G. P. McEntee

The need to retrieve the dropped stone during laparoscopic cholecystectomy

The effect of bile and gallstones on the peritoneal cavity was evaluated in an experimental animal study. Ninety male Sprague-Dawley rats were randomly allocated to one of six groups (n = 15). Groups 1 to 3 received an intraperitoneal injection (2 mL) of saline, sterile bile, and infected bile, respectively. Groups 4 to 6 underwent a lower midline abdominal incision (3 to 5 mm). In groups 4 and 5, a single gallstone (< 3 mm diameter) was placed in the right upper quadrant and, after closure of the wound, the animals were injected with sterile bile and infected bile, respectively. Group 6 animals underwent laparotomy alone, followed by injection of sterile saline (2 mm). All animals were killed at 4 weeks and the peritoneal cavity was carefully examined. No intra-abdominal lesions were noted in groups 1 to 3. Adhesions were noted in 11 (73%) and 10 (67%) animals of groups 4 and 5, respectively. Two intra-abdominal abscesses were noted in group 4 animals. No intra-abdominal lesions were noted in any group 6 animals. This study suggests that bile in combination with gallstones in the peritoneal cavity is associated with an increased risk of intra-abdominal adhesion formation and possible abscess formation, and that every attempt should be made to retrieve stones lost during cholecystectomy.

Intraperitoneal pethidine versus Intramuscular pethidine for the relief of pain after laparoscopic cholecystectomy: Randomized trial

Laparoscopic cholecystectomy is widely used and may be performed as an ambulatory procedure. We undertook a randomized comparison of the benefits of intraperitoneal pethidine compared with intramuscular pethidine for postoperative analgesia following laparoscopic cholecystectomy. A series of 100 consecutive American Society of Anesthesiologists (ASA) I or II patients were randomly assigned to intramuscular pethidine (54 patients) or intraperitoneal pethidine (46 patients). Each was combined with intraperitoneal bupivacaine. The primary end-points were the pain and nausea scores at intervals after operation. All recruited patients completed the study. Pain scores at rest and upon movement were significantly lower in the group receiving the intraperitoneal pethidine at each of the time periods examined (pain at rest at 4 hours: 1.6±0.8 vs. 2.4±0.9 cm; p<0.001; pain upon movement at 4 hours: 2.1±0.9 vs. 3.1±1.2 cm; p<0.001). The total dose of pethidine administered via patient-controlled analgesia (PCA) during the first 24 hours after surgery was also significantly lower in this group (total dose 50.9±3.9 vs. 55.9±4.4 mg; p<0.001). There were no significant differences in the respiratory rate at any of the time periods. Intraperitoneal pethidine analgesia was superior to an equivalent dose of intramuscular pethidine for the relief of postoperative pain in patients undergoing laparoscopic cholecystectomy. This was achieved at the expense of increased nausea but no significant increase in vomiting. The accessibility of this route of analgesia administration has implications for patients undergoing laparoscopic procedures, particularly with the recent trend toward increased use of ambulatory techniques.RésuméLa cholécystectomie laparoscopique est réalisée dans le monde entier et peut être réalisée en ambulatoire. Nous avons comparé par une étude randomisée les bénéfices de la pethidine en intraperitoneal comparée à la pethidine en intramusculaire pour l’analgésie postcholecystectomic laparoscopique. Cent patients consécutifs, ASA I ou II, ont été randomisés pour recevoir soit de la pethidine en intra-musculaire (54 patients) ou en intrapéritonéale (46 patients). De la bupivacaïne a été administrée en intrapéritonéale chez tous les patients. Les critères de jugement principaux et secondaires ont été les scores de la douleur et de la nausée à des intervalles successifs post-opératoires. Tous les patients inclus ont complété l’étude. La douleur au repos et lors des mouvements a été significativement moindre dans le groupe recevant de la pethidine en intrapéritonéale à chaque intervalle étudié [douleur au repos à 4 heures: 1.6 (0.8) cm vs. 2.4 (0.9) cm; p=0.001; douleur lors des mouvements à 4 heures: 2.1 (0.9) cm vs. 3.1 (1.2) cm; p=0.001]. La dose totale de pethidine administrée via la PCA pendant les 24 premières heures après chirurgie a également été plus basse dans ce groupe [dose totale 50.9 (3.9) mg vs. 55.9 (4.4) mg; p=0.001]. Il n’y avait aucune différence statistiquement significative en ce qui concernait la fréquence respiratoire quel que soit le moment de l’étude. La pethidine en intrapéritonéale est supérieure à la pethidine en intramusculaire pour l’analgésie de la douleur post-cholécystectomie laparoscopique. Cette amélioration a été accomplie au prix de plus de nausées mais sans augmentation significative des vomissements. L’utilisation de cette route d’administration a des implications importantes chez le patient opéré sous laparoscopic, en particulier, vu la tendance actuelle à élargir les indications de la chirurgie ambulatoire.ResumenLa colecistectomía laparoscópica es el procedimiento más empleado en cirugía ambulatoria. Efectuamos un estudio comparative aleatorio sobre los efectos, de la petidina intraperitoneal vs intramuscular, en la analgesia postcolecistectomía laparoscópica. 100 pacientes ASA I o II fueron aleatoriamente distribuidos en 2 grupos: petidina intramuscular (n=54) y petidina intraperitoneal (n=46); a este último grupo se le asoció bupivacaina intraperitoneal. Se investigaron el dolor y las nauseas durante el postoperatorio. Todos los pacientes completaron el estudio. El dolor postoperatorio tanto en reposo como con la movilización fue significativamente menor en el grupo de petidina intraperitoneal [dolor en reposo a las 4 horas 1.6 (0.8) cm vs 2.4 (0.9) cm; p<0.001; dolor a la movilización a las 4 horas 2.1 (0.9) cm vs 3.1 (1.2) cm; p<0.001]. Además, en este grupo la dosis total de petidina administrada en las primeras 24 horas del periodo postoperatorio fue menor [dosis total 50.9 (3.9) mg vs 55.9 (4.4) mg, p<0.001]. No se observaron diferencias significativas en la frecuencia respiratoria a lo largo del periodo postoperatorio. La analgesia proporcionada por la administración intraperitoneal de petidina es superior a la obtenida por inyección intramuscular, aunque se produzcan más nauseas pero sin que se incremente la frecuencia de vómitos. Dada la accesibilidad de esta vía para la administración de analgésicos este proceder debe tenerse muy en cuenta en las técnicas laparoscópicas, especialmente si se quiere incrementar la realización de las mismas de manera ambulatoria.

Giant solitary non-parasitic cyst of the liver

BackgroundCystic diseases of the liver and intrahepatic biliary tree are uncommon. The majority of cases are detected only when patients become symptomatic, or as an incidental finding on radiological imaging.MethodsWe discuss the case of a 25-yr-old female with a centrally located giant liver cyst causing obstructive jaundice, and briefly discuss the management options in the treatment of this uncommon problem.Results and ConclusionsIntervention is recommended in patients with symptomatic simple cysts of the liver. Surgical cystectomy is the treatment of choice for large deep seated cysts.

Acute lymphocytic leukaemia presenting as spontaneous splenic rupture.

SummaryA case of spontaneous rupture of the spleen as a primary manifestation of acute lymphocytic leukaemia is presented. Pathological findings suggest that the splenic rupture in this case was due to infiltration and destruction of the trabecular arteries by leukaemic cells. Splenectomy was carried out successfully and remission subsequently obtained with chemotherapy.

Traumatic arteriovenous fistula of the liver.

A 16-year-old jockey presented with right upper quadrant pain after a kick from a horse. CT revealed a parenchymal laceration (A, arrows), involving the right liver, with a focal collection of contrast consistent with active extravasation (A, arrowhead). He was hemodynamically stable and was managed nonoperatively. Serial imaging demonstrated gradual resolution of the hematoma. A CT performed 7 months postinjury demonstrated a persistent abnormal collection of contrast in the right liver (B, arrowhead) and differential enhancement of the posterior part of the right liver compared with the anterior part of the right liver and left liver (B, arrows). Angiography with the catheter in the common hepatic artery demonstrated a fistula (C) from the right hepatic artery to the right hepatic vein (C, arrow). This was successfully embolized. A CT 2 months later demonstrated the coils in good position, but an area of abnormal enhancement persisted in the right lobe of the liver. An angiogram with the catheter in the celiac axis demonstrated occlusion of the hepatic artery but revealed multiple collaterals from the inferior phrenic artery (D, small arrows), the left gastric artery (D, curved arrows), and the superior mesenteric artery supplying the arterio-venous fistula (arrow indicates right hepatic vein). A right hepatectomy was performed to prevent the development of intractable portal hypertension. We speculate that angiography with embolization at the time of initial trauma may have prevented the development of an established fistula and subsequent surgery. A B

Pelvic inflammatory pseudoturmour: problems in clinical and histological diagnosis. Case report

Case report A 48-year-old woman was admitted t o this hospital with a 6-month history of menorrhagia and a 4-week history of suprapubic and left iliac fossa pain. She had been treated by her general practitioner for urinary tract infection 1 month before admission; a 1 -week course of nalidixic acid gavc sonic symptomatic improvement. On admission. the patient had a temperature of 38.3”C. A large tender mass was palpable suprapubically, extending to the left iliac fossa. Uterine fibroids were diagnosed on vaginal examination; rectal examination was normal. Subsequent laboratory investigations included hacmoglobiri 10-3 gldl; white ccll count 13-2 X

Renal failure from obstructive uropathy secondary to aortic aneurysm

Abstract A case of renal failure secondary to perianeurysmal fibrosis involving both ureters is presented. After ureterolysis and excision of the aneurysm renal function returned to normal.