Three major coronary artery-to-left ventricular shunts: report of three cases and review of literature

The gallbladder is perforated and stones are spilled more frequently during laparoscopic cholecystectomy than during open cholecystectomy. Recent reports have implicated spilled gallstones as a source of infrequent but serious complications of laparoscopic of laparoscopic cholecystectomy. They can cause serious morbidity, and in most cases the patient will require open surgery for management of these complications. The authors report the case of a patient who was ill for 14 months after laparoscopic cholecystectomy when spilled stones formed a nidus for intra-abdominal abscess and colocutaneous fistula. Every effort must be made to prevent gallbladder perforation. When it does occur, all stones should be retrieved. Attempts at repairing gallbladder perforations are often unsatisfactory. A simple solution to this potential problem is to retrieve all stones immediately, place them in an intraperitoneal specimen bag, and "park" the bag on the liver. As soon as the gallbladder is dissected off the liver it should be placed in the specimen bag with the stones and removed through the umbilical port opening.     

Failed or difficult laparoscopic cholecystectomy: can preoperative ultrasonography identify potential problems?

A prospective study was performed to assess the role of preoperative ultrasonography in predicting failed or difficult laparoscopic cholecystectomy. Fifty patients underwent detailed preoperative ultrasound examinations. The number and size of calculi, evidence of acute or chronic cholecystitis, gallbladder morphology, and the presence or absence of aberrant anatomy were documented. A comparison was made of the surgical outcome and the ultrasound findings in each patient. Six patients were converted to open cholecystectomy because of inflammatory changes in the gallbladder. The preoperative ultrasound studies in 5 of these patients demonstrated evidence of cholecystitis and cholelithiasis. Gallbladder wall thickening and contraction were also seen. Five gallbladder resections had intraoperative difficulties; preoperative ultrasonography demonstrated a thickened gallbladder wall in 2. Of 31 uneventful cases, 7 had evidence of gallbladder wall thickening and/or contraction. There were no ultrasound features that identified between the unsuccessful, difficult, or uneventful laparoscopic cholecystectomies. We conclude that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases.     

Cystic duct syndrome and minimally invasive surgery

Cholecystectomy is an established successful operation which provides total relief of presurgical symptoms in up to 85% of patients. About 5% of patients after cholecystectomy experience severe episodes of upper abdominal pain, similar to those that they had prior to cholecystectomy. These so called postcholecystectomy syndromes may be due to biliary strictures, retained biliary calculi, cystic duct stump syndrome, stenosis or dyskinesis of the sphincter of Oddi. Postcholecystectomy symptoms caused by cystic stump and gallbladder remnant had been described early in this century and several papers have been published on the topic. During recent years laparoscopic cholecystectomy became popular but we have not found in the literature the mention of either that it could cause cystic duct stump syndrome or it could be used for its treatment. During the last seven years in 8 patients we found gallbladder remnants or cystic duct stumps causing their symptoms. Among the 8 patients 3 had laparoscopic and 5 classic cholecystectomies. After incomplete cholecystectomy we usually find that the cystic duct stump and the Calot triangle embedded in inflamed scar tissue. For this reason the surgical risk is to high with laparoscopic surgery to reoperate for these pathological changes. In all 8 cases the pathological cystic duct stumps and gallbladder remnants were removed using 3-4 cm single microlaparotomy incisions. The postoperative stay of these patients were uneventful and they were discharged home 2-3 days after surgery.     

Calibration of a reflectance pulse oximeter in fetal lambs for arterial oxygen saturations below 70%

Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.     

Long-term consequences of intraoperative spillage of bile and gallstones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy is associated with a higher incidence of iatrogenic perforation of the gallbladder than open cholecystectomy. The long-term consequences of spilled bile and gallstones are unknown. Data were collected prospectively from 1059 consecutive patients undergoing laparoscopic cholecystectomy over a 3-year period. Details of the operative procedures and postoperative course of patients in whom gallbladder perforation occurred were reviewed. Long-term follow-up (range 24 to 59 months) was available for 92% of patients. Intraoperative perforation of the gallbladder occurred in 306 patients (29%); it was more common in men and was associated with increasing age, body weight, and the presence of omental adhesions (each P < 0.001). There was no increased risk in patients with acute cholecystitis (P = 0.13). Postoperatively pyrexia was more common in patients with spillage of gallbladder contents (18% vs. 9%; P < 0.001). Of the patients with long-term follow-up, intra- abdominal abscess developed in 1 (0.6%) of 177 with spillage of only bile, and in 3 (2.9%) of 103 patients with spillage of both bile and gallstones, whereas no intra- abdominal abscesses occurred in the 697 patients in whom the gallbladder was removed intact ( P < 0.001). Intraperitoneal spillage of gallbladder contents during laparoscopic cholecystectomy is associated with an increased risk of intra-abdominal abscess. Attempts should be made to irrigate the operative field to evacuate spilled bile and to retrieve all gallstones spilled during the operative procedure.     

Training staff to provide a continence helpline

We report here the operative findings, the incidence of successful laparoscopic treatment, and the perioperative complications in patients with nonvisualized gallbladder on drip infusion cholangiography (DIC). Eighty-five patients with a nonvisualized gallbladder on DIC were entered into the study. None of the patients had a minimal adhesive gallbladder; 51 to 85 patients (60.0%) had moderate adhesive gallbladders, and 34 (40.0%) had severely adhesive ones. The rate of successful laparoscopic treatment, including laparoscopy-assisted abdominal surgery, was 97.6% (83 of 85 patients). Perioperative complications occurred in only three patients (3.5%), and there were no deaths related to the operation. Thus, when patients with a nonvisualized gallbladder on DIC undergo laparoscopic cholecystectomy, meticulous procedures must be carried out; however, as the rate of successful laparoscopic treatment is high, cholecystectomy under laparoscopy is feasible for experienced surgeons.     

Computational site-directed mutagenesis of haloalkane dehalogenase in position 172

Laparoscopic cholecystectomy is considered as the new gold standard operation for removal of the gallbladder, and has several advantages over the traditional open cholecystectomy. However, in the last few years there is an increasing number of case reports of port site metastases following laparoscopic cholecystectomy for unsuspected carcinoma of the gallbladder. Two case reports of trocar site metastases are presented, and they further highlight the concern of the role of minimal invasive surgery in the presence of unsuspected carcinoma of the gallbladder. In this review we speculate on the mechanisms which may be responsible for metastatic deposits during laparoscopic cholecystectomy and suggest certain recommendations.     

Laparoscopic subtotal cholecystectomy

Subtotal cholecystectomy is a definitive and safe operation to treat diseases of the gallbladder, whenever there are major difficulties in dissection from the liver. Described herein is successful experience with 6 patients using this technique, through the laparoscopic approach. In cases with severe inflammatory changes, gallbladder embedded in liver tissue, and liver cirrhosis, they enabled reduction of operative time and avoidance of excessive bleeding that could have caused the conversion of the laparoscopic approach to open laparotomy.     

Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis

BACKGROUND: The open subtotal cholecystectomy technique has simplified removal of the difficult gallbladder. Increasing laparoscopic experience has made laparoscopic subtotal cholecystectomy (LSC) a feasible option in patients with complicated acute or chronic cholecystitis. METHODS: LSC was performed in 29 patients with severe inflammation or fibrosis of the gallbladder associated with gallstone disease over a 23-month period. These 29 patients (mean age 53 years; 22 women) constituted 8.5 per cent of the total number of laparoscopic cholecystectomies performed (n = 340) and 15.6 per cent of 186 patients with acute cholecystitis. Eighteen patients in the latter group underwent conversion to open cholecystectomy. The indications for LSC were acute cholecystitis/empyema (n = 23) and severe fibrosis (n = 6). RESULTS: The cystic duct was either clipped before division (n = 15), sutured (n = 2) or ligated using an Endoloop (n = 10). In two patients the gallbladder bed was drained without isolating the cystic duct. The posterior wall of the gallbladder was left intact to avoid excessive bleeding or damage to bile ducts in the gallbladder bed. A suction drain was inserted in 14 cases. Median operating time was 73 (range 45-130) min. One patient died after operation from a myocardial infarction. Six patients had local complications (two haematomas, three bile leaks, one minor wound sepsis) and nine developed respiratory infections. Median hospital stay was 5 (range 2-28) days. CONCLUSION: LSC is a safe, relatively simple and definitive procedure allowing removal of a difficult gallbladder and reducing the need for open conversion or cholecystostomy in the majority of patients.     

Welch''s comments on Shapiro''s walk in the woods and the origin of eye movement desensitization and reprocessing

Polypoid lesions of the gallbladder in children are rare. We report a case of a gallbladder polyp in a 14-year-old boy who presented with recurrent right upper quadrant abdominal pain. Ultrasound examination of the abdomen revealed a polypoid lesion of the gallbladder. His symptoms resolved after laparoscopic cholecystectomy. Histological examination of the gallbladder demonstrated a benign adenomatous polyp. Although the experience with polypoid lesions of the gallbladder in children is limited, we currently recommend cholecystectomy because these lesions are associated with acalculous cholecystitis, and because their long-term effects are unknown.     

Comparison of laparoscopic and minilap cholecystectomy for acute cholecystitis

The charts of all patients with acute cholecystitis undergoing either laparoscopic or minilap cholecystectomy at the Chinle Comprehensive Health Care Facility between October 1, 1991, and August 15, 1993, were retrospectively reviewed. During that period, 54 patients underwent laparoscopic cholecystectomy and 45 patients had minilap procedures. The two groups had similar mean age, sex distribution, temperature, leukocyte count, gallbladder wall thickness, and duration of preoperative symptoms. While laparoscopic cholecystectomy took an average of 16 min longer to perform than minilap cholecystectomy, patients who had laparoscopic cholecystectomy had less blood loss, reduced postoperative narcotic needs, and shorter hospital stays.     

Methods of analysis and resources available for genetic trait mapping

Stones can be spilled from the gallbladder during laparoscopic cholecystectomy. These stones can be left in the peritoneal cavity or trapped at the trocar site. The potential late sequel and associated morbidity are not well documented. We reviewed the records of four patients who underwent laparoscopic cholecystectomy at Mount Sinai Medical Center in New York City who suffered from late complications attributed to gallstones left in the peritoneal cavity or abdominal wall. Four patients presented 1-14 months after laparoscopic cholecystectomy with intraabdominal and abdominal wall abscesses. The spillage of gallstones was noticed during the initial operation only in one of the patients. Three patients required laparotomy and open drainage of intraabdominal abscesses with drainage of pus and gallstones after failed attempts at percutaneous drainage. Two patients underwent local exploration of an abdominal wall abscess containing stones. Stones left in the abdominal cavity or trapped in trocar sites after laparoscopic cholecystectomy can cause serious late complications requiring repeated surgical interventions. Every effort should be made in order to avoid spillage of stones during dissection of the gallbladder and cystic duct and during retrieval of the gallbladder through the abdominal wall.     

Hoarseness

OBJECTIVE: To evaluate management and pregnancy outcomes in pregnant women with gallbladder disease. STUDY DESIGN: We reviewed the records from three teaching hospitals in central North Carolina from 1986 to 1993 to evaluate women who were admitted with gallbladder disease during pregnancy. RESULTS: Forty-two women were admitted with symptomatic cholelithiasis; 67% were white, the average age was 26 years, and the mean gestational age at presentation was 26 weeks. Conservative management with intravenous hydration, narcotics, dietary changes and antibiotics, if needed, was the first line of treatment in all 42 cases. Conservative management was successful in 17 women, with 8 requiring more than one admission. Nineteen patients failed medical management and needed cholecystectomy; three cases were laparoscopic. The diagnosis in the surgical group included 3 women with biliary colic, 14 with cholecystitis and 2 with gallstone pancreatitis. Four cholecystectomies were performed in the first trimester, 10 in the second and 5 in the third. Thirteen of 19 patients had no postoperative complications and delivered at term. Four women had uterine contractions controlled with tocolytics and delivered at 35 weeks or more. Two of 19 delivered prematurely--one at 32.5 weeks, 15 weeks after a laparoscopic cholecystectomy, and another at 34 weeks, 10 weeks after an open cholecystectomy. Of the patients who delivered prematurely, none were within the immediate postoperative period, and it appears unlikely that the cholecystectomy was causative. No maternal or perinatal mortality was noted. CONCLUSION: This review and others indicate that surgery should be reconsidered as possible primary management in pregnant women with symptomatic gallbladder disease.     

Laparoscopic cholecystectomy in the geriatric population

OBJECTIVE: To assess effectiveness and conversion rates of inpatient laparoscopic cholecystectomy in older people living in the community. SETTING AND SUBJECTS: All acute care hospitals providing cholecystectomy in a single state. Medicare patients who underwent inpatient cholecystectomy in fiscal year 1994 in Arkansas. METHODS: A random sample comprising 449 of 2182 geriatric patients who underwent inpatient cholecystectomy in fiscal year 1994, stratified by hospital bed size, had charts reviewed for type of cholecystectomy performed, occurrence of conversion from a laparoscopic to an open cholecystectomy, surgical complications, and need for transfusion. RESULTS: Eighty-two percent of nonincidental cholecystectomies were initially laparoscopic. Total conversion rate for all inpatient laparoscopic cases was 20%. Forty-two percent of this group suffered acute cholecystitis with male patients exhibiting a higher rate of acute cholecystitis than female patients. Conversion rates for elective cholecystectomy for both sexes was between 13 and 14%. Conversion rate to an open procedures was 28% for patients with acute disease, with male patients again having a higher rate than female patients (40% vs 19%, P < .001). Surgical complications and intraoperative transfusions were rare. Conversion rates did not vary between large and small hospitals or among different age groups within the older population. CONCLUSIONS: Inpatient laparoscopic cholecystectomy is common in older people both for acute and chronic gallbladder conditions. Conversion rates ranged from 13% for elective cholecystectomy to 28% for acute disease. These rates are higher than published literature, which focuses on younger populations undergoing elective procedures. Audit committees need to be aware of this higher conversion rate in older people when assessing surgical proficiency.     

Videolaparoscopic cholecystectomy. Experience, evolution, and comparison of techniques

The paper broadly outlines the technique of laparoscopic cholecystectomy used by the authors to treat patients suffering from calculosis of the gallbladder. Basing their comments on the French school, the authors review the literature to identify those innovations introduced by individual operators in elation to the original technique which have enabled this method to be extended to those cases complicated by acute cholecystitis, VBP calculosis or sequelae from abdominal surgery. The most important innovations include the use of a laparoscope with oblique 30-degrees vision, which is extremely useful during the dissection of Calot's triangle since it allows VBP to be identified with greater ease and precision, above all in the event of phlogistic sequelae enclosing the peduncle. In addition, laparoscopic suture or ligation using Roeder's running-knot, used by the Dundee school to treat the cystic duct and artery, presents considerable advantages compared to the conventional use of metal clips. The authors also emphasise the growing return to intraoperative cholangiography which is routinely performed by some authors and is of value in identifying anatomic anomalies, iatrogenic lesions and VBP calculi unnoticed by preoperative tests. A second innovation which is highlighted consists of the treatment of choledocholithiasis during the course of laparoscopic cholecystectomy, in addition to pre- and postoperative endoscopic papillo-sphincterotomy.     

Saint's triade presenting as volvulus of the gallbladder

Saint's triade of hiatus hernia, colonic diverticula, and cholelithiasis presenting with volvulus of the gallbladder is a unique occurrence. Possible etiology of volvulus of the gallbladder involves kyphosis, viceroptosis, cholelithiasis, and in this case adhesive bands. Laparoscopic decompression of the gallbladder, division of the adhesive bands, detorsion of the volvulus, and finally laparoscopic cholecystectomy successfully resolved this uncommon clinical problem. We describe a case and review the literature.     

Control of the temporal aspect when considering risk factors for acute otitis media

Laparoscopic cholecystectomy, initially performed in France in 1987, has rapidly spread to other European countries, the United States, and elsewhere. Of the techniques that have evolved, the "French" technique, in which the surgeon stands between the patient's legs, and the "American" technique, in which the surgeon stands on the patient's left side, are the most commonly used. In the former technique, the liver is retracted via the mid-clavicular cannula and the infundibulum of the gallbladder via the anterior axillary port. In the latter technique, the liver is retracted by axial traction on the gallbladder through the anterior axillary cannula and the infundibulum through the mid-clavicular cannula. This position may increase the risk of bile duct injury. The technique selected for operative cholangiography should be adapted to the problem at hand. Cystic duct cholangiography shows ductal calculi more reliably due to better filling of the common bile duct; direct puncture of the gallbladder is safer when the biliary anatomy is unclear. A number of European studies confirm the safety of laparoscopic cholecystectomy. Mortality rates vary between 0% and 0.1%, and duct injury rates range between 0.2% and 0.6%. Conversion, which is done in 3% to 8% of cases, may be necessary in the case of uncontrollable hemorrhage, bile duct injury unsuitable for laparoscopic repair, or if the gallbladder is densely scarred (scleroatrophic). It can also be done for safety reasons, when the anatomy is unclear. Complications include bile collections due to accessory duct or cystic duct stump leaks or less commonly to common duct injury. The average postoperative stay is longer in Europe (3.2 days) than in the United States. A decision tree is presented for the management of common bile duct stones. In general, preoperatively identified ductal stones are removed by endoscopic sphincterotomy, which is then followed by laparoscopic cholecystectomy to remove the source of the calculi. The techniques of laparoscopic choledochotomy and transcystic exploration for the removal of stones in the common bile duct are only beginning to be used, but they may well prove to be the most popular procedures. Results with these procedures will need to be evaluated against those obtained with endoscopic sphincterotomy.     

Subcostal, 3-4 cm, mini-cholecystectomy. A 3-year follow-up

The authors report the results of mini-cholecystectomy performed through a 3 to 4 cm long subcostal incision in 29 patients with the diagnosis of acute or chronic cholecystitis, from February 1991 to November 1922. Some of the patients were obese, diabetics or presented as emergency cases. The patients were operated on in the morning, as in laparoscopic cholecystectomy, began oral intake in the afternoon and were discharged on the day after surgery. Dissection of the gallbladder was facilitated by the use of a modified gynecologic valve and long thin instruments. Duration of surgery varied from 40 to 140 minutes. Patients could return to work on the third day after surgery. Notably, the costs/benefits were on the third more favorable than those of laparoscopic cholecystectomy.     

Laparoscopic management of acute cholecystitis with subtotal cholecystectomy

Approximately 20 per cent of laparoscopic cholecystectomies performed for acute cholecystitis require conversion to open cholecystectomy because of severe inflammation. In a retrospective review of 125 consecutive patients undergoing laparoscopic surgery for gallbladder disease from January 1995 through June 1997, 31 had acute cholecystitis. Eight patients underwent a subtotal cholecystectomy because of severe inflammation. There were no conversions to open cholecystectomy and no intraoperative complications. Selected patients were evaluated and treated for common duct stones with preoperative endoscopy to avoid intraoperative cholangiography. One patient had a retained common duct stone successfully managed with postoperative endoscopy. Laparoscopic subtotal cholecystectomy is a safe and effective alternative to conversion to open cholecystectomy for severe inflammation associated with acute cholecystitis. Endoscopic assessment and treatment of common duct stones when indicated either before or after surgery omits the use of intraoperative cholangiography and potential injury to the inflamed ducts.     

Laparoscopic cholecystectomy. Do preoperative factors predict the need to convert to open?

We reviewed our experience with the last 587 laparoscopic cholecystectomies performed between May 1990 and January 1993 to correlate preoperative findings that may predict the conversion of a laparoscopic cholecystectomy to that of an open procedure. The prediction of a need to convert to an open cholecystectomy would allow the surgeon to discuss the higher risk of conversion with the patient and also allow for an earlier intraoperative decision to convert if difficulty was encountered. In addition to routine demographic data, ultrasound reports were available for 526 patients and the following information was recorded: presence of stones, thickened gallbladder wall, common bile duct dilatation, gallbladder sludge, and cystic duct impaction. Overall, a two times higher rate of conversion was found for male patients and patients with a body mass index > 27.2 kg/m2. Additionally, a thickened gallbladder wall on preoperative ultrasound was correlated with a six times higher conversion rate to open cholecystectomy. As expected, the positive intraoperative cholangiogram was associated with a higher incidence of conversion. Additionally, finding a dilated common bile duct on ultrasound was found to be associated with a nearly seven times higher rate of positive intraoperative cholangiogram. No statistical significance was found between conversion and age, previous abdominal operations, the presence of stones, common bile duct dilatation, gallbladder sludge, cystic duct impaction, or a distended gallbladder. Thus, these predictive findings allow the surgeon to preoperatively discuss the higher risk of conversion and allow for an earlier judgment decision to convert if intraoperative difficulty is encountered.