Small Bowel Adenomyoma: An Incidental Intraoperative Finding While Performing Hepaticojejunostomy for CBD Injury

Adenomyoma is a benign lesion that is most commonly seen in the gallbladder, however, rare cases have been reported where this pathology was encountered in the vicinity of the gastrointestinal tract. The pathogenesis of this lesion is still a controversy, with the previous reports suggesting it to be either a form of hamartoma or incomplete heterotopic pancreas. Jejunal and ileal adenomyoma have been rarely reported, and as of 2016 less than 30 cases were reported in the English literature. The clinical presentation is variable depending on the location of the lesion. Although there are no specific management guidelines for this pathology, a surgical resection is sufficient. However, aggressive surgical approaches, such as pancreaticoduodenectomy for periampullary adenomyoma, have been undertaken in the previous reports due to the misdiagnosis with carcinoma preoperatively. We report a case of a 58-year-old gentleman who was referred to our Hepato- Pancreato-Biliary facility with common bile duct injury post laparoscopic cholecystectomy for hepatico- jejunostomy. Intra-operatively, an intra-luminal, jejunal mass was found measuring 2x2 cm and was about 95 cm from the DJ junction. The lesion was resected with safety margins, and primary anastomosis was done. The final histopathology of the specimen was consistent with adenomyoma, and all of the surgical margins were free.

Extra hepatic bile duct injury after laparoscopic cholecystectomy: a retrospective study

Background: Laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedure among the basic surgeries. Incidence of common bile duct (CBD) injury as high as 1.4-3% has been reported in some studies. The aim of this study was to estimate the incidence and predictors of CBD injury who underwent elective laparoscopic cholecystectomy.Methods: A retrospective observational study conducted at Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh India. Data was collected for a period of 1 year between March 2019 till 2020.Results: In majority of laparoscopic cholecystectomy we encountered moderate degree of difficulty. Extra hepatic bile duct injuries occurred in 1.4% of cases and were classified according to Strasberg classification. Type A injury was most common followed by type E2. Most major bile duct injuries were recognized intraoperatively. No mortality was noted in our study.Conclusions: Bile duct injuries is a major complication of laparoscopic cholecystectomy with significant morbidity and mortality, reduced survival impaired quality of life and subsequent litigations. Majority of bile duct injuries, results mainly from the surgeon’s inexperience, misinterpretation of anatomy and poor surgical techniques.

Effect of laparoscopy on liver enzymes

Background: Laparoscopic procedures have gained popularity in recent days because of advantages like small incision, less postoperative pain and discomfort, short hospital stay, early ambulation and early discharge. Very few studies are available to correlate Laparoscopic Surgeries and liver enzyme elevation. This effect may be due to either CO2 pneumoperitoneum, diathermy extruding liver, injury to branch of the hepatic artery or general anesthesia. This study was done to evaluate the changes in liver enzymes pre-operatively and post-operatively following laparoscopy.Methods: This prospective study included 103 patients who underwent various laparoscopic surgeries over a period of 2 years in Bharati Hospital & Research Centre, Pune, India. Serum AST, ALT and bilirubin levels were measured preoperatively and on post-operative day 1 and post-operative day 3. Patients with coexisting liver disease, Patients on long term use of hepatotoxic drugs, patients who developed complications such as CBD injury, obstruction, infection, leakage and high grade fever during surgery and in the post-operative period were excluded.Results: All laparoscopic procedures cause a transient elevation of serum bilirubin and liver enzymes. Elevation in the liver enzymes correlated directly with the duration of pneumoperitoneum. Elevation in the serum bilirubin but doesn’t correlates with the duration of pneumoperitoneum. These elevations do not have clinical significance in patients with normal hepatic function preoperatively.Conclusions: Duration of laparoscopic procedure should be kept to minimum and undue prolongation should be avoided. Decision to convert the operation to open surgery from a laparoscopic surgery should be prompt.

Bile Leak Following Laparoscopic Cholecystectomy

Bile leakage is a very dangerous condition after laparoscopic cholecystectomy and may lead to fatal complications and serious care should be taken to diagnose the cause as early as possible because it may be sign of bile duct injury which is a major concern to the surgeons as if it is not diagnosed early, it will lead to dangerous complications such as biliary peritonitis, hepatic failure and even death. Early diagnosis is important to decrease morbidity and mortality. This study aimed to determine the incidence of bile leakage, its types of management and the outcome in patients with gallstone who are submitted to laparoscopic cholecystectomy. This prospective study was done in Basrah Al-Sadr Teaching Hospital in a two-year period from October 2013 to October 2015 on 560 patients; they were 378 females and 182 males. All of them have symptomatic gallstones and underwent laparoscopic cholecystectomy. All converted cases to open cholecystectomy were excluded. From the total number of 560 patients, nine patients developed bile leak in early post-operative period, 6 of them have drains, the other three have no drain, and they were presented with signs and symptoms of intra-abdominal collection. The causes of leak were common bile duct (CBD) injury in 2 cases, accessory duct in 3 patients, leak from the gall bladder bed in 3 cases and one case iatrogenic from intra-hepatic drain. All the patients were treated conservatively except the two patients with CBD injury who were treated; one with the aid endoscopic retrograde cholangio-pancreatography (ERCP) and the other by re-exploration. In conclusion, bile leak is a serious complication after laparoscopic cholecystectomy, although it is not common but it is important to identify the site of leak and should be tre

Choledochodudenostomy for bile duct injuries: a less demanding option, in a demanding surgical situation

Cholecystectomy is one of the most common surgical procedure performed worldwide and therefore a common cause for iatrogenic biliary tract injury. Bile duct injuries are associated with significant morbidity and are a potentially fatal complication. Choledochodudenostomy in patients of post cholecystectomy bile duct injury can be done safely by experienced surgeons in CBD injuries distal to the confluence of the cystic and common hepatic duct after eradication of sepsis. Choledochoduodenostomy has its own technical advantages and it maintains the normal anatomy. As compared with a routine Roux-en-Y hepaticojejunostomy, CDD is technically easier, faster, requires less manipulation of the CBD, and is more physiological. We present a case report of a patient of laparoscopic cholecystectomy with CBD injury managed with choledochoduodenostomy who did extremely well after procedure with no immediate and delayed postoperative complication.

An analysis of discrepancies in consent form for laparoscopic cholecystectomy in a tertiary care hospital: “FILTER” model

Background: Informed consent is needed to be full-proof but many discrepancies arise as it is subjected to individualization for each patient depending on their IQ, personality etc. Considering all aspect, the study aims to identify the issues and seek for potential remedies through “FILTER” model.Methods: This is a retrospective, Institution-based, observational study conducted in R.G. Kar Medical College over 3 years on 500 patients who underwent laparoscopic cholecystectomy.Results: Most of the consents (79%) were taken by consultant surgeons and rest was by junior residents. Junior residents wrote the consent form on behalf of patients in most cases (67%). 78% of the forms were signed by the patient party, 23% by patient himself and 19% by the surgeons. 67% of the total consent forms were printed and rest were hand-written. 65% of the total consent forms were signed after the patient or the patient party was informed and rest were signed without informing them. CBD injury (72%), bleeding (55%), bile leak (46%) and post-op collection (37%) were the frequency of complications encountered by the patients not informed beforehand. As the patients were informed beforehand, the need for conversion to open operation (62%), retained stone (89%), cardio-respiratory (98% and 93% respectively) complications were common. Need for an open operation, cardio-respiratory complications were most commonly informed. Bleeding (10%), CBD injury (2%) and bile leak (12%) was less informed.Conclusions: Proper and more standardized procedures and protocols should be followed for obtaining consent irrespective of the intervention required.

Complications of laparoscopic surgery in general surgical practice and their management

Background: Any new technique is associated with the development of new complication. Laparoscopic surgery has gained popularity over last 20 years, owing to many advantages for patients in terms of smaller scar, less post-operative pain and quicker recovery. Despite the relative safety of laparoscopic techniques, inadvertent serious injuries to bowel, bladder and vascular structures do occur. Therefore, the need has arisen to study the various complications and their management inherent in this technique. The objective was to determine percentage of complications in laparoscopic surgeries of abdomen and also to study their management.Methods: Inpatients of Ramaiah hospitals undergoing abdominal laparoscopic surgeries from October 2014 to October 2015 who are above 14 years of age and undergoing elective or emergency surgeries or diagnostic laparoscopy for acute/chronic appendicitis, cholelithiasis and inguinal hernia repair. Demographic information, clinical findings, intra operative and postoperative findings will be noted. Follow up of the patient is done for 4 weeks.Results: Out of the 272, 134(49.3%) were male patients and 138 (50.7%) were female patients, age group ranging between 31-40 years. Four patients (1.4%) showed CBD injury, three patients (1.1%) showed bowel injury, twelve (4.4%) showed bile leak, all these 9 (3.3%) patients were managed by converting the laparoscopic cholecystectomy into open cholecystectomy. Sixteen patients (5.9%) had laparoscopy converted into open procedure due to the intraoperative complications. Statistically significant impact was noted on the outcome of surgery due the complication that patient underwent during the study.Conclusions: Laparoscopy is a safe, effective and well tolerated procedure if conducted in the skilled and experienced hands. The morbidity and mortality are dependent on age, general condition, presence/ absence of comorbidities and hence preoperative thorough work up is imperative. Large proportions of these complications occur during the initial learning curve of the inexperienced laparoscopic surgeon.

Factors resulting in conversion of laparoscopic cholecystectomy to open cholecystectomy-institution based study

Background: Laparoscopic surgery has revolutionized the way it is performed for an increasing number of patients. In this study, we determined the various reasons for conversion of laparoscopic cholecystectomy in our setup.Methods: This was a descriptive study, conducted at Government Medical College Srinagar, Frommay 2015 to June 2017. The study included 450patients with symptomatic cholelithiasis, who underwent laparoscopic cholecystectomy. All patients were operated by experienced laparoscopic surgeons with experience of more than 300 Laparoscopic cholecystectomies. Cases that required conversion from laparoscopic to open surgery were analyzed and the factors possible for such conversion were studied.Results: The mean age of patients was 45.6 years and male to female ratio 1:3.8. The mean operating time was 49 minutes and average hospital stay was 2 days. Out of 450 patients, 26(5.8%) required open conversion. Factors responsible for open conversion were dense adhesions in 12(2.7%), obscure anatomy at clot’s triangle in 6, (1.3%), significant intra-operative bleeding 5 (1.1), CBD injury 1(0.2%), visceral injury 1 (0.2%), and instrument failure in 1(0.2%) conversions.Conclusions: Open conversion rate of laparoscopic cholecystectomy in this study was 5.8%. The commonest cause of conversion was dense adhesions around the gall-bladder. Preventable factors like instrument failure or power breakdown can be addressed by a reliable back up.