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

Anatomical Considerations for Gallbladder Sonography: A Cross-Sectional Study of CT Imaging by BMI Group

Objective The purpose of this study was to establish an association between the body mass index (BMI) group and anatomical gallbladder position to aid novices in gallbladder sonography. Methods This was a cross-sectional, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)-compliant study that examined the association between gender and the BMI group with quantitative gallbladder position measurements from computed tomography (CT) scans. Results A quantitative analysis determined that the gallbladder was positioned relatively higher and oriented more horizontally within the abdomen of individuals with obese BMI than those with normal BMI (p < 0.001), irrespective of gender. Additionally, the gallbladder was more obstructed by the rib cage in individuals with obese BMI than those with normal BMI (p = 0.007 for females and p < 0.001 for males). The gallbladder was significantly more horizontal in overweight males than females (p < 0.001) and more obstructed by the rib cage in obese males than females (p = 0.013). Conclusion This association provides ultrasound novices knowledge for a more targeted approach in localizing the gallbladder and evidence to recommend an intercostal approach for gallbladder sonography in obese patients.

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.

Robotic surgery in patients with achondroplastic dwarfism: evaluation of risks and issues in an anatomical challenging bilateral partial nephrectomy

The reports on the performance of robotic surgery in patients with dwarfism are anecdotal; anesthesiological issues and a challenging anatomy are the main factors that lead most of surgeons to prefer a more traditional approach. We present a case of bilateral robotic partial nephrectomy in a patient affected by achondroplastic dwarfism and aim to evaluate risks and issues in this type of surgery.

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.