Resection of gallbladder remnants after subtotal cholecystectomy: presentation and management

BACKGROUND

Subtotal cholecystectomy (SC) involves removal of a portion of the gallbladder typically due to hazardous inflammation. While this technique reliably prevents common bile duct (CBD) injury, future procedures can be required if the gallbladder remnant becomes symptomatic. The morbidity associated with resection of gallbladder remnants in patients that previously underwent SC is reviewed.

METHODS

Records for patients having undergone redo cholecystectomy for symptomatic gallbladder remnants in a tertiary care system from 2013 to 2017 were retrospectively reviewed.

RESULTS

Fourteen patients underwent repeat cholecystectomy. Five surgeons dictated the initial procedure as a subtotal cholecystectomy. All patients returned with symptomatic cholelithiasis between zero months and seven years after the index cholecystectomy. Redo cholecystectomy was attempted laparoscopically in two patients but ultimately required an open approach in all. One patient had a recognized CBD injury requiring a hepaticojejunostomy, and a second patient had a minor wound infection. Symptoms resolved in 13/14 patients.

CONCLUSIONS

Redocholecystectomy (RC) for gallbladder remnants has been detailed in case reports, but no sizable North American series have been presented. These results illustrate a drawback to the reconstituting technique of SC. RC effectively resolves symptoms but requires adherence to safe principles of cholecystectomy and is one indication for an open approach.

Stressors and Coping Strategies Among Successful Female African American Baccalaureate Nursing Students

Interview and descriptive methods were used to investigate the stressors and coping strategies of academically successful African American female baccalaureate nursing students (N = 23) in the three predominantly Caucasian universities in South Carolina. The study addressed three questions: 1) What are major stressors for African American female students? 2) Which coping strategies do these students use? and 3) Which coping strategies do these students find to be most successful? Major stressors identified, both by priority and frequency of occurrence, were academic in nature, followed in descending order by environmental, financial, interpersonal, and personal stressors. Coping strategies used with the greatest regularity and success were active coping (taking action to remove or circumvent the stressor), seeking social support for instrumental reasons (seeking assistance, information, or advice about what to do from someone in a position to help), and seeking social support for emotional reasons (getting sympathy or emotional support from someone). Behavioral disengagement, denial, and alcohol-drug disengagement were reported to be unsuccessful coping strategies in the majority of instances.

Palliative gastric transposition following pharyngolaryngoesophagectomy

Extensive extirpative resection of advanced head and neck tumors followed by functional reconstruction is a formidable undertaking. Poor long-term survival and substantial morbidity and mortality have often conferred a nihilistic approach toward these patients. We reviewed our experience with transhiatal gastric transposition with pharyngogastric anastomosis for reconstruction of pharyngoesophageal defects to assess the value of undertaking such a formidable surgical intervention. A retrospective analysis (1990-1994) of 20 consecutive patients with advanced head and neck tumors who underwent pharyngolaryngoesophagectomy followed by transhiatal gastric transposition with pharyngogastric anastomosis was performed. Morbidity was 35 per cent; mortality was 10 per cent. Pharyngogastric leaks occurred in 10 per cent of patients. The median postoperative stay was 19 days. Ninety-four per cent of patients had good to excellent palliation. Follow-up averaged 14.3 months. Late stricture occurred in two patients that was easily amenable to dilatation. Tumor recurrence caused dysphagia in one patient; otherwise, all patients are swallowing well or have died without dysphagia. Gastric transposition without thoracotomy is a versatile and reliable method for reconstruction of large pharyngoesophageal defects and is associated with an acceptable morbidity and mortality, thus allowing good palliation in a patient population with an extremely poor prognosis and an otherwise poor quality of life.

Complications of laparoscopic cholecystectomy: the experience of a university-affiliated teaching hospital

BACKGROUND

In most published reports on laparoscopic cholecystectomy, the cases have been accrued from small community hospitals in a multicenter fashion. The purpose of this study was to compare the rate of complication following laparoscopic cholecystectomy performed at a single university-affiliated teaching hospital to those quoted in the literature.

STUDY DESIGN

A retrospective review of the first 1300 laparoscopic cholecystectomies performed at the Videoscopic Surgery Center at Pennsylvania Hospital from May 1990 through January 1994 was undertaken. Complications were classified as those related to creation of the initial pneumoperitoneum and those related to cholecystectomy.

RESULTS

A 3% conversion rate to open cholecystectomy (n = 40) was noted due to the presence of dense adhesions, gangrenous cholecystitis, or difficult anatomic relationships. There were 18 complications (1.4%) related to creation of the initial pneumoperitoneum and 14 complications (1.1%) related to cholecystectomy. Complications related to laparoscopy included bleeding from the abdominal wall (n = 2), trocar site hernia (n = 11), hollow viscus injury (n = 1), and wound infection (n = 4). Complications related to cholecystectomy included unanticipated retained CBD stone (n = 5), symptomatic bile leak (n = 6), hollow viscus injury (n = 1), intraabdominal abscess (n = 1), and a retained portion of gallbladder (n = 1). There were no perioperative deaths related to laparoscopic cholecystectomy, and the overall morbidity was 2.4%. Long-term follow-up revealed no cases of benign biliary strictures.

CONCLUSIONS

With attention to anatomy, technique, and meticulous dissection, laparoscopic cholecystectomy can be safely performed in a university-affiliated teaching hospital setting.

Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental preexisting umbilical hernia

With the expansion of both laparoendoscopic surgery and the number of those performing it, the surgeon must remain cognizant of the uncommon complication of herniation through a previous trocar site. Herniation through laparoscopic trocar defects most often occurs as a Richter's hernia, hence its presentation can be insidious and can lead to significant morbidity. A retrospective chart review of 1300 consecutive laparoscopic cholecystectomies over 5 years was performed. An incidence of 0.77 per cent for trocar site herniations was found. All of the trocar site hernias occurred through large (> or = 10 mm) defects at the umbilical site. Ninety per cent of those patients with trocar site herniations had an umbilical hernia or midline incisional hernia found incidentally upon entrance into the peritoneal cavity. All of the herniations occurred despite primary fascial closure of the trocar sites. One trocar site hernia resulted in a small bowel obstruction secondary to an incarcerated Richter's hernia. This required a small bowel resection. Consequently, we now close trocar fascial defects in patients with preexisting hernias in a formal fashion. We recommend that trocar ports be removed under direct vision and that large fascial defects (> or = 10mm) be primarily closed. Furthermore, we recommend in those patients with incidentally found umbilical hernias that both the fascial edge and complete extent of the hernia defect be defined and then closed as a formal herniorrhaphy with interrupted nonabsorbable suture and a synthetic patch if necessary.

Bile leak following laparoscopic cholecystectomy

The incidence and significance of bile leak after open cholecystectomy have been studied. The purpose of this study was to determine the incidence and significance of postoperative bile leak associated with both emergent and elective laparoscopic cholecystectomies. One thousand four hundred patients undergoing laparoscopic cholecystectomy from July 1990 to January 1995 were retrospectively reviewed. Twenty-seven percent of laparoscopic cholecystectomies were performed urgently for acute cholecystitis. Diisopropyl-iminodiacetic acid (DISIDA) scan was used to determine the presence of a bile leak or obstruction. Also, a subgroup of 63 patients from March to May of 1992 was studied in a nonblinded prospective fashion to determine the rate of asymptomatic bile leak. The incidence of bile leak in the subgroup of 63 patients was 4.7% (n = 3). All of these bile leaks were asymptomatic and of no clinical significance. The incidence of bile leak in the remaining 1337 was 0.14% (n = 2). These bile leaks were discovered by DISIDA scan following a workup of atypical abdominal pain following laparoscopic cholecystectomy. Both of these patients underwent ERCP with papillotomy. There were no ductal injuries in the entire series. Symptomatic bile leaks following laparoscopic cholecystectomy are rare. Asymptomatic bile leaks occur infrequently and are of no clinical significance.

Small bowel obstruction following endoscopic extraperitoneal-preperitoneal herniorrhaphy

Laparoscopic hernia repair has a number of unique potential complications. These include complications of pneumoperitoneum, general anesthesia, trocar injuries and complications of small bowel obstruction related to trocar site fascial defects, intraabdominal adhesions, and reaction with the synthetic mesh. A totally extraperitoneal approach should, in theory, eliminate postoperative small bowel obstruction in that the peritoneal space is never entered. A case of small bowel obstruction following totally extraperitoneal-preperitoneal herniorrhaphy is presented.