Use of hand held Doppler to identify venous tributaries in in situ vein arterial bypass.

BACKGROUND: It very important to reduce the morbidity associated with arterial bypass surgery by minimizing the length of incision used in infrainguinal bypass surgery using in situ vein as a conduit. This paper describes a quick and less invasive method of identifying the location of vein tributaries using Hand Held Doppler in arterial bypass surgery with local cut down instead of extensive exposure. METHODS: The technique was used in 19 consecutive procedures. Fourteen grafts were subsequently evaluated for completeness of tributary ligation using duplex scanning. RESULTS: A mean of 2.5 tributaries were identified per limb. Thus, there were 35 patent tributaries in our cohort of 14 patients. None was of clinical significance. Four occluded spontaneously during the period of study. Wound length was reduced by 30-60% depending on the total length of the incision. CONCLUSION: This technique is an effective, cheap and simple means of performing bypass surgery in high-risk patients (with significant comorbidity and a high ASA score) and also reducing inherent complications associated with the length of the incision.

Torsion of the gallbladder: a case report.

INTRODUCTION: Torsion of the gallbladder is a rare condition that most commonly affects the elderly. Pre-operative diagnosis is the exception rather than the rule. Any delay in treatment can be fatal as the gallbladder may rupture, leading to biliary peritonitis. CASE PRESENTATION: We present the case of an 80-year-old woman who was admitted with right upper quadrant pain initially thought to be secondary to acute cholecystitis. Subsequent ultrasound and computed tomography scans of the abdomen revealed signs suggestive of acute cholecystitis but neither modality detected any gallstones. As the patient's symptoms failed to resolve on conservative management, she was taken to theatre for an open cholecystectomy. Intra-operatively, the gallbladder had undergone complete torsion and appeared gangrenous. A routine cholecystectomy followed and she recovered from the operation without incident. CONCLUSION: It is rare to diagnose torsion of the gallbladder pre-operatively despite advances in diagnostic imaging. However, this differential diagnosis should be borne in mind particularly in the elderly patient, without proven gallstones, who fails to improve on conservative management. An emergency cholecystectomy is indicated in the event of diagnosing torsion of the gallbladder to avert the potentially lethal sequelae of biliary peritonitis.