Abdul Aziz Laghari

Iatrogenic biliary injuries during laparoscopic cholecystectomy. A continuing threat

BACKGROUND Despite improvement in the technique and increasing experience, complications of different nature and severity continue to occur during laparoscopic cholecystectomy all around the world. We present bile duct injuries in this series with regards to the incidence, severity and management of this problem. STUDY DESIGN Descriptive. PLACE AND DURATION Department of surgery, Liaquat University of medical and Health Sciences, Jamshoro and other private hospitals at Hyderabad city during April 2003 to December 2007. MATERIALS AND METHODS A total of 1132 patients with symptomatic gallstone disease were included in the study regardless of their age and gender. Laparoscopic cholecystectomy by classical four-port technique performed in all cases with few amendments as per situation. Patients with growth in gallbladder and with severe associated medical or cardiac problems were excluded from the study. Details of every patient collected on a proforma and data finally analyzed on SPSS version 10. RESULTS Of total 1132 patients, 1088 (96%) were females and 44 (4%) were males with a mean age of 47.64 years. Elective laparoscopic cholecystectomy was performed in 1118 (98.7%) patients whereas emergency laparoscopic cholecystectomy was done in 14 (1.23%) patients. Various types of common bile duct injuries as well as post -operative bile leaks and their management is discussed with a view to improve upon the technique and out come. CONCLUSION Iatrogenic biliary injuries continue to occur despite tremendous overall improvement in technique and expertise.

Laparoscopic cholecystectomy in empyema of gall bladder: An experience at Liaquat University Hospital, Jamshoro, Pakistan

Objective: To find out the safety profile of laparoscopic cholecystectomy in empyema of gallbladder. Background: Empyema of gall bladder is a severe form of acute cholecystitis with superadded suppuration. It has been considered a contraindication for the laparoscopic cholecystectomy (LC) because of fear of life-threatening complications. This study aimed to determine the safety and feasibility of LC in empyema of gallbladder. Materials and Methods: LC was attempted in 67 patients of empyema of gallbladder within 24h. However in few cases there was a delay because of reluctance for surgery or delay in giving consent etc. The procedure was performed by standard four-port technique with few changes made to facilitate dissection according to situation. Results: Between April 2003 to June 2006, 970 LC performed for gallstone disease at surgical unit-1 of LUMHS by the same surgical team. Among these, 67 (6.90%) patients were diagnosed to have empyema gall bladder. LC successfully completed in 54 (80.59%) patients. In 13 (19.40%) patients the procedure was converted to open cholecystectomy (OC) due to various operative difficulties of which the most serious injuries included bleeding from cystic artery (four cases), common bile duct injury (two cases) and duodenal injury in one case. Maximum operating time was up to 160 minutes (one case). Postoperative complications occurred in 10 (18.51%) successfully operated patients. Maximum patients (n=45, 83.33%) were discharged in 48-96 hours while three patients were discharged after two weeks. Conclusion: Laparoscopic cholecystectomy can be performed in empyema of gallbladder keeping in mind a slightly increased risk of complications even in the best hands. However, the experience of the surgeon plays a key role in the overall outcome.

Extra-biliary complications during laparoscopic cholecystectomy: How serious is the problem?

Objective: To deteremine the incidence, nature and management of extra-biliary complications of laparoscopic cholecystectomy. Materials and Methods: This study presents a retrospective analysis of extra-biliary complications occuring during 1046 laparoscopic cholecystectomies performed from August 2003 to December 2006. The study population included all the patients with symptomatic gallstone disease in whom laparoscopic cholecystectomy was performed. The extra-biliary complications were divided into two distinct categories: (i) Procedure related and (ii) Access related. Results: The incidence of access-related complications was 3.77% and that of procedure-related complications was 6.02%. Port-site bleeding was troublesome at times and demanded a re-do laparoscopy or conversion. Small bowel laceration occurred in two patients where access was achieved by closed technique. Five cases of duodenal and two of colonic perforations were the major complications encountered during dissection in the area of Calots triangle. In 21 (2%) patients the procedure was converted to open surgery due to different complications. Biliary complications occurred in 2.6% patients in the current series. Conclusion: Major extra-biliary complications are as frequent as the biliary complications and can be life-threatening. An early diagnosis is critical to their management.

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.