Three-Port Laparoscopic Cholecystectomy as a Safe and Feasible Alternative to the Conventional Four-Port Laparoscopic Cholecystectomy.

Aims A prospective observational study was performed to assess the feasibility and safety of three-port laparoscopic cholecystectomy. Parameters comprising age, sex, number of cases in which intra-operative difficulty were encountered, and outcomes such as number of cases that required conversion to four-port laparoscopic cholecystectomy, postoperative pain on the visual analog scale (VAS), and postoperative hospital stay were assessed. We also documented difficult cases that were operated successfully with three ports, and the number of cases that needed conversion to four ports along with the reason for the conversion. Material and methods The patients were operated upon in the supine position in all cases. A pre-emptive analgesia with 1% lignocaine was administered in all cases prior to making the incision. The first port was 10-mm supraumbilical and inserted by the open technique. After insertion of the umbilical port, pneumoperitoneum was created by maintaining a maximum pressure of 12 mmHg and a flow rate of 8 L/minute. A camera head with a 30° telescope was introduced in the peritoneal cavity, and diagnostic laparoscopy was performed. A 10-mm subxiphoid port and a 5-mm subcostal port were placed under vision, with the latter placed more lateral and inferior to the conventional port position for better triangulation and ergonomics. The outcomes measured were operative time, the number of cases requiring a fourth port, postoperative pain (VAS), and postoperative hospital stay (number of days patients stayed in the hospital post-surgery until discharge). Data were collected using MS Excel, and an analysis was performed using SPSS Version 21.0. Results Data of 102 patients were analyzed prospectively. The mean age of the patients was 50.98 years, with an SD of 16.88, and the gender ratio was 73:29 (female: male). The mean operative time was 52.68 ± 20.84 minutes, with an SD of 20.84. Difficulty was encountered in 18.6% of cases in the form of pericholecystic adhesions, aberrant Calot's anatomy, empyema or mucocele of the gallbladder, or bleeding from the liver bed or cystic artery stump. Postoperative pain was less in our study due to the reduced number of ports and the use of a pre-emptive analgesia, with a mean VAS score of 1.22 and an SD of 0.56. The mean postoperative hospital stay was 1.08 days, with an SD of 0.31. We needed to convert to a four-port procedure for safety in 2.9% cases. The operative time and postoperative hospital stay in our study were similar to those of other studies, but our average pain score was less due to the use of the pre-emptive analgesia. Only three cases required conversion to four ports, and 99 cases were successfully managed with three ports without compromising safety. No bile duct injury occurred in any of our 102 cases. Conclusion From this study, we conclude that three-port cholecystectomy is feasible, and it can be performed even in difficult cases without compromising safety. The surgical time is similar to that of four-port cholecystectomy, and the postoperative stay is shorter. The decreased number of ports and the pre-emptive analgesia reduced postoperative pain, cosmesis was better, and the incidence of bile duct injury did not increase. The procedure can also be converted to four-port cholecystectomy at any time if safety is compromised. Therefore, three-port cholecystectomy is a viable and safe option in the treatment of gallstone disease.

Clinical, Biochemical, and Radiological Correlation in the Severity of Acute Pancreatitis: A Retrospective Study.

OBJECTIVES: To analyze the etiologies and the varying clinical presentations and to validate the clinical, biochemical, and radiological signs with severity and prognosis of acute pancreatitis. METHODS: A retrospective study of 1316 patients diagnosed with acute pancreatitis in an industrial hospital in Jamshedpur, Jharkhand, was conducted, and their clinicoradiological profiles, etiological factors, and outcomes were studied. RESULT: A total of 1316 cases were enrolled, out of which maximum cases (411 [31.23%]) were from the age group of 30-44 years, and the mean and median age were 44.54 and 47 years, respectively. A total of 731 (55.45%) patients had social habits (i.e., alcohol and smoking), and 585 (44.45%) patients did not have any social habits. Based on the etiology of acute pancreatitis (AP), the majority of cases were due to alcoholism (710 [53.95%]) followed by gallstone (343 [26.06%]) and idiopathic pancreatitis (217 [16.48%]). As per the severity of AP, most patients showed mild pancreatitis (937 [71.20%]) followed by moderate (312 [23.71%]) and severe pancreatitis (67 [05.09%]). Mild and moderate pancreatitis patients were shown in 85 and 28 cases, respectively, suggestive of chronic pancreatitis after repeated episodes of AP. But severe pancreatitis shown in 19 cases had hypocalcemia + shock + multi-organ dysfunction syndrome (MODS). In mild, moderate, and severe AP, the mortality rates were 19 (02.03%), 44 (14.10%), and 21 (31.34%), respectively. Overall, 1232 (93.62%) of AP cases recovered and were discharged in stable condition, but 84 (06.38%) cases expired. CONCLUSION: AP is a common cause of acute abdomen in patients presenting to the surgical emergency department. The management is mainly conservative with surgery limited to only a few selected cases, depending upon the severity of the disease.

A Rare Case of Kostmann Syndrome Presenting Difficult Airway Challenges and Patient Preparedness for Anesthesiologists.

Severe congenital neutropenia (SCN), commonly known as the Kostmann syndrome, is a rare and complex set of disorders defined by a lack of neutrophil maturation in the bone marrow, leading to life-threatening complications. This case report discusses a young adult patient scheduled for elective laparoscopic cholecystectomy. The patient presented with skin lesions which are a common scenario of Kostmann syndrome, but along with that, our patient posed challenges of short neck, limited neck extension, and gynecomastia. These additional conditions dramatically increased the challenges for anesthesiologists to address the anticipated difficult airway. The anticipated difficult airway challenges were handled by following the protocols of difficult airway guidelines 2022.

Anesthetic Considerations for Elective Laparoscopic Cholecystectomy in a Patient With Previous Pneumonectomy.

Patients presenting for surgery after pneumonectomy pose significant challenges to anesthesiologists. The disease process necessitating pneumonectomy may involve the surviving lung too. Cholecystectomy is a major surgery, and the open approach has significant risks of post-operative pulmonary complications in these patients partly owing to the large incision and postoperative atelectasis, associated with inadequate post-operative analgesia. Contemplating a laparoscopic procedure in patients with a single, possibly damaged lung, involves a good understanding of the physiology of the single lung as well as the challenges posed by capnoperitoneum. Here, we present a case of a female with a history of previous pneumonectomy undergoing laparoscopic cholecystectomy. There are very few reports of patients after pneumonectomy who have subsequently undergone a laparoscopic cholecystectomy successfully and this report highlights some crucial factors to be kept in mind during anesthetic management of such patients.

A rare case of gall bladder containing accessory lobe of liver stuck to its wall: A case report.

Introduction: Accessory liver lobe (AL) is a very rare congenital anomaly found during surgery incidentally and not usually possible to diagnose preoperatively. Here, we are reporting this rare case in which the accessory liver was diagnosed at the time of surgery and was ectopically connected to the gallbladder wall. Case Summary: A 71-y-old woman, attended our outpatient department (OPD) with pain in the epigastrium. She was diagnosed early having gallstone disease. Ultrasound abdomen was advised, which revealed cholelithiasis. Laparoscopic cholecystectomy was performed and we discovered a small liver-looking tissue stuck to the anterior wall of the gall bladder, which was removed along with the gall bladder. Subsequently, the tissue was confirmed to be liver tissue. Conclusion: It is a rare variation of the accessory lobe of the liver attached to the gall bladder. It remains asymptomatic clinically and may pose a danger of transforming to hepatocellular carcinoma; hence, total excision of the lobe should be considered.

Insulinoma: Presenting as hypoglycemia in a non-diabetic patient: A rare case report.

PNETs (pancreatic neuroendocrine tumors) are a rare sub-type of pancreatic tumors, with the majority of them being insulinomas. The vast majority of insulinomas (90%) are benign and solitary, with only 10% being malignant. It has a wide range of clinical manifestations and requires a high level of suspicion to diagnose. Surgical excision has long been the gold standard for treating localized PNET and is still the therapy of choice. Recurrent hypoglycemia is usual in diabetic patients, but this is a rare finding in non-diabetic individuals. Here, we are presenting a rare case of insulinoma who was non-diabetic and presented with recurrent hypoglycemic episodes. A 61-year-old non-diabetic male presented with multiple episodes of hypoglycemia in the past. On thorough workup, there was an increased fasting insulin level with the fasting blood glucose level ranging from 60 to 90 mg/dl. His C-peptide and proinsulin were markedly elevated. His abdominal ultrasound failed to pick up any abnormality. His DOTANOC scan revealed a 2 × 2 cm sized lesion in the distal pancreas suggestive of neuroendocrine pathology. He subsequently underwent spleen preserving distal pancreatectomy, following which his blood sugar levels remained normal, and continued to be free of symptoms on follow-up. Our instance emphasizes the need for evaluating insulinoma as a cause of recurrent hypoglycemia in people who are not diabetic. A high index of suspicion in hypoglycemic individuals who do not respond to standard treatment or whose symptom pattern changes will lower the likelihood of insulinoma diagnosis being delayed.

Non-functional retroperitoneal paraganglioma: A case report.

Paragangliomas are extra-adrenal tumors of the autonomic nervous system and may be found within the skull base, neck, chest, and abdomen. When presenting within the abdominal cavity, they may arise as a primary retroperitoneal neoplasm and can mimic vascular malformations or other conditions related to specific retroperitoneal organs such as the pancreas, kidneys.[1] They synthesize, store, and secrete catecholamines because of which they may present with headache, sweating, palpitation, and symptoms of hypertension (functional).[2] In the absence of histological diagnosis and symptoms of catecholamine excess (non-functional), these may be mistaken for GISTs.[3] We are reporting a case of a 36-year-old female who was clinically diagnosed as GIST, underwent excision, and postoperative histopathological examination was found to be paraganglioma.

Surgery in Pancreatic Necrosis-Challenges and Outcomes in an Industrial Hospital.

Twenty-seven cases of pancreatic necrosis were admitted and treated at our hospital from Jan 2010 till Jan 2015. Eight of these patients (29 %) underwent pancreatic necrosectomy. Of a total number of 957 patients admitted for acute pancreatitis, 27 patients (3 %) were diagnosed to have necrotizing pancreatitis. Of the 8 patients operated on, 5 patients (62.5 %) were treated successfully. The 3 patients who died had 3 organ (renal, respiratory and cardiovascular) failures. Nineteen patients of pancreatic necrosis responded to medical management and were successfully treated.