Laparoscopic cholecystectomy in a patient with ankylosing spondylitis with severe spinal deformity

Laparoscopic cholecystectomy for the treatment of acute cholecystitis in a Vietnamese male patient with ankylosing spondylitis combined with chronic obstructive pulmonary disease: A rare case report

INTRODUCTION

Ankylosing spondylitis (AS) presents with difficulty in intubation, restricted ventilatory abnormalities, and frequent cardiac involvement. However, with improvements in anaesthesiology and surgical expertise, laparoscopic cholecystectomy can be extended to individuals with kyphoscoliosis caused by AS.

CASE PRESENTATION

We report the case of a 68-year-old man who had severe AS for more than 30 years following necrosis acute cholecystitis. Signs of severe AS included the patient's inability to lie down and difficulty in breathing. We utilised four trocars but changed the placement positions and used suction tubes during laparoscopic cholecystectomy. The patient was discharged from the hospital after 14 days.

DISCUSSION

Severe AS is not a contraindication to laparoscopic surgery. However, patients with AS or kyphosis must be carefully assessed for respiratory dysfunction, cardiac impairment, difficult airway, and other special conditions. Anaesthesiologists and surgeons should collaborate with surgical decisions in patients with severe respiratory limitations.

CONCLUSION

Laparoscopic cholecystectomy can be performed effectively in patients with severe AS. With the use of a laparoscopic hook and suction equipment, it is possible to easily dissect the Calot triangle during acute cholecystitis.

Laparoscopic resection of retroperitoneal paraganglioma behind the Spiegel lobe in a kyphotic patient: A rare case report

Extra-adrenal paraganglioma is a rare form of neuroendocrine neoplasm capable of catecholamine secretion. The surgical risks associated with the tumor location are compounded in this case of a kyphotic patient. This report presents the successful application of laparoscopy on extra-adrenal paraganglioma located behind the Spiegel lobe in a kyphotic patient. The operation was performed after 1 week of α-blocker administration. The laparoscopic approach, with the patient in the left hemilateral decubitus position on a rotating table, provided optimal access for safe tumor resection after complete hepatic right lobe mobilization. The patient's postoperative course was uneventful. Based on the results, the laparoscopic approach can be a safe and effective method for resecting extra-adrenal paraganglioma in the challenging case of a kyphotic patient.

Spine Fractures in Ankylosing Diseases: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU)

STUDY DESIGN

Review of literature and case series.

OBJECTIVES

Update and review of current treatment concepts for spine fractures in patients with ankylosing spinal disorders.

METHODS

Case presentation and description of a diagnostic and therapeutic algorithm for unstable spinal injuries with an underlying ankylosing spinal disorder (ASD) of the cervical and thoracolumbar spine.

RESULTS

Nondisplaced fractures can be missed easily using conventional X-rays. Thus, computed tomography (CT) scans are recommended for all trauma patients with ASD. In doubt or presence of any neurologic involvement additional magnetic resonance imaging (MRI) scans should be obtained. Spine precautions should be maintained all times and until definitive treatment (<24 h). Nonoperative fracture treatment is not recommended given the mechanical instability of the most commonly seen fracture patterns (AOSpine B- and C-type, M2) in patients with ASD and inherent high risk of secondary neurologic deterioration. For patients with ankylosing spondylitis (AS) or diffuse idiopathic hyperostosis (DISH) sustaining cervical spine fractures, a combined anterior-posterior instrumentation for fracture fixation is recommended. Closed reduction and patient positioning can be challenging in presence of preexisting kyphotic deformities. In the thoracolumbar (TL) spine, a posterior instrumentation extending 2 to 3 levels above and below the fracture level is recommended to maintain adequate reduction and stability until fracture healing. Minimally invasive percutaneous pedicle screws and cement augmentation can help to minimize the surgical trauma and strengthen the construct stability in patients with diminished minor bone quality (osteopenia, osteoporosis).

CONCLUSIONS

Current concepts, treatment options, and recommendations of the German Orthopedic Trauma Society-Spine Section for spinal fractures in the ankylosed spine have been outlined.

Successful laparoscopic cholecystectomy for acute cholecystitis with kyphoscoliosis by the devised placement of trocar ports: A case report

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Kyphoscoliosis has various surgical difficulties for laparoscopic cholecystectomy.

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Low-lying costal arches prevents surgeons from accessing the gall bladder.

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A transumbilical multi-port and left abdominal port is useful for patients with kyphoscoliosis.

Introduction

Kyphoscoliosis, which is a deformity of the spine caused by aging and osteoporosis, results in various surgical difficulties for laparoscopic cholecystectomy (LC) due to low-lying costal arches, such as a small abdominal working space, disturbance of the surgical view and decreased controllability of the surgical instrument.

Presentation of case

We herein report the case of a 92-year old woman with severe kyphoscoliosis who was diagnosed with Grade II acute cholecystitis. Taking her general status into consideration, emergency percutaneous transhepatic gallbladder drainage (PTGBD) was initially performed. After PTGBD, the patient’s physical status and systemic inflammation markedly improved. She then underwent interval LC. The surgical view of the upper abdomen including the gallbladder was entirely interrupted by bilateral low-lying costal arches with adhesion to the greater omentum. To access the gallbladder without interruption by the low-lying costal arch, the first umbilical port was changed to a multi-port with surgical glove and an additional port was added in the left abdomen. Consequently, LC was safely accomplished with the creation of the critical view.

Discussion

A low-lying costal arch due to kyphoscoliosis can prevent surgeons from accessing the gallbladder. LC with the standard 4-port method could not be accomplished because of insufficient lifting of the low-lying costal arch. Devised placement of the ports is needed to access the gallbladder between bilateral low-lying costal arches.

Conclusion

A transumbilical multi-port and left abdominal port may be effective for successful LC of acute cholecystitis with kyphoscoliosis.

Reduced port laparoscopic surgery for colon cancer in a patient with tuberculous kyphosis and dwarfism: a rare case and literature review

With accumulated surgical experience, the contraindications to laparoscopic surgery have been decreasing. Reduced port laparoscopic surgery has been widely adopted for a variety of diseases. However, surgery in patients with anatomic deformities are still a challenge for surgeons, specifically abdominal surgery in patients with severe kyphosis. A 71-year-old man with a diagnosis of ascending colon cancer had severe kyphosis with extremely short stature, secondary to tuberculous spondylitis. Laparoscopic right hemicolectomy was successfully performed with a single umbilical incision plus one port. This is the first reported case involving laparoscopic surgery in a patient with tuberculous kyphosis. The purpose of this report is to describe the surgical skills of reduced port laparoscopic surgery in a patient with altered habitus. With proper planning and a meticulous operation, minimally invasive surgery could be safely achieved.

Laparoscopic cholecystectomy in patients with anesthetic problems

Laparoscopic cholecystectomy is a standard operation for benign gallbladder disease. As experience with laparoscopic cholecystectomy has increased, the procedure has become possible in patients with anesthetic problems. Patients with ankylosing spondylitis or severe kyphosis represent a challenging group to anesthesiologists and laparoscopic surgeons since these diseases are associated with difficult intubation, restrictive ventilatory defects, and cardiac problems. The relatively new approach of awake fiberoptic intubation is considered to be the safest option for patients with anticipated airway difficulties. Laparoscopic cholecystectomy is usually performed under general anesthesia but considerable difficulties in anesthetic management are encountered during laparoscopic surgery; for example, hemodynamic instability may develop in patients with cardiopulmonary dysfunction due to pneumoperitoneum and position changes during the operation. Nonetheless, regional anesthesia can be considered as a valid option for patients with gallbladder disease who are poor candidates for general anesthesia due to cardiopulmonary problems. We report three cases of laparoscopic cholecystectomy successfully performed in patients with anesthetic problems that included cardiopulmonary disease, severe kyphosis, and ankylosing spondylitis.

Prediction and management of a low-lying costal arch which restricts the operative working space during laparoscopic cholecystectomy

BACKGROUND/PURPOSE

Laparoscopic cholecystectomy is difficult to perform in patients with a low-lying costal arch that entirely covers the liver. We conducted this study to clarify the factors related to a low-lying costal arch and establish countermeasures to circumvent this characteristic.

METHODS

The study included 103 consecutive patients who underwent a laparoscopic cholecystectomy. The possible clinical factors associated with a low-lying costal arch restricting the operative working space were analyzed. The position of the liver against the costal arch and the presumed surgical visual angle for laparoscopic cholecystectomy, comprising the hepatic porta, umbilicus, and costal arch, were estimated with abdominal multidetector computed tomography (MDCT).

RESULTS

Seven (7%) patients had a low-lying costal arch presenting an inadequate exposure of Calot's triangle and restricted instrument mobility during laparoscopic cholecystectomy, and three patients required conversion to a laparotomy. A low-lying costal arch was significantly associated with advanced age, shorter stature, lighter body weight, coexisting kyphoscoliosis, gallbladder pathology, laparotomy conversion, and most of all, the liver edge lying above the costal arch and a narrow surgical visual angle upon MDCT. Of the seven patients with a critical low-lying costal arch, four underwent a successful laparoscopic cholecystectomy, this being done by lifting the right costal arch to create a workable surgical field; the rib-lifting procedure was planned as part of the scheduled procedure in the other three patients because the preoperative MDCT examination indicated a poor working space for a laparoscopic cholecystectomy.

CONCLUSIONS

A low-lying costal arch is a substantial risk factor for conversion to a laparotomy when performing a laparoscopic cholecystectomy. However, the operative difficulty related to a low-lying costal arch can be predicted by using preoperative MDCT images and can be managed with proper planning and the appropriate use of the rib-lifting technique.