Kamal I.A. Gharaibeh

Retained Surgical Sponges (Gossypiboma)

OBJECTIVE Retained surgical sponges are seldom reported due to medicolegal implications. Awareness of this problem among surgeons and radiologists is essential to avoid unnecessary morbidity. We present our experience with this entity and review the related literature. METHODS The medical records of 11 patients who were diagnosed as having retained surgical sponges from 1990 to 2003 were reviewed. RESULTS The incidence was 1:5,027 inpatient operations. There were four males and seven females with a median age of 45 years. The original operations were gynaecological (n=4), general (n=4), urological (n=2) and laminectomy (n=1). In seven cases, the original operation was performed on an emergency basis. Five patients were obese. A presumed correct sponge count was documented in eight cases. The median time between the original procedure and diagnosis of retained sponges was 12 months. The tentative diagnosis was intestinal obstruction (4 patients), urinary tract infection (1 patient), Crohns disease (1 patient) and tumour recurrence (1 patient). The correct diagnosis was suggested in the remaining four patients. Surgical removal of the retained sponges was carried out in all cases except one, in which the patient passed the sponge spontaneously through the rectum. CONCLUSION Retained sponges are more common in obese patients and after emergency surgery. A high degree of suspicion is important for preoperative diagnosis. Despite the use of radio-opaque sponges and thorough sponge counting, this moribund mishap still occurs. Although human errors cannot be completely abolished, continuous medical training and strict adherence to regulations should reduce the incidence to a minimum.

Effect of Timing of Surgery, Type of Inflammation, and Sex on Outcome of Laparoscopic Cholecystectomy for Acute Cholecystitis

BACKGROUND AND PURPOSE Studies have shown the safety and effectiveness of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC). Our aim was to establish the outcome of LC in patients with AC on the basis of duration of the attack before surgery took place, the type of gallbladder inflammation, and patient sex. PATIENTS AND METHODS All 204 patients at Princess Basma Teaching Hospital who underwent LC for AC by the authors between September 1994 and June 1999, were retrospectively reviewed. They were categorized into Group I, where surgery took place within 72 hours of the acute attack (N = 78; 54 women and 24 men), and Group II, if later than that (N = 126; 70 women and 56 men). Gallbladder pathology was classified as gangrenous, empyema, edematous, mucocele, or AC along with contracted fibrosed gallbladder. RESULTS Conversion to open cholecystectomy was needed in 12% of the total series. In Group I, 3.8% of the patients needed conversion compared with 16.7% in Group II patients (P = 0.01). Also, 4% of the female patients needed conversion compared with 24% of the male patients (P = 0.000). There was an association between the pathological type of AC and the likelihood of conversion (P = 0.002), conversion being least common in those with mucocele and most common in those with empyema and gangrene. The median operation time was 75 +/- 36 minutes, but the operation time for Group II patients was significantly longer (P = 0.001) than in Group I patients. Operation time in the male patients was significantly longer than in the female patients (P = 0.000). There was no statistically significant difference in the duration of hospital stay in the two groups or in men and women. There were no deaths or main bile duct injuries in the series. In successful LC, missed stones occurred in 3.3% of the patients. Bile collection, which was treated by open surgery, developed in one female patient. CONCLUSION Laparoscopic cholecystectomy is a reliable and safe modality for the management of AC. It was not associated with an increased incidence of bile duct injury in this series. It should be the first choice before resorting to open surgery. Factors associated with increased conversion include delay in surgery of more than 3 days from the acute attack and certain pathology, with conversion being more likely in empyema. Conversion also was more likely in male patients.

Laparoscopic cholecystectomy for gallstones: a comparison of outcome between acute and chronic cholecystitis.

BACKGROUND Laparoscopic cholecystectomy (LC) is now a common method of treating symptomatic gallstones, and it is increasingly being requested by the informed general public. Our aim was to evaluate the role of LC for cholelithiasis and to establish its outcome and the effect of gender on the results. PATIENTS AND METHODS Between September 1994 and June 1999, all patients who underwent LC for cholelithiasis were retrospectively reviewed. They were classified as having acute or chronic cholecystitis (AC or CC). RESULTS There were 791 patients with CC (633 females, 158 males) and 204 patients with AC (124 females, 80 males). Conversion to open cholecystectomy was needed in 0.76% and 11.8% of the patients with CC and AC, respectively (P<0.00). Four percent of the female patients with AC needed conversion as compared to 23.8% in the males (P<0.00). The low conversion rate in CC limited gender comparison. Median operation time in the patients with CC was 53+/-16 minutes as compared to 74.5+/-35.7 minutes in those with AC (P<0.00). Operation time in the male patients with CC and AC was significantly higher than in the female patients, even after excluding the converted cases (P<0.00). Median postoperative stay for patients with CC was 1.33+/-0.9 days as compared to 1.9+/-1.34 days in patients with AC (P<0.00). No statistical significance in the hospital stay was found between males and females (in CC and AC). There was no mortality in the series. There were three bile duct injuries in the patients with CC. In patients with successful LC, gallbladder perforation occurred in 18% and 31% of CC and AC patients, respectively (P<0.003). Missed stones occurred in 1.4% and 3.3% of the patients with successful LC for CC and AC, respectively. Bile collection, which was treated with open drainage, occurred in four patients with CC and one patient with AC. CONCLUSION LC for symptomatic cholelithiasis is safe and feasible; it should be the first choice before resorting to open surgery. In patients with AC as compared to CC, there is an increased conversion rate, longer operation time, longer hospital stay, and higher incidence of gallbladder perforation without an increase in the incidence of bile duct injuries (BDI). Male patients have a longer operation time and higher conversion rate than female patients.

Empyema of the gall bladder: reappraisal in the laparoscopy era.

BACKGROUND In evaluations of laparoscopic cholecystectomy for acute cholecystitis, the role of this technique specifically for empyema of the gall bladder has not been separately addressed. Therefore, we describe the demographic characteristics, clinical and laboratory findings, management and outcome of patients presenting with empyema of the gall bladder who were treated with open cholecystectomy or laparoscopic cholecystectomy. PATIENTS AND METHODS Our retrospective evaluation included 1449 patients who underwent cholecystectomy over 88 months, including a 30-month period when open cholecystectomy was the standard operation and a 58-month period when laparoscopic cholecystectomy became the standard operation for acute and chronic cholecystitis. RESULTS Of the 1449 cholecystectomies, 29 cases proved to have empyema, an incidence of 2%. Males constituted 48.3% of the patients (vs. 22% for the whole cholecystectomy group, P < or = 0.005) and the average age was 54.6 years (vs. 43 years for the whole cholecystectomy group, P < or = 0.005). The clinical picture was indistinguishable from other forms of acute cholecystitis. Laparoscopic cholecystectomy was attempted for all the patients in the laparoscopy era with a conversion rate of 42%, significantly higher than other forms of gall bladder diseases (P=0.002). CONCLUSION Empyema of the gall bladder is more often encountered in males and the elderly. The clinical picture is indistinguishable from other forms of acute cholecystitis and a preoperative diagnosis is difficult. Early laparoscopic cholecystectomy is advisable for all patients with acute cholecystitis. A higher conversion rate is expected for patients with empyema.