Gallbladder and gallstone removal, open versus closed laparoscopy, and pneumoperitoneum

An 8-mm port site hernia after robotic-assisted ileocecal resection: a case report

BACKGROUND

Robotic-assisted surgery is steadily becoming more prominent. The majority of reports regarding port site hernias (PSHs) have involved laparoscopic procedures. Currently, it is common to suture the fascia at port sites that are 10 mm or larger; however, the closure of 5-mm port sites is not considered mandatory. The da Vinci® surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) utilizes a distinctive 8-mm port. We report a case of an early-onset PSH at an 8-mm port site after robotic-assisted ileocecal resection.

CASE PRESENTATION

A 74-year-old male patient with a body mass index of 19.7 kg/m2 was diagnosed with cecal cancer and underwent robotic-assisted ileocecal resection. A 3-cm midline incision was made at the umbilicus for insufflation. Under laparoscopic visualization, three ports (12 mm, 8 mm, and 8 mm) were inserted in the lower abdomen. An 8-mm port was inserted in the left subcostal region, and a 5-mm port was inserted in the left lateral abdomen. The procedure was performed without significant intraoperative complications. The fascia was closed only at the umbilicus and 12-mm port site; the fascia at the 8-mm port sites was not closed. The patient was initially discharged without complications; however, on postoperative day 11, the patient was urgently hospitalized again because of PSH incarceration. After manual reduction, the fascia was sutured closed under local anesthesia. The hernial defect was small and barely allowed the insertion of a little finger. There was no evidence of compression or significant damage to the fascia. On postoperative day 27, the patient was discharged after experiencing good recovery.

CONCLUSIONS

Robotic-assisted colectomy could contribute to the risk of PSHs because of its surgical characteristics. Although routine closure of the fascia at 8-mm port sites is not mandatory, it may be beneficial in certain cases.

Management of Postcholecystectomy Complications

Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article

BACKGROUND

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

METHODS

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

RESULTS

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

CONCLUSIONS

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.

[Laparoscopic cholecystectomy for acute cholecystitis gallstones: about 22 cases compiled at the Rebirth hospital of Ndjamena]

Déterminer la faisabilité de la cholécystectomie laparoscopique pour cholécystite aiguë lithiasique dans notre contexte d'exercice, et d'en évaluer les résultats. Nous rapportons une série de 22 patients ayant bénéficié d'une cholécystectomie laparoscopique pour cholécystite aiguë lithiasique sur une période de 16 mois (Décembre 2013- Mars 2015). Sur 22 patients été opérés, il y avait une nette prédominance féminine (20 femmes soit 91%). La durée moyenne de l'intervention était de 90 mn avec des extrêmes de 38 et 142 mn. L’âge moyen de nos patients était de 42 ans avec des extrêmes de 16 à 65 ans. La durée d'hospitalisation a été de 2 à 6 jours avec une moyenne de 3 jours. Le taux de conversion en laparotomie était de 4.5%. Les suites opératoires immédiates ont été simples dans 90.9% des cas. Les complications concernaient 2 patients (9.1%) dont 1 suppuration pariétale et 1 hémorragie de paroi. La cholécystectomie laparoscopique pour cholécystite aigue lithiasique est faisable dans notre contexte au delà des 72 heures d’évolution sans majoration de risques.

Attitudes and Practices of Surgeons towards Spilled Gallstones during Laparoscopic Cholecystectomy: An Observational Study

The sequelae of spilled gallstones after Laparoscopic cholecystectomy (LC) and the occurring complications may go unnoticed for a long time and can be a diagnostic challenge. The aim of this survey was to study the knowledge, attitude, and practices of surgeons regarding spilled gallstones during LC. An observational, cross-sectional survey, using a questionnaire based on 11 self-answered close-ended questions, was conducted among general surgeons. Of the 138 respondents only 29.7% had observed a complication related to gallstone spillage during LC. There was varied opinion of surgeons regarding management of spilled gallstones, documenting the same in operative notes and consent. It was observed that there is lack of knowledge regarding the complications related to gallstone spillage during LC. There is need to educate surgeons regarding safe practices during LC to avoid gallstone spillage, early diagnosis, and management of complications. There is need to standardize practice to retrieve lost gallstones to reduce complication and legal consequences.

A safe quick technique for placement of the first access port for creation of pneumoperitoneum

The authors recommend a modified open technique in placing the first port when intraabdominal adhesions are expected.

Introduction:

Closed and open techniques for creation of pneumoperitoneum are being used simultaneously with varying frequencies. Some studies analyzing slight modifications to both approaches have been published and others are under way. We conducted this study to eliminate some of the disadvantages of the open technique, an already proven safer technique.

Patients & Methods:

In a total of 1250 consecutive patients, who underwent various laparoscopic procedures, a modified open technique was used. This technique involves identification and incision of a point at a junction of the umbilical stalk and linea alba infraumbilically. With this technique, penetration of a blunt trocar was possible under direct vision with minimal and controlled axial force. Time needed to induce pneumoperitoneum, intraoperative (vascular and other organ injury) and postoperative complications were recorded, and data were analyzed.

Results:

Intraabdominal access was successfully achieved in all cases without any vascular or solid organ injury except in 3 (0.24%) cases. In these 3 cases, the procedure failed due to severe adhesions, because of previous abdominal surgeries. Mean time taken to induce pneumoperitoneum was 4.0 minutes (range, 2 to 9.5), while time required to close the first access port was 4.5 minutes (range, 3 to 8). Enterotomy occurred in 2 (0.16%) cases, while a postoperative port-site hernia occurred in 2 (0.16%) cases. Port-site infection occurred in 6 (0.48%) cases, and port-site hematoma in 4 (0.32%) cases. Gas spillage was recorded in only 6 (0.48%) cases.

Conclusion:

We recommend a modified open technique as the technique of choice in all cases requiring laparoscopic surgery in general and developing countries in particular where intraabdominal adhesions are not uncommon.

The last place you would expect to find a gallstone

The increasing use of laparoscopic cholecystectomy has led to an increased frequency of gallbladder perforation and subsequent gallstone spillage in the abdominal cavity. Occasionally unretrieved gallstones can cause infection, adhesions, and obstruction. Furthermore, spilt stones can cause erosion into adjacent organs and can migrate to distant sites, causing a variety of complications. We report the unusual case of a patient who presented with spontaneous erosion of gallstones through Grynfeltt's triangle, 1 year after laparoscopic cholecystectomy and review the current literature.

[Trocar site incisional hernia in laparoscopic surgery]

Trocar site incisional hernias (TSIH) are the most common complications in laparoscopic surgery. We have carried out a review of the literature with the aim of establishing their incidence, the reasons for them happening, and their prevention. After a search in the MEDLINE PubMed and PubMed CENTRAL data bases from 1991 to 2009, combining the words: "hernia", "laparoscopy" and "trocar", we obtained 545 articles, of which we analysed 60 of them. The incidence of TSIH varies between 0.18% and 2.8%. The diameter of the trocar, obesity and age play a fundamental role when proceeding to close the fascia, a closure which is the most important factor to prevent these incisional hernias appearing. The appearance of new laparoscopic material and the increasing more common closure of defects of the fascia means that new and more extensive prospective studies should be performed.

Dropped gallstones during laparoscopic cholecystectomy: the consequences

During laparoscopic cholecystectomy, gallbladder perforation has been reported, leading to bile leak and spillage of gallstones into the peritoneum. Because the consequences can be dangerous, conversion to laparotomy as an instant management for gallstone spillage is one of the topics of current discussion in laparoscopic cholesystectomy. In this article, we discussed the option of not converting to laparotomy after intraperitoneal gallstone spillage as an acceptable approach to management or not.A prospectively maintained database of 1528 consecutive laparoscopic cholecystectomies performed during a 10-year period at the 4th Surgical Clinic of The Ankara Numune Education and Research Hospital was analyzed. Perforations resulting in gallstone spillage into the abdominal cavity were documented in 58 (3.8%) patients. Among those 58 patients seven (12%) experienced complications from retained stones. To maintain acceptable management of such patients, surgeons should inform each patient preoperatively that stones may be spilled. In the event of spillage, the patient should be informed postoperatively, and followed closely for complications. Follow-up should not waste time and money with unnecessary examinations, and it should avoid psychological trauma to the patient with a wrong diagnosis of cancer as a stone may mimic cancer radiologically. Thus the surgeon should not hesitate to record the events and inform the patient about the spillage of the stones and possible consequences.

Complete Evidence Regarding Major Vascular Injuries During Laparoscopic Access

Recent reports by the Australian Safety and Efficacy Register for New interventions and Procedures (ASERNIP-S) and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) concluded that insufficient evidence is available to assess the safety of the open versus closed laparoscopy in regard to major vascular and visceral injuries. The aim of this study was to assess the relative safety of open and closed laparoscopy with respect to rates of major vascular and visceral injuries. A combined prospective/retrospective review of a single-surgeon series of 5900 open laparoscopies was performed. A meta-analysis of all reported series of open and closed laparoscopy was conducted using PubMed and MEDLINE search engines to compare major vascular and visceral injury rates. Medicolegal and manufacturer device reports were also reviewed. The case series of 5900 open laparoscopies reported a single visceral injury and no major vascular injuries. The meta-analysis revealed 336 major vascular injuries in 760,890 closed laparoscopies, a mean rate of 0.044%, 1 injury per 2272 cases, compared with 0 injuries in 22,465 open laparoscopies (P = 0.003). Visceral injuries occurred more frequently, 515 injuries in 760,890 closed laparoscopies (mean rate, 0.07) and 11 injuries in 22,465 open laparoscopies (mean rate, 0.05; P = 0.18). Medicolegal and device reports revealed a further 647 major vascular injuries and 500 major visceral injuries. In contrast to the conclusion formed by the RANZCOG and ASERNIP-S, the available evidence shows that open laparoscopy eliminates the risk of major vascular injury and reduces the rate of major visceral injuries. Open laparoscopy using the Hasson cannula should be the preferred method of peritoneal access.

Spilled gall stones during laparoscopic cholecystectomy: a review of the literature

Laparoscopic cholecystectomy is associated with spillage of gall stones in 5%-40% of procedures, but complications occur very rarely. There are, however, isolated case reports describing a range of complications occurring both at a distance from and near to the subhepatic area. This review looks into the various modes of presentation, ways to minimise spillage, treating the complications, and the legal implications.

Spilled gallstones after laparoscopic cholecystectomy

Spilled gallstones have emerged as a new issue in the era of laparoscopic cholecystectomy. We treated a 77-year-old woman who underwent laparoscopic cholecystectomy. Subsequently, a right flank abscess developed. During the cholecystectomy, the gallbladder was perforated and stones were spilled. After a failed attempt to drain the abscess percutaneously, the patient required open drainage, which revealed retained gallstones in the right flank. The abscess resolved, although the patient continued to have intermittent drainage without evidence of sepsis. Review of the literature revealed 127 cases of spilled gallstones, of which 44.1% presented with intraperitoneal abscess, 18.1% with abdominal wall abscess, 11.8% with thoracic abscess, 10.2% with retroperitoneal abscess, and the rest with various clinical pictures. In case of gallstone spillage during laparoscopic cholecystectomy, every effort should be made to locate and retrieve the stones.

A survey of entry techniques and complications of members of the Australian Gynaecological Endoscopy Society

OBJECTIVE

To identify various aspects of laparoscopic entry technique and visceral injury experienced by members of the Australian Gynaecological Endoscopy Society (AGES).

DESIGN

A retrospective mailed survey.

SAMPLE

All members of the Australian Gynaecological Endoscopy Society (AGES).

MAIN OUTCOME MEASURES

Numbers of bowel and major retroperitoneal vascular injuries experienced, entry techniques utilised, alternative entry sites.

RESULTS

Of the respondents, 73% use a Veress needle entry. In subjects with an increased risk of peri-umbilical adhesions 83% of respondents use an alternate site of entry, 66% of which use Palmer's point. Sixty-four per cent of respondents had experienced one or more bowel injuries, 21% had experienced major retroperitoneal vascular injury, 33% of respondents had no plan in place for the management of vascular injury and 51% of respondents would alter their clinical practice if accepted entry technique guidelines were available.

CONCLUSIONS

The majority of respondents use the Veress needle method of entry, have had at least one entry-related bowel injury and use Palmer's point as an alternative entry site in high-risk subjects. The majority of subjects would alter their clincal practice if accepted entry technique guidelines were available.

Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry

OBJECTIVE

To obtain consensus as to the optimal form of entry technique for access to the peritoneal cavity.

DESIGN

A meta-analysis of all relevant English language studies of laparoscopic entry complications.

MAIN OUTCOME MEASURES

Incidence of bowel and major vascular injuries.

RESULTS

Bowel injuries occur in 0.7/1,000 and major vascular injuries in 0.4/1,000. The overall incidence of major injuries at time of entry is 1.1/1,000. The direct entry technique is associated with a significantly reduced major injury incidence of 0.5/1,000, when compared to both open and Veress entry produces (1.1 and 0.9/1,000 respectively, p = 0.0005). Entry-related bowel injuries are reported more often following general surgical laparoscopies than with gynaecological procedures (p = 0.001). No such difference is seen in the incidence of vascular injuries (p = 0.987). Open entry is statistically more likely to be associated with bowel injury than either Veress needle or direct entry However, open entry appears to minimise vascular injury at time of entry.

CONCLUSIONS

There remains no clear evidence as to the optimal form of laparoscopic entry in the low-risk patient. However, direct entry may be an under-utilised and safe alternative to the Veress needle and open entry technique.

Percutaneous Removal of Spilled Gallstones in a Subhepatic Abscess

Abscess formation from spilled gallstones after laparoscopic cholecystectomy is infrequent. However, if an abscess does form and contains the spilled stones simple percutaneous drainage will not resolve the dilemma of a recurrent abscess. Open drainage has previously been recommended to remove the retained stones and decrease recurrent abscess formation. We report two cases in which the retained stones within an abscess were successfully removed using a percutaneous minimally invasive urological technique.

Radially expanding trocar: a less painful alternative for laparoscopic surgery

BACKGROUND AND PURPOSE

One advantage of minimal-access surgery is that it produces less pain. A radially expanding trocar has been claimed to reduce pain further. We aimed to evaluate this claim.

PATIENTS AND METHODS

This was a randomized controlled single-blind clinical trial. Fifty-four patients who underwent laparoscopic cholecystectomy at the Department of Surgery, United Christian Hospital, Hong Kong, between July 1997 and September 1998 were randomized into either the study group or the control group. The radially expanding 10-mm trocar was used for the epigastric port in the study group. The conventional 10-mm metal trocar was used similarly in the control group. The operation was otherwise performed with a standardized technique. Another conventional 10-mm metal trocar was used for the subumbilical port for all patients. Pain was measured using a visual analog scale. Pain scores for the epigastric port and subumbilical port were documented for 3 days after the surgery.

RESULTS

There was no difference in age, sex, diagnoses, operating time, or conversion rate. There was consistently no difference in the pain experienced in the subumbilical wound, whereas pain at the epigastric wound was consistently less with the radially expanding trocar (p < 0.05).

CONCLUSION

The radially expanding trocar produces less early postoperative pain than the conventional metal trocar.

Elimination of biliary stones through the urinary tract: a complication of the laparoscopic cholecystectomy

The introduction and popularization of laparoscopic cholecystectomy has been accompanied with a considerable increase in perforation of gallbladder during this procedure (10% - 32%), with the occurrence of intraperitoneal bile spillage and the consequent increase in the incidence of lost gallstones (0.2% - 20%). Recently the complications associated with these stones have been documented in the literature. We report a rare complication occurring in an 81-year-old woman who underwent laparoscopic cholecystectomy and developed cutaneous fistula to the umbilicus and elimination of biliary stones through the urinary tract. During the cholecystectomy, the gall bladder was perforated, and bile and gallstones were spilled into the peritoneal cavity. Two months after the initial procedure there was exteriorization of fistula through the umbilicus, with intermittent elimination of biliary stones. After eleven months, acute urinary retention occurred due to biliary stones in the bladder, which were removed by cystoscopy. We conclude that efforts should be concentrated on avoiding the spillage of stones during the surgery, and that no rules exist for indicating a laparotomy simply to retrieve these lost gallstones.

Pelvic adhesion formation after intraperitoneal installation of gallstones in a rabbit model

OBJECTIVE

To investigate whether intraperitoneal gallstones increase the risk of pelvic adhesions in a rabbit model.

DESIGN

Prospective, randomized, blinded, sham and human antigen controlled trial.

SETTING

An academic research environment.

SUBJECT(S)

Twelve New Zealand white rabbits.

INTERVENTION(S)

Twelve rabbits were divided into three groups of four each; a sham operation group, a gallstone and bile group (study group), and a human serum albumin and bile group (antigenic control). Three weeks after the operation individual subjects were randomized, with groups concealed to observers, and a necropsy was performed on each rabbit.

MAIN OUTCOME MEASUREMENT(S)

Necropsy was performed on each rabbit, and the adhesions were scored for extent, type, tenacity, inflammation, and gallstone involvement.

RESULT(S)

There was a statistically and biologically significant increase in gallstone involvement in adhesions, especially pelvic adhesions, in the study group.

CONCLUSION(S)

This study, along with an increasing number of case reports, suggests that gallstones inadvertently left in the peritoneal cavity may increase the morbidity of laparoscopic cholecystectomy. In females of reproductive age these gallstones may induce pelvic adhesions that may interfere with fertility or be associated with pelvic pain.

Recurrent gallbladder carcinoma along laparoscopic cholecystectomy port tracks: CT demonstration

PURPOSE

To describe the computed tomographic (CT) appearance of recurrent gallbladder carcinoma along port tracks after laparoscopic cholecystectomy and to assess the effect of recurrence on patient care.

MATERIALS AND METHODS

Seventeen abdominal CT scans in 16 of 19 consecutive patients who underwent hepatic resection for gallbladder carcinoma diagnosed at laparoscopic cholecystectomy were reviewed retrospectively. Medical records were reviewed to determine the clinical effect of tumor recurrence along a port track.

RESULTS

CT revealed 12 tumor recurrences along laparoscopic port tracks in six (32%) patients (mean, two recurrences per patient; range, one to four per patient). Eight (67%) CT-depicted recurrences appeared homogeneous, and nine (75%) directly involved subjacent omental fat. The mass was the only site of recurrence at CT in two (33%) patients. The presence of an abdominal wall tumor recurrence affected patient care in four (67%) of six patients. Histopathologic examination results confirmed recurrent tumor in all five (100%) patients who underwent biopsy.

CONCLUSION

Tumor recurrence along port tracks is a potential complication of laparoscopic cholecystectomy when gallbladder carcinoma is present, even after subsequent hepatic resection is performed for attempted cure. Recurrences appear as a new or enlarging abdominal wall mass, often involving subjacent omental fat, and may be the only site of recurrent disease at CT. Demonstration of abdominal wall tumor recurrence affects patient care.

Routine use of open laparoscopy: 1,006 consecutive cases

Blind insertion of the Veress needle and of the first trocar is a significant cause of laparoscopic surgery complications. Despite this risk, the closed technique is still more popular than the open one. The authors retrospectively evaluated 1006 consecutive laparoscopic operations in which Hasson's technique was routinely performed. The overall complication rate was 2.2%, but the vast majority of complications occurred during the first 50 cases (6% vs. 1.9%). They conclude that after a learning phase of about 50 cases, Hasson's technique is a quick and safe procedure.

EFEITO DE CÁLCULOS BILIARES HUMANOS NA CAVIDADE PERITONEAL DE RATOS

Este estudo tem por objetivo analisar experimentalmente as características macroscópicas e microscópicas de cálculos biliares humanos na cavidade peritoneal de ratos. Foram utilizados 32 ratos Wistar, machos, pesando entre 205 e 268 g. Estes animais foram distribuídos em dois grupos e o procedimento cirúrgico foi realizado em cada grupo: no grupo A (n =16), os animais foram submetidos a manipulação intestinal; no grupo B (n=16), cálculos biliares humanos foram colocados na cavidade peritoneal. Os ratos foram avaliados no 21º e 42º dias do período pós-operatório. Os resultados mostraram que a simples manipulação causou aderências nos animais (n=10). As aderências foram notadas em 11 cálculos no grupo B. Histologicamente não houve fibrose intensa em torno do cálculo, principalmente no 42º dia do período pós-operatório. Não foram observados macro ou micro abscessos e não houve evidências de fluído livre intra-peritoneal. Este estudo demonstra que apesar da baixa incidência de complicações, todas as tentativas devem ser feitas para recuperar cálculos perdidos durante colecistectomia.

Does chemical composition have an influence on the fate of intraperitoneal gallstone in rat?

Perforation and spillage of gallstones is a common occurrence in laparoscopic cholecystectomies. The long-term complications of these stones remains controversial. Experimental studies have been carried out to elucidate the outcome of intraperitoneal gallstones, but the chemical composition of these stones has not been considered in previous studies. In this study, we investigated the local effects of intraperitoneal gallstones in rats with respect to their chemical composition. Bile and gallstones were taken from human cholecystectomy specimens, and sent for bacteriologic and chemical analysis. Twenty cholesterol and 10 pigment stones were placed in the abdominal cavity of rats. Long-term local effects of gallstones were determined at the end of 3 months with macroscopic and microscopic examination. The fragments of two pigment stones were infected by Staphylococcus aureus. Five (17%) cholesterol stones were found free in the abdominal cavity, and 25 stones (83%) were wrapped with adjacent structures. Granuloma formation was found around 4 pigment stones (13% of all stones, 40% of pigment stones; p = 0.0077). We observed large granulomas and cutaneous fistula formation in two rats with infected pigment stones placed in the abdominal cavity. Histhopathologic examination also showed significantly severe inflammatory reactions secondary to pigment stones (p<0.001). In conclusion our findings revealed that chemical composition has a significant influence on the fate of intraabdominal gallstones, and infection may aggravate local reactions and complications. Based on our findings, laparoscopic retrieval of spilled stones whenever possible seems to be useful to prevent subsequent infectious complications and inflammatory reactions. Patients with retained intraperitoneal pigment stones after laparoscopic cholecystectomy must be followed up closely.

Retroperitoneal abscess as a complication of retained gallstones following laparoscopic cholecystectomy

Retroperitoneal abscess formation secondary to retained spilled gallstones after laparoscopic cholecystectomy is a rare complication. We describe the case of a patient with this complication as well as a novel method utilizing interventional radiologic localization with subsequent operative drainage and removal of the stones. A review of the literature is provided.

Empyema due to spilled stones during laparoscopic cholecystectomy

We describe a patient who suffered right pleuritic chest pain and an exudative pleural effusion, leading to empyema formation. Thoracotomy revealed this to be due to a subphrenic abscess around spilled gall stones.

Carcinoma involving the gallbladder in elderly patients presenting with acute cholecystitis

BACKGROUND

The unexpected intraoperative finding of a cancerous gallbladder has become particularly problematic, because cancer recurs rapidly after laparoscopic cholecystectomy. It would be desirable to identify the patients of greatest risk for gallbladder cancer before operation. After several elderly patients presenting with acute cholecystitis were found to have gallbladder cancer, we performed the following study.

METHODS

Records of patients (60 years of age or older, 1987 to 1995) with an admitting diagnosis of acute cholecystitis and symptoms including right upper quadrant pain, nausea, vomiting, fever, and leukocytosis were reviewed.

RESULTS

Eighty patients were included in the study. Carcinoma involving the gallbladder was found in seven patients; six had primary and one had metastatic carcinoma. The 73 patients without cancer underwent cholecystectomy. The differences between the noncancer and cancer patients included age (68 +/- 7 versus 74 +/- 8 years, p < 0.05), total bilirubin (mg/dl, 1.5 +/- 1.5 versus 3.7 +/- 3.4, p < 0.01), alkaline phosphatase (IU/L, 179 +/- 132 versus 369 +/- 226, p < 0.01), and aspartate aminotransferase (IU/L, 77 +/- 93 versus 158 +/- 157, p < 0.05).

CONCLUSIONS

Additional work-up and open cholecystectomy should be considered in elderly patients presenting with apparent acute cholecystitis, especially when liver functions are abnormal.

The fate of intraperitoneally retained gallstones with different morphologic and microbiologic characteristics: an experimental study

Management of intraperitoneally retained gallstones after laparoscopic cholecystectomy (LC) is controversial, as their natural course is not known. This study was undertaken to assess the probable effects of stone morphology and clinically obvious infection on the outcome of retained gallstones in a mouse model. Forty albino mice were divided into four groups. Group I served as the control group (simple laparotomy, n = 10). Groups II, III, and IV (n = 10 in each group) were study groups. "Intact-sterile-cholesterol" (group II), "crushed-sterile-cholesterol" (group III), and "intact" (n = 5) [group IVa] and "crushed" (n = 5) [group IVb] "infected-cholesterol" gallstones aseptically retrieved from three different human patients were implanted to the peritoneal cavity of the animals. Group IV animals were implanted with stones retrieved from an acutely inflamed gallbladder with proven infection. Animals were sacrificed 6 and 12 weeks after the operations. Cultures and tissue samples were obtained. No animal was lost, no microscopic or macroscopic abnormality was observed in groups I and II, and cultures remained negative. In group III, adhesions surrounding the fragmented stones were evident at the 12th week, and no mortality was encountered. The histopathology revealed a fibroblastic reaction, and cultures remained negative in group III. In group IV, three animals from group IVb and one animal from group IVa died because of intra-abdominal sepsis before their sacrifice. All remaining mice showed severe adhesions with localized abscesses at the 12th week. In conclusion, intraperitoneally retained cholesterol gallstones remain inert and do not cause serious peritoneal reaction unless they are crushed into fragments or are from an acutely inflamed gallbladder. It is for this group of patients that laparotomy for total stone clearance is probably not justifiable. Better stone retrieval techniques or even laparotomy may be worthwhile considering in patients with crushed and particularly infected retained stones.

A new, radially expanding access system for laparoscopic procedures versus conventional cannulas

The safety, postoperative pain, and costs associated with a newly developed, radially expanding access (REA) system for laparoscopic surgery were evaluated. This prospective, patient-blinded, self-controlled study was conducted at a free-standing surgicenter. Nineteen women underwent various outpatient laparoscopic surgical procedures consecutively between November 1994 and February 1995. In each patient an REA system was placed laterally as an ancillary port, and a size-matched contralateral ancillary port was placed using a conventional cannula. In 8 patients 5-mm bilateral access devices were placed, and in 11 patients, 12-mm devices. All five complications and device-related adverse events were associated with conventional cannulas. At 1 day, 1 week, and 1 month after laparoscopic surgery, patients were asked on which side incisional pain was greater or whether there was no difference between the sides. A significantly higher proportion of patients rated pain on the REA system side lower at all three evaluations. This was the case for recipients of both 5- and 12-mm access devices. The REA system is safer, better tolerated, and more cost effective than conventional cannulas for a range of laparoscopic surgical procedures.

The spilled stone. A potential danger after laparoscopic cholecystectomy

The application of laparoscopic techniques in digestive surgery to areas in which there was no previous experience has favored the appearance of new complications and clinical situations that were not observed during the open era. Initial opinion considered that stones left in the abdominal cavity were harmless, and a few clinical and experimental studies supported this opinion. But cumulative reports of cases suggest a potential danger. From 1991 to date, 49 cases of complications related to stones left in the abdominal cavity have been reported with severe complications that required an open surgical procedure. Stone spillage has not always been considered an indication of conversion of laparoscopic cholecystectomy but is now accepted as a source of infrequent but severe complications that may require a reintervention for treatment. Therefore it is recommended that efforts should be made to retrieve all spilled stones; the surgical procedure should be prolonged until this is achieved, in order to reduce one source of unpredictable morbidity. Open retrieval should be considered in selected cases if a large number or large stones are lost.

Minimizing trochar site herniation in laparoscopic cholecystectomy

The technique for laparoscopic cholecystectomy (LC) was originally devised and described has remained unchanged because of its efficacy. LC involves a 10-mm trochar in periumbilical region, 10-mm trochar in the epigastrium, and two 5-mm trochars at the right anterior axillary line and right midclavicular line. The exposure and dissection provided by the instruments placed through these trochars is usually adequate and the necessity for additional ports is rare. Our technique modification eliminates the epigastric 10-mm port and replaces it with a 5-mm epigastric port and also eliminates one of the lateral 5-mm ports. Recent articles have reported a significant incidence of Richter's or incisional hernias at the trochar sites. Our modification of the standard technique has the advantage of eliminating a potential incisional hernia at the epigastric port site and further improvement of cosmetic result.

Incarcerated paraumbilical incisional hernia and abscess--complications of a spilled gallstone

Gallstones may fall into the peritoneal cavity during performance of cholecystectomy. They are more easily retrieved in an open operation. Some controversy exists as to what should be done with gallstones lost during laparoscopic cholecystectomy (LC) because complications of abandoned stones have been reported. This case report describes a patient who presented with an incarcerated hernia and an associated abscess cavity containing a large spilled gallstone, which on computed tomography scan suggested a possible abdominal wall tumor. Spilled stones may cause subsequent problems and should be removed whenever possible, but should not be an indication for conversion to open operation.

Delayed peritoneal and retroperitoneal abscesses caused by spilled gallstones: a complication following laparoscopic cholecystectomy

Many complications following laparoscopic cholecystectomy have been reported. We report a case of delayed peritoneal and retroperitoneal abscesses caused by spilled gallstones from a laparoscopic cholecystectomy performed 1 year earlier. This diagnosis was suggested only at sonography because the aggressive behavior of the lesions containing nonopaque gallstones suggested, by computed-tomography scan, peritoneal metastatic disease.

Spilled gallstones--complications of abdominal-wall abscesses. Case report and review of the literature

Laparoscopic cholecystectomy has become the preferred method for removal of the diseased gallbladder. While its morbidity and mortality rates are lower than those of the open technique, it does have associated complications which may cause significant morbidity. The morbidity associated with spilled gallstones is not well studied and little can be found in the literature on this subject. We encountered a patient who developed abscesses within the abdominal wall following laparoscopic cholecystectomy. We recommend that spilled gallstones be removed when possible and that surgeons be aware of this possible complication.

Gallstone ileus: post cholecystectomy

A case of gallstone ileus occurring 5 months after laparoscopic cholecystectomy is presented. The possible aetiology is discussed and the literature regarding consequences of intraperitoneal stone spillage reviewed.

Gallstone shrapnel contamination during laparoscopic cholecystectomy

The fate of lost gallstones in the peritoneal cavity following laparoscopic cholecystectomy is unknown. We report a case of microabscesses and granuloma formation in the peritoneal cavity and abdominal wall caused by infected gallstone shrapnel due to rupture of the gallbladder during extraction.

Use of doxorubicin and dacarbazine for the management of unresectable intra-abdominal desmoid tumors in Gardner's syndrome

PURPOSE

The aim of this study was to describe the natural history and management of surgically unresectable intra-abdominal desmoid tumors in two patients with Gardner's syndrome from two unrelated families, where each had failed on conventional therapy.

METHODS

Two patients with Gardner's syndrome were placed on a chemotherapy regimen which included doxorubicin (90 mg/m2) and dacarbazine (900 mg/m2) in divided doses over four days of continuous infusion. Their progress on chemotherapy was assessed by abdominal computerized tomography and laparoscopy.

RESULTS

The computerized abdominal tomography scans proved difficult to interpret because of adhesions and matted small bowel resulting from the patients original colectomies. These findings made it difficult to differentiate postoperative changes from residual desmoid tumor. Second-look laparotomy in such patients was contraindicated as this may predispose to further desmoid production. Laparoscopy disclosed a complete response to this chemotherapy. Nevertheless, we had an iatrogenic small bowel perforation in one of these patients. Each patient showed a complete response to chemotherapy.

CONCLUSION

Surgical resection remains the first-line treatment of intraabdominal desmoid tumors. However, doxorubicin/dacarbazine chemotherapy on a clinical trial basis may be indicated in patients whose intra-abdominal desmoid is unresectable, or who have failed to respond to treatment with hormones (tamoxifen, Toremifene), steroids (prednisone), and nonsteroidal anti-inflammatory agents (Clinoril; Merck & Co., Inc., West Point, PA).

Cholelithoptysis and cholelithorrhea: rare complications of laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now considered a safe procedure for the management of cholelithiasis. During the procedure, stone spillage can occur and is usually not considered a serious complication. Clearance of stones can be laborious and is often avoided. Two patients with complications from gross intraperitoneal stone spillage during laparoscopic cholecystectomy, namely cholelithoptysis and cholelithorrhea, are presented. Both patients developed cholelithoptysis, or the coughing up of gallstones, within 1 year of their laparoscopic surgery. In addition, the second patient also experienced the passage of stones from a fistula at the incision site of a remote lumbar laminectomy, which we term cholelithorrhea. We propose that cholelithoptysis developed from the transdiaphragmatic extension of intraperitoneal abscesses and the subsequent formation of bronchopleural fistulas. We believe that gross intraperitoneal stone spillage should be avoided and remedied, if possible, by removal of stones and copious irrigation.