Axillary nodal metastasis of operated gallbladder carcinoma: remote site of aggression—a case report

Background Gallbladder cancer is a very aggressive type of biliary tract cancer. The only curative treatment is complete surgical excision of the tumour. However, even after surgery, there is still a risk of recurrence of the cancer. Case presentation A 63-year-old gentleman presented with the complaint of a non-healing ulcer at upper abdomen for the last 1 month. He had undergone a laparoscopic cholecystectomy at a private centre 4 months ago. Investigations confirmed the diagnosis of epigastric port site metastasis from a primary from gall bladder adenocarcinoma. After undergoing completion radical cholecystectomy with wide local excision of the epigastric ulcer, he received 6 cycles of concurrent chemoradiotherapy. Eighteen months later, he presented to us with bilateral axillary swellings. Investigations confirmed isolated bilateral axillary metastasis and the patient underwent a bilateral axillary lymphadenectomy (Level 3). However, PET scan after 6 months showed widespread metastasis and the patient succumbed to the illness 1 month later. Conclusion Axillary metastasis probably occurs due to the presence of microscopic systemic metastasis at the time of development of port site metastasis. An R0 resection of the malignancy is the only viable option for effective therapy. The present case highlights the rare involvement of isolated bilateral axillary lymph nodes as a distant metastatic site with no evidence of disease in the locoregional site. However, the prognosis after metastasis remains dismal despite multiple treatment modalities.

Trocar-site hernia following laparoscopic salpingo-oophorectomy in a middle-aged Japanese woman: an initial case report after 40 years of experience at a single center and a brief literature review

Background In gynecology, the number of laparoscopic surgeries performed has increased annually because laparoscopic surgery presents a greater number of advantages from a cosmetic perspective and allows for a less invasive approach than laparotomy. Trocar site hernia (TSH) is a unique complication that causes severe small bowel obstruction and requires emergency surgery. Its use has mainly been reported with respect to gastrointestinal laparoscopy, such as for cholecystectomy. Contrastingly, there have been few reports on gynecologic laparoscopy because common laparoscopic surgeries, such as laparoscopic salpingo-oophorectomy, are considered low risk due to shorter operative times. In this study, we report on a case of a woman who developed a TSH 5 days postoperatively following a minimally invasive laparoscopic surgery that was completed in 34 min. Case presentation A 41-year-old woman who had undergone laparoscopic salpingo-oophorectomy 5 days previously presented with the following features of intestinal obstruction: persistent abdominal pain, vomiting, and inability to pass stool or flatus. A computed tomography scan of her abdomen demonstrated a collapsed small bowel loop that was protruding through the lateral 12-mm port. Emergency surgery confirmed the diagnosis of TSH. The herniated bowel loop was gently replaced onto the pelvic floor and the patient did not require bowel resection. After the surgical procedure, the fascial defect at the lateral port site was closed using 2-0 Vicryl sutures. On the tenth postoperative day, the patient was discharged with no symptom recurrence. Conclusions The TSH initially presented following laparoscopic salpingo-oophorectomy; however, the patient did not have common risk factors such as obesity, older age, wound infection, diabetes, and prolonged operative time. There was a possibility that the TSH was caused by excessive manipulation during the tissue removal through the lateral 12-mm port. Thereafter, the peritoneum around the lateral 12-mm port was closed to prevent the hernia, although a consensus around the approach to closure of the port site fascia had not yet been reached. This case demonstrated that significant attention should be paid to the possibility of patients developing TSH. This will ensure the prevention of severe problems through early detection and treatment.

Analgesic efficacy of ultrasound-guided transversus abdominis plane block for laparoscopic gynecological surgery: a randomized controlled trial

Background: This study aimed to determine whether ultrasound-guided transversus abdominis plane (TAP) block is more effective in reducing postoperative pain and analgesic consumption than local anesthetic infiltration (LAI) at the port site for elective laparoscopic gynecological surgeries.Methods: Eighty patients with the American Society of Anesthesiologists status I/II undergoing laparoscopic gynecology surgery were enrolled for this randomized control trial. After general anesthesia was administered, patients in group C received LAI at each port site, and patients in group T received bilateral ultrasound-guided TAP. Postoperative pain was assessed at time intervals of 1/2, 2, 4, 6, 8, and 24 h using the numeric pain scale (NPS). Clinical metrics such as postoperative analgesic diclofenac consumption, need for rescue fentanyl, nausea-vomiting scores, and antiemetic requirements were also recorded.Results: Seventy-four patients were included in the final analysis. Postoperatively, patients in group T had significantly lower NPS than those in group C (P < 0.05). The highest difference in the postoperative NPS was observed at 2 h (median [1Q, 3Q]; group C = 3 [2, 4]; group T = 1 [0, 2]; P < 0.001). A statistically significant difference was observed in the frequency of diclofenac (75 mg intravenous) requirement between the groups (P = 0.010). No significant difference was observed between the groups in need of rescue fentanyl or antiemetic and the nausea-vomiting scores.Conclusions: In patients undergoing laparoscopic gynecological surgery, ultrasound-guided TAP block provided greater postoperative analgesic benefits in terms of lower NPS and reduced analgesic requirements than port site LAI.

A Clinicopathological Appraisal of Port-site Infections after Laparoscopic Cholecystectomy: Our Experience at Shaheed Suhrawardy Medical College Hospital

Background: Undoubtedly the port site infections have remarkably enhanced to be a stigma as post laparoscopic morbidity and is still a field of debate and further exploration to surgeons. These port site infections (PSI) are infrequent surgical site infection, complicating the recovery of patients undergoing laparoscopic cholecystectomy. Hence, the necessity of further evaluation of the regarded facts was intended to be explored. Aim: This study was aimed to evaluate the factors that created or provoked PSI after laparoscopic removals of gall-bladder and at analysing which of these factors can be traced and modified to combat PSI in a trail to conquer these complications and to achieve maximum advantages from laparoscopic surgeries. Methods: A prospective descriptive qualitative study conducted on patients who underwent laparoscopic cholecystectomies in our hospital as well as at other facilities remote from our work stations. Factors as gender, site of infected port, types of microorganism, acuteness versus chronicity of the disease, types of infection (superficial or deep infection) and intraoperative spillage of stones, bile or pus were analysed in our study. Swabs were taken for culture and sensitivity tests in all patients who developed infections. Explorations were done under GA for some patients who had deep surgical site infections and wound debridement was done, excisional biopsies were taken for histopathological studies, and tissue samples for Gene-Xpert analysis for detection of Mycobacterium tuberculosis was done. All patients were followed up for six months postoperatively at our surgery unit rooms. Results: Port site infection rate was recorded in 40 cases amongst 340 procedures from the July 2018 to June 2020 (11.76%). A higher rate was observed in female patients 32 cases (9.41%) and 13 cases (3.82%) of acute cholecystitis. Larger number of cases of the PSI were superficial infections (77.5%) with non-specific microorganism in 34 cases (80.0%). Conclusion: We reconciled a significant association of PSI with spillage of bile or stones during the procedure and with acute cholecystitis. Most of the infections are superficial and more common in males. Precautions and protocols should be taken in measure to avoid unnecessary hurry and faulty procedure of sterilization during and prior to the whole surgery to combat PSI effectively. J Shaheed Suhrawardy Med Coll 2020; 12(2): 76-81

Frequency of Port Site Wound Infection with and Without End Gloves Techniques of Retrieval of Gallbladder in Pouch

Background: The gallbladder is a hollow organ that sits just beneath the right lobe of the liver. Chief functioning of gallbladder is to store gall, also known as bile that is required for digestion of food. Removing gallbladder through small incision in the abdomen is called laparoscopic cholecystectomy. Among benefits of cholecystectomy are decreased need for postoperative analgesia, decreased postoperative pain and shortened hospital stay from 1 week to less than 24 hours. Objective: To compare the frequency of port site wound infection with and without endogloves techniques of retrieval of gallbladder in pouch after laparoscopic cholecystectomy for chronic calculus cholecystitis. Design: It was a randomized controlled trial. Study Settings: This study was conducted at Department of General Surgery, Midland Doctors Medical Institute Tandali Muzaffarabad from July 2019 to July 2021 Material and Methods: A total of 260 cases who fulfilled inclusion criteria were enrolled in the study through wards of Department of General Surgery. Written informed consent was obtained from all the patients. Two groups were made by random division of patients. Conventional laparoscopic cholecystectomy was performed in patients of group I. Through umbilical port gall-bladder was retrieved in these patients, exactly spot on by a sterile surgical hand glove endobag. Vicryl “O” with J-shaped needle was used to close 10mm umbilical port (fascial defect) and 5mm ports were conventionally closed. In patients of group II, conventional laparoscopic cholecystectomy was performed and gall-bladder was retrieved as in patients of group I but without using surgical sterile hand glove endobag. Results: The mean age of the patients in study group was 48.09±15.402 years and in control group it was 47.51±16.48 years. Male to female ratio was 1.06:1. The post-op wound infection was found in 11 (4.23%) patients. Statistically significant difference was found in groups (P<0.05). Conclusion: The use of endoglove technique of retrieval of gallbladder in pouch after laparoscopic cholecystectomy for chronic calculus cholecystitis is safe, cheap, simple and potentially reduces significant port site wound infection compared to without endogloves. Keywords: Laparoscopic Cholecystectomy, Endoglove, Gallbladder (GB).

Port-Site Metastasis (PSM): Definition, clinical contexts and possible preventive actions to reduce risk

The "port-site metastasis" represents a tumor recurrence that develops in the abdominal wall within the scar tissue of the insertion site of one or more trocars, after laparoscopic surgery, not associated with peritoneal carcinomatosis. This last aspect is central because in the literature some isolated cases are reported, but most cases are associated with peritoneal carcinomatosis. The first case in the literature dates back to 1978 and in the literature, the incidence varies from 1% to 21%, although most published research reports a very small number of patients. Currently, the incidence in a specialized cancer center is consistent with the incidence of recurrence on a laparotomy scar. Possible mechanisms for cell implantation at the port site are direct implantation into the wound during forced, unprotected tissue retrieval or from contaminated instruments during tumor dissection; the effect of gas turbulence in lengthy laparoscopic procedures, and embolization of exfoliated cells during tumor dissection or hematogenous spread. Probably, however, the triggering mechanism is necessarily multifactorial. To date, the only significant prognostic factor in patients diagnosed with port-site metastasis is the interval between laparoscopy and the diagnosis of the port site: in fact, patients who develop the port site within 7 months after surgery have a generally worse prognosis, as well as port-site metastasis are more frequent in advanced cancers and the presence of ascites. To reduce the risk, the following measures are proposed in the literature: 1) Select the patient who does not have a metastatic oncologic condition or friable cancerous masses or lymph node spread or attached external or intracystic vegetations, preferring well-localized, benign or low-malignant or otherwise intact tumors; 2) Use wound protectors and use of protective bags (or endo bag) for tissue retrieval; 3) Peritoneal washing with heparin, to prevent free cell adhesion, or washing with cytocidal solutions. Evaluate the utility of using Povidone-iodine, Taurolidine (which has anti-adhesion activity and decreases proangiogenic factors), and chemotherapy products; 4) Avoid removing pneumoperitoneum with trocars in place; 5) Avoiding direct contact between the solid tumor and the port site; 6) Prefer laparoscopy to laparotomy, if possible; 7) Avoid the use of gas or direct CO2 insufflation, although in literature the point is controversial and deserves more attention and study, as the initial hypothesis that CO2 increased the invasion capacity of tumor cells (in vitro and in vivo) has been refuted several times. Insufflation of hyperthermic CO2 and humidified CO2 leads to a better outcome in patients with a malignant tumor who undergo a laparoscopic procedure compared with normal CO2 pneumoperitoneum; 8) Comply with surgical protocols and techniques by updating one's surgical skills, as it has been demonstrated, as already reported here, the presence of cancerous cells on instruments, washing systems and trocars (in particular, on the trocars of the first operator). Suturing all layers of the abdominal wall decreases the risk of the port site; 9) Avoid excessive manipulation of the tumor mass during the surgical/operative procedure.