Overcoming Anatomical Challenges: Laparoscopic Cholecystectomy in Situs Inversus Totalis

Situs inversus totalis (SIT) is a rare genetic condition characterized by the sagittal inversion of thoracoabdominal organs. Surgeons may face substantial challenges when dealing with surgical pathologies in SIT patients, particularly those involving the gallbladder and bile ducts, such as cholelithiasis and acute cholecystitis. In this report, we present the case of a 46-year-old male with a previously known diagnosis of SIT, who presented with recurrent episodes of atypical abdominal pain. Cholelithiasis was diagnosed through ultrasound and as a result, elective surgery was scheduled. In addition, we detail the adjustments implemented by our surgical team in the laparoscopic cholecystectomy procedure, which contributed to a successful surgical outcome. Nevertheless, like any patient, those with SIT are not exempt from postoperative complications, as detailed in this case. Hence, we emphasize the importance of comprehensive preoperative diagnostics to reduce the risk of perioperative complications in this group of patients.

Conservative Management of Mirizzi Syndrome in Community Hospital Setting

Mirizzi syndrome (MS) is a rare complication of chronic cholecystitis caused by the gallbladder wall compression of the common hepatic duct (MS1, based on McSherry classification) or as a cholecystocholedochal fistula (MS2). The incidence of MS in symptomatic cholelithiasis is very low. Patients often present with obstructive jaundice and right upper quadrant abdominal pain; symptoms not clinically unique from biliary colic or cholecystitis, and often misdiagnosed preoperatively.

We present the case of a 76-year-old female, initially diagnosed with chronic cholecystitis, who was found to have MS2 intraoperatively. She denied a prior history of abdominal surgery or biliary instrumentation. The patient underwent a subtotal cholecystectomy with common bile duct exploration, t-tube placement, and wide local drainage. She progressed well and was discharged home from the hospital on day seven with outpatient hepatobiliary surgery follow-up. At one-month follow-up, the patient had t-tube output of 200-300cc per day with remaining drains removed after having diminished output and no signs of biloma on CT. At the two-month follow-up, the patient had a minimal t-tube output with t-tube cholangiography showing contrast dye into the duodenum. Her t-tube was clamped and was removed at the three-month follow-up.

Surgical management of MS1 is generally laparoscopic or open cholecystectomy. Management of MS2 is complex and dependent on anatomic and pathologic factors. Surgical repair generally focuses on biliary-enteric reconstruction, with cholecystcholedochoduodenostomy or Roux-en-Y hepaticojejunostomy. Conservative surgical approach with subtotal cholecystectomy, common bile duct exploration, and biliary drainage is also reported as a safe alternative option. MS is a rare complication of chronic cholecystitis, and can be a cause of cholecystocholedochal fistula, which is often discovered intraoperatively during cholecystectomy; general surgeons should be familiar with conservative management of MS.

Cholecystoduodenal Fistula Evading Imaging and Endoscopic Retrograde Cholangiopancreatography: A Case Report

Cholecystoduodenal fistulas are a type of internal biliary fistula that occur due to chronic inflammation of the gallbladder/biliary tree; if left untreated, perforation and necrosis can occur. Cholecystoduodenal fistulas are often difficult to diagnose due to their non-specific signs and symptoms. Since the widespread use of techniques such as magnetic resonance cholangiopancreatography and imaging modalities such as computed tomography, the frequency of reports describing intraoperative cholecystoduodenal fistula has reduced dramatically. Here, we report the case of a 54-year-old female who presented with a two-day history of non-radiating epigastric abdominal pain, initially diagnosed with acute cholecystitis and choledocholithiasis. Upon undergoing laparoscopic cholecystectomy, she was found to have extensive fibrosis of the gallbladder, adhesions, and an impacted gallstone in the wall of the gallbladder. Imaging and endoscopic retrograde cholangiopancreatography performed prior to surgery did not detect a cholecystoduodenal fistula that was discovered intraoperatively. She was treated successfully with laparoscopic cholecystectomy and repair of the duodenum.

The Spectrum of Gallbladder Histopathology at a Tertiary Hospital in a Developing Country: A Retrospective Study

Background

Affections of the gallbladder remain exceedingly ubiquitous and often warrant surgical intervention. The histopathological patterns represent a spectrum, ranging from cholecystitis to gallbladder carcinoma. The present study aims to delineate the occurrence of various gallbladder histopathologies in a tertiary care hospital in Pakistan.

Methods

A retrospective study was conducted at Maroof International Hospital, Islamabad, Pakistan. Histopathological records of 442 gallbladder specimens obtained from cholecystectomy were analysed. The prevalence of various histopathological outcomes was assessed. The data were eventually analysed using the SPSS 23.0 software (Armonk, NY: IBM Corp.). Thereafter, the distribution of various gallbladder histopathologies was tabulated across gender. 

Results

Of the 442 patients included, 330 were females and 112 were males, with the mean age hovering at 45.77±14.65 years. The most common histopathological findings were chronic cholecystitis and cholesterolosis, observed in 78.6% and 32.8% of the patients, respectively. While only one case of gallbladder adenocarcinoma was observed, multiple specimens divulged premalignant lesions including reactive atypia and intestinal metaplasia.

Conclusions

Diseases of the gallbladder often mandate prompt surgical intervention. Of these, chronic cholecystitis, which is an established risk factor for gallbladder carcinoma, is exceedingly common. The employment of histopathological techniques remains imperative in the detection of premalignant and malignant lesions that might otherwise evade macroscopic detection and thus progress to adenocarcinoma.