Laparoscopic management of remnant cystic duct calculi: a retrospective study.

INTRODUCTION: Even though cholecystectomy relieves symptoms in the majority of cases, a significant percentage suffer from 'post-cholecystectomy syndrome'. Cystic duct/gall bladder remnant calculi is a causative factor. We present our experience with the laparoscopic management of cystic duct remnant calculi. PATIENTS AND METHODS: We managed 15 patients with cystic duct remnant calculi from 1996 to 2007 in our institute. All these patients had earlier undergone laparoscopic subtotal cholecystectomy at our centre. They were successfully managed by laparoscopic excision of the remnant. RESULTS: The mean duration between first and second surgery was 8.35 months (range, 6-10.7 months). The mean operating time was 103.5 min (range, 75-132 min). Duration of hospital stay was 4-12 days. There was a higher incidence of remnant duct calculi following laparoscopic subtotal cholecystectomy than conventional laparoscopic cholecystectomy - 13/310 (4.19%) versus 2/9590 (0.02%). The morbidity was 13.33%, while there were no conversions and no mortality. CONCLUSIONS: Leaving behind a cystic duct stump for too long predisposes stone formation, while dissecting too close to the common bile duct and right hepatic artery in acute inflammatory conditions is dangerous. We believe that the former is a wiser policy to follow, as cystic duct remnant calculi are easier to manage than common bile duct or vessel injury. Laparoscopic excision of the remnant is effective, especially when performed by experienced laparoscopists. 'T'-tube is used to canulate the common bile duct in case the tissue is friable. Magnetic resonance cholangiopancreaticography is the imaging modality of choice, and is mandatory.

An innovative technique for colorectal specimen retrieval: a new era of "natural orifice specimen extraction" (N.O.S.E).

PURPOSE: The common incisions for transabdominal specimen retrieval after laparoscopic colorectal surgery are lower quadrant, midline, or transverse suprapubic incision. This study was designed to evaluate a novel method of specimen extraction after totally laparoscopic proctocolectomies. METHODS: We retrospectively studied seven women patients from 2004 to 2007. The indication for surgery was familial polyposis coexisting with adenocarcinoma of the upper rectum. A totally laparoscopic proctocolectomy with ileal pouch-anal anastomosis was successfully performed for all cases. The entire specimen was extracted via a transvaginal route. RESULTS: The mean age of the patients was 49.5 years, and mean body mass index was 25.3 kg/m(2). The mean operating time was 222.5 minutes, and average blood loss was 172 ml. The average hospital stay was 25.5 days. Postoperative complications included ileus (n = 1), pouchitis (n = 1), and deep vein thrombosis (n = 1). The vaginal wound had healed completely by the first follow-up. There was no mortality. CONCLUSIONS: Our technique of transvaginal retrieval effectively prevents wound-related complications by completely eliminating minilaparotomies for specimen retrieval. It could be called "Natural Orifice Specimen Extraction," or N.O.S.E. We stress the need for innovations in specimen extraction, for which importance is not given by surgeons.

Laparoscopic management of a retroperitoneal duodenal perforation following ERCP for periampullary cancer.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a fairly common procedure being performed in several centers worldwide. Although it is proven to be efficient and relatively safe, complications do occur (1.8%). We present a patient with ERCP-induced retroperitoneal perforation of the duodenum treated laparoscopically at our institution. CASE REPORT: The patient is a 60-year-old female who underwent ERCP for obstructive jaundice due to periampullary carcinoma, during which the perforation occurred. Laparoscopy was performed 5 hours later and the perforation sutured primarily. RESULTS: The operating time was 125 minutes. On the fourth postoperative day, the patient developed a retroperitoneal collection, confirmed by computed tomographic scan. Re-look laparoscopy was performed and the fluid drained. She recovered completely and was discharged on the eighth postoperative day. CONCLUSION: Duodenal perforation following ERCP is rare, with an incidence of 1.8%. Both surgical and non-surgical management have been reported, each with its specific indications. Our patient needed surgery, because the perforation was large and a retroperitoneal collection was present. Laparotomy is the preferred approach, though now laparoscopy is a viable and effective alternative, because it provides the benefits of minimal access, such as reduced pain and early ambulation.