of Peripheral vascular injuries. [II] To study the relationship between latent period for revascularization and outcome of surgery. Non interventional observational study. CMH Kohat. From 01 Jan 2004 to 31 Dec 2006. Total of 46 cases of all age and sex groups was included in the study. Only those patients were included who had vascular injury to extremities whether direct [penetrating, blunt] or indirect [associated with fracture and dislocations] injuries. Relevant history was obtained from the patients themselves and from their relatives or witnesses. Relevant physical examination was performed. Necessary investigations were done. Patients were treated according to standard protocol. The peripheral vascular injuries were more common in 21-40 years of age group [69%] and among male [82%].Vascular trauma caused by the firearm injuries [60.86%] was the most common cause, other being road traffic accidents [26.08%] and blunt trauma [13.04%]. The most common clinical presentation was shock and paresthesia [50%]. Most of the patient reached hospital within 6-12 hours [47%], and belongs to rural areas [69%]. Frequency of involvement of vessels was femoral artery [41%] and brachial artery [23%]. Types of vascular injuries were, laceration to the vessel wall [56%] and loss of vessel wall segment [17%]. End-to-end anastomosis was most common [78%] .others being interposition reverse vein graft [13%] and direct suturing of vessel wall [8.7%] Amputation rate was highest in cases where revascularization occurred after more than 12 hour [71%]. Common complications after repair were residual edema [17%] and infection [6%]. Overall mortality rate was 4% and morbidity rate was 28%. All cases of peripheral vascular injuries should be surgically explored. Revascularization should be achieved within 12 hours. Patients presenting late or with crush injuries may need amputation

Gall bladder tuberculosis: a case report

An 80-year old man presented with mild right upper quadrant abdominal pain of six months duration. The pain exacerbated off and on. Clinical examination of the patient revealed a mildly tender right hypochondrium. No mass or enlarged viscus was palpable. Ultrasonography of abdomen revealed a contracted gallbladder containing multiple calculi. Chest X-ray was suggestive of chronic obstructive airway disease [COAD]. His hemoglobin was 12.6 gm/dl and total leukocyte count was 5.6x10e9/L. Neutrophils were 65% while lymphocytes were 30%. Blood glucose levels and liver function tests were within normal limits. Hepatitis B surface antigen and anti-HCV antibodies were negative. Peroperatively, gallbladder was seen to be contracted and had thickened walls. Its serosal surface was granular. The greater omentum and mesentery were studded with nodules. No spread was seen into the gallbladder fossa or into the liver. Lymph node of Lund and those in the mesentery were enlarged. Gallbladder contained multiple small calculi. The resected gallbladder and a biopsy of greater omentum were sent for histopathology, which revealed gallbladder tuberculosis with caseating granulomas, as well as tuberculous omentitis. Patient is on anti-tuberculosis therapy and is improving steadily