Spilled cells, spilled clips, spilled stones. New problems or old challenges

Retrobulbar Metastasis from Gallbladder Carcinoma after Laparoscopic Cholecystectomy. A Case Report

Extra-abdominal metastases from gallbladder cancer are very rare; the sites outside the abdomen most frequently affected are the skin, bone and central nervous system. In the literature, only one case of orbital metastasis from gallbladder cancer has been reported, in a patient previously treated by open cholecystectomy. We report the case of a 53-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallbladder stones. Postoperative histological examination revealed an unsuspected gallbladder adenocarcinoma. One month later she came to our observation after having developed diplopia and ophthalmic pain due to an orbital metastasis. We decided not to perform a surgical second look because of the already rapid dissemination of the malignant tumor.

The few cases of uncommon gallbladder cancer metastases after laparoscopic cholecystectomy described in the literature are discussed, as well as the possible role of laparoscopy in the dissemination and localized seeding of malignant cells.

Unusual consequences of 'incomplete' laparoscopic cholecystectomy

In recent years, laparoscopic cholecystectomy (LC) has become the standard surgical practice for the treatment of cholecystolithiasis. As a recognized technical difficulty, it may be associated with the mechanical injury of the gallbladder and/or spilling some of the gallstones into the abdominal cavity. The actual incidence of the latter complication is ~10%. The removal of lost stones from the abdominal cavity is rather elaborate if not infeasible. There is little information about the behaviour of retained gallstones in the free abdominal cavity. Publications report on subsequent intraperitoneal abscesses and fistulas or on the extreme localization of the impacted gallstones. This paper presents two cases with late complications of the abandoned gallstones or gallbladder. Case 1: A 56-year-old female patient underwent an LC 7 years ago. She was recently admitted with a chronic septic condition and suspected autoimmune disease. Preoperative examinations indicated hepatic abscess. Surgery showed gallstones impacted in the gallbladder bed. Case 2: A 59-year-old male patient underwent an LC a year before his admission. His operation was followed by the development of a septic condition and a subphrenic abscess was identified. During his reoperation, a remnant gallbladder containing bile stones was found and removed. Special attention should be paid to careful revision of residual stones during LC.

Single-fulcrum laparoscopic cholecystectomy: a single-incision and multi-port technique

BACKGROUND

  Single-incision laparoscopic cholecystectomy (LC) is still technically demanding and usually requires specially designed instruments. This article describes our own technique, a single-fulcrum LC using only standard ports and instruments.

METHODS

  Between March 2009 and December 2010, 130 consecutive patients, all scheduled to undergo elective LC, underwent this single-fulcrum LC for benign gallbladder disease. Perioperative surgical outcomes were retrospectively evaluated.

RESULTS

  One hundred and ten patients (84.6%) underwent successful single-fulcrum LC, and 20 patients (15.4%) were converted to conventional surgery (n= 18) or required additional trocars (n= 2) during the procedure because of umbilical hernia (n= 3), severe inflammation or adhesion (n= 9), impacted cystic duct stone (n= 3), anatomical anomaly (n= 3) and iatrogenic injury (n= 2). Two intraoperative complications (iatrogenic injury) were securely managed using additional trocars and there was no post-operative morbidity or mortality. This single-fulcrum LC could be performed with comparable cost to conventional LC, and the sequential operative time showed reasonable learning curve.

CONCLUSION

  Single-fulcrum LC is feasible, safe and quite reproducible. The surgical wound can be dramatically reduced at a similar cost to conventional LC. It may be an alternative procedure for most uncomplicated benign gallbladder disease.

Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating?

Laparoscopic cholecystectomy is now one of the most frequently performed abdominal surgical procedures in the world. The most common major complication is bile duct injury, which can have catastrophic repercussions for patients and it has been suggested that intraoperative cholangiography may reduce the rate of bile duct injury. Whether this procedure should be performed routinely is still an active subject of debate. We discuss the available evidence and likely implications for the future.

Complications of laparoscopic cholecystectomy: our experience in a district general hospital

BACKGROUND

Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstone disease. Some of the associated complications are rare, but often serious. The purpose of this study is to present our data about the type and the incidence of these complications and our experience in their management, in a district hospital, during the last 8 years.

PATIENTS AND METHODS

A retrospective study was performed on 1009 patients, 229 males and 780 females, with age ranging from 19 to 84 years, who underwent laparoscopic cholecystectomy for symptomatic gallstone disease, during the period from January 2000 to January 2008. The procedure was performed urgently due to acute cholecystitis in 78 patients (7.73%).

RESULTS

Complications occurred in 96 (9.51%) patients. Bile leakage occurred in 15 patients (1.49%). One patient (0.10%) had a major bile duct injury (common bile duct transection). Bleeding occurred in 9 patients (0.89%), wound infection in 14 patients (1.39%), abdominal wall hematomas in 3 patients (0.30%), omental hematoma in 3 patients (0.30%), port site hernias in 3 patients (0.30%), subphrenic abscess in 1 patient (0.10%), subcapsular liver hematoma in 1 patient (0.10%), bowel injury in 5 patients (0.51%), postoperative acute pancreatitis in 4 patients (0.40%), respiratory and cardiovascular complications in 11 patients 1.09%). Finally in 14 patients (1.39%), the gallbladder was unintentionally opened during laparoscopic procedure and spillage of gallstones occurred into the peritoneal cavity. All patients had satisfactory results and no death occurred.

CONCLUSIONS

We conclude that laparoscopic cholecystectomy is a safe procedure, although it is associated with some serious complications. The most usual complication during laparoscopic cholecystectomy is bile leakage, which remains a significant cause of morbidity. Early identification and management of these complications will minimize a potentially devastating outcome.

Spectrum of biliary and nonbiliary complications after laparoscopic cholecystectomy: radiologic findings

OBJECTIVE

The purpose of this article is to illustrate the radiologic features of various biliary and nonbiliary complications after laparoscopic cholecystectomy.

CONCLUSION

Various complications should be considered in patients who do not make an uneventful postoperative recovery after laparoscopic cholecystectomy. Sonography is the easiest and most noninvasive method for screening for such complications. MR cholangiography is most effective in showing biliary complications and CT, for the evaluation of nonbiliary complications. Endoscopic retrograde cholangiography enables not only detailed biliary estimation but also biliary decompression.

Migrated endoclip and stone formation after cholecystectomy: A new danger of acute pancreatitis

Endoclip migration into the common bile duct following laparoscopic cholecystectomy (LC) is an extremely rare complication. Migrated endoclip into the common bile duct can cause obstruction, serve as a nidus for stone formation, and cause cholangitis. We report a case of obstructive jaundice and acute biliary pancreatitis due to choledocholithiasis caused by a migrated endoclip 6 mo after LC. The patient underwent early endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and stone extraction.

Unsuspected gallbladder carcinoma after laparoscopic cholecystectomy

BACKGROUND/PURPOSE

Many cases have been reported of disastrous port-site recurrence after laparoscopic cholecystectomy (LC) revealed unsuspected gallbladder carcinoma (GBC). Some investigators have reported that the prognosis of patients after LC showed unsuspected GBC is not worsened by laparoscopic procedures. We retrospectively reviewed our cases and the literature to reconfirm the intrinsic risks of LC for unsuspected GBC.

METHODS

Of 1663 patients who underwent LC from January 1991 to December 2003 in a single institution, 9 (0.54%) with unsuspected GBC were reviewed.

RESULTS

These 9 patients consisted of 5 men and 4 women, whose ages ranged from 58 to 87 years, with a median age of 73 years. Two patients with a pT1a tumor (limited to mucosa) and 2 patients with a pT1b tumor (muscle layer) underwent no further operation. The remaining 5 patients with a pT2 tumor (subserosa) underwent further operations with lymph node dissection. Five patients (2 patients with pT1b and 3 patients with pT2) developed recurrence and all of them died within a median period of 19 months (range 14-37 months) after LC. The causes of death were bone metastases in 1 patient (pT2), local recurrence in 2 patients (pT1b and pT2), and peritoneal metastasis in 2 patients (one elderly patient with pT1b who underwent laparoscopic common bile duct exploration, and one patient with pT2 in whom the cystic duct was damaged during surgery). Four patients (2 with pT1 and 2 with pT2) have been doing well with a median follow-up of 39.5 months (range 12-99 months) after LC.

CONCLUSIONS

Surgeons should always prevent bile spillage during LC and when removing the resected gallbladder. When laparoscopic common bile duct exploration is planned, especially for elderly women, surgeons should also bear in mind the increasing possibility of unsuspected GBC.

Imaging findings of biliary and nonbiliary complications following laparoscopic surgery

Laparoscopic techniques are evolving for a wide range of surgical procedures although they were initially confined to cholecystectomy and exploratory laparoscopy. Recently, surgical procedures performed with a laparoscope include splenectomy, adrenalectomy, gastrectomy, and myomectomy. In this article, we review the spectrum of complications and illustrate imaging features of biliary and nonbiliary complications after various laparoscopic surgeries. Biliary complications following laparoscopic cholecystectomy include bile ductal obstruction, bile leak with bile duct injury, dropped stones in the peritoneal cavity, retained CBD stone, and port-site metastasis. Nonbiliary complications are anastomotic leakage after partial gastrectomy, gangrenous cholecystitis after gastrectomy, hematoma at the anastomotic site following gastrectomy, gastric infarction after gastrectomy, port-site metastasis after gastrectomy, hematoma after splenectomy, renal infarction after adrenalectomy, and active bleeding after myomectomy of the uterus.

Hand Port-Site Metastasis of Renal-Cell Carcinoma Following Hand-Assisted Laparoscopic Radical Nephrectomy: Case Report

A 66-year-old man underwent hand-assisted laparoscopic radical nephrectomy (HALN) for a 10 x 7-cm, stage T(2)N(0)M(0) right-sided renal-cell carcinoma. Nine months later, tumor recurrence was noted at the previous hand port site. This is the first case report of such a metastasis. Possible mechanisms for tumor metastasis are reviewed, and preventive strategies are suggested.

Laparoscopic cholecystectomy in the treatment of patients with gall bladder cancer

BACKGROUND

Surgical procedures based on the depth of the primary tumor invasion (pT category) have been proposed in the treatment of gallbladder cancer (GBC). Trocar site metastases have been reported in patients who underwent laparoscopic cholecystectomy (LC) for preoperatively undiagnosed GBC.

STUDY DESIGN

The aim of this study was to clarify the role of LC as a surgical strategy for GBC. From 1986 to 1998, 56 patients with GBC underwent surgical resection. Survival rates were compared retrospectively according to pT category and use of LC.

RESULTS

Five-year survival was 91% for pT1 (n = 13), 64% for pT2 (n = 25), 34% for pT3 (n = 14), and 0% for pT4 tumors (n = 4; p<0.0001). LC was performed on 11 patients (4 with pT1, 5 with pT2, and 2 with pT3 tumors). Of the seven patients with pT2 or pT3 tumors, three underwent a second radical operation, three had an open radical operation to which the procedure was converted from LC, and one underwent no additional procedures. For pT1 tumors, one patient died of trocar site metastasis from bile spillage after LC. For pT2 or pT3 tumors, 5-year survival was 63% for radical surgery (n = 35) and 0% for cholecystectomy alone (n = 4; p<0.05). For pT2 or pT3 tumors treated by radical surgery, 5-year survival was 75% for laparoscopic approach (n = 6) and 60% for open surgery (n = 29; not significant).

CONCLUSIONS

LC may help to establish the diagnosis and to determine the surgical strategy for undiagnosed GBC. It is important to prevent spillage or implantation of malignant cells during LC. For pT2 or pT3 tumors diagnosed laparoscopically, a second or converted open radical surgery is necessary.

Spread of ovarian cancer after laparoscopic surgery: report of eight cases

OBJECTIVE

The aim of this study was to describe early occurrences of metastases after laparoscopy of ovarian masses later found to be malignant.

METHODS

The hospital charts of eight women having undergone laparoscopic surgery for ovarian mass were reviewed and analyzed.

RESULTS

The mean age of the patients was 40 years (range 25 to 66). Size of the tumor ranged from 2 to 15 cm. In four patients the ovarian mass was suspected to be malignant in the laparoscopy. Diagnostic procedure (biopsy of the tumor) was performed in two and salpingo-oophorectomy in six patients. Staging laparotomy was performed within the mean of 17 days (range 7-29). In four patients (50%) the cancer had spread from a localized to an advanced stage during the delay. Ascites was present in the laparoscopy in two of the four patients with port site or abdominal wall metastases.

CONCLUSIONS

Laparoscopic surgery of ovarian mass later found to be malignant can cause considerable and early spread of the cancer.

Port-site metastases following laparoscopic surgery

BACKGROUND

Application of laparoscopy to the resection of malignancy has been followed by a literature describing cases of metastatic involvement at laparoscopic port sites. These include patients who underwent surgery for early stage carcinoma and instances following laparoscopic procedures during which tumours were not dissected.

METHODS

Recently published clinical and experimental studies, and case reports related to this problem are reviewed; their relevance is discussed.

RESULTS

Experimental studies incorporating bench top and large animal models have confirmed that tumour cells may be redistributed to port sites during laparoscopic surgery either directly from contaminated instruments or indirectly via the insufflation gas. Small animal models suggest that the incidence of wound metastasis is increased following conventional laparoscopic surgery, and that it may be decreased by gasless laparoscopy or helium insufflation. This evidence suggests that the development of port-site metastases depends not only on the physical redistribution of tumour cells but also on the specific insufflation gas used, possibly because of influences on local metabolic or immune factors acting at the wound site.

CONCLUSION

Further research in this area is urgent. Until the issue is better understood, patients undergoing laparoscopic surgery for malignancy should be entered into clinical trials.

Colorectal carcinoma and the relationship of peritoneal cytology

BACKGROUND

This study was designed to investigate the frequency of the association between colorectal cancer and peritoneal cytology as well as the impact of surgical resection on conversion of cytology from benign to malignant cells being present. Furthermore, increasingly frequent reports of port site recurrences with laparoscopic colectomy for limited stage colon carcinoma prompted us to evaluate the incidence of tumor cell spillage with traditional "open" colonic surgery.

METHODS

Fifty random patients undergoing surgery for colorectal carcinoma were prospectively evaluated with peritoneal washings prior to and following colon resection.

RESULTS

Five patients (10%) were found to have malignant cytology, with no patients converting from negative to positive cytology. All five positive cytologies were associated with stage IV disease and poorly differentiated colon cancer.

CONCLUSION

Intraoperative peritoneal cancer dissemination could not be demonstrated by cytologic washings of the abdominal cavity before and after colorectal resection utilizing standard cytomorphological criteria.