Gallbladder Fossa Research Articles

VS 04 - HPB Laparoscopic trans-vesical approach is safe management for cholecystoduodenal fistula

Abstract Background A 71 year old female initially presented cholangitis. Her MRCP showed a distal common bile duct (CBD) stone. An ERCP was then performed which was not successful due to anatomical challenge in the form of a large diaphragmatic hernia. An elective laparoscopic cholecystectomy with IOC was performed. An incidental cholecystoduodenal fistula was found therefore the clinical decision was made to perform a trans-vesical approach to fistulogram. This showed a fistula was present and that it was not complicated further. This case shows that this approach avoided iatrogenic injury by confirming presence of the fistula and aided further surgical planning. Method Standard four-port technique with 10mm, 30-degree laparoscope. Blunt, sharp, energised and hydro-dissection were employed. The duodenum was adherent to the gallbladder body therefore a trans-vesical enterotomy was performed. Fistulogram confirmed presence of a cholecystoduodenal fistula but nil further pathology. The fistula was dissected from the gallbladder and stapled with the GIA endo- tri-staple 45 Purple. Further dissection to gallbladder to ensure clear visualisation of calot’s triangle. Basket trawl of the CBD was performed and repeat cholangiogram was clear. The gallbladder was dissected from gallbladder fossa, all gallstones were removed and 3L of wash was used to irrigate the intra-abdominal cavity. Results The patient was admitted following the procedure and was discharged on day two with PPI. She was reviewed post-operatively at 12 weeks and had no further issues. She remains well and has had no further episodes of cholangitis or hospital admissions in almost four years since the procedure. Conclusion This case shows an unexpected finding of cholecystoduodenal fistula in a planned laparoscopic cholecystectomy with IOC. It is important to note that some gas was seen in the gallbladder on initial imaging therefore indicating a possible cholecystoduodenal fistula. This trans-vesical approach with fistulogram confirmed a simple fistula and no further pathology and aided safe surgical planning. This improved patient outcomes and avoided iatrogenic injury thus providing a safer way to manage cholecystoenteric fistula. This novel approach to cholecystoduodenal fistula repair improves patient safety, length of stay and by aiding intra-operative planning and avoiding iatrogenic injury.

Primary dedifferentiated liposarcoma of the gallbladder: a case report and literature review

BackgroundLiposarcoma (LPS) is a kind of malignancy of soft tissue usually found in the retroperitoneal, limb, or neck region, and some may be detected with delayed symptoms (pain or palpable mass), and less frequently occurs in organs of the digestive system. In contrast, Dedifferentiated liposarcoma (DDLPS) is a common histological subtype of LPS. The present study reported a case of dedifferentiated liposarcoma originating in the gallbladder. Differentiated liposarcoma originating from the gallbladder is rarely reported.Case descriptionA 64-year-old female patient presented to our hospital with a painless abdominal mass. Abdominal computed tomography (CT) showed that the gallbladder had lost its normal shape, and a 9.1 cm × 7.1 cm × 12.1 cm mass was seen in the area of the gallbladder fossa and the right upper abdomen below it, which had an irregular morphology, inhomogeneous density, and nodular calcification, with marked inhomogeneous enhancement on enhancement scan. Preoperative tumor markers and liver function indicators were not abnormal. With suspicion of a giant malignant tumor of the gallbladder, she underwent a cholecystectomy combined with abdominal mass resection. After surgery, the tumor and gallbladder, were completely resected, and postoperative pathological results confirmed the diagnosis of dedifferentiated liposarcoma deriving from gallbladder. After surgery, the patient and his family refused to continue treatment. After 15 months follow-up, the patient remains asymptomatic and does not show any signs of recurrence. And she is now under continued follow - up.ConclusionsTreatment of dedifferentiated liposarcoma is still at exploratory stage, and a lack of clinical evidence for this condition might hinder access to clinical trials and studies. Currently, the treatment of choice for dedifferentiated liposarcoma remains radical resection. In the available clinical studies, there are no robust data to support clinical use of neoadjuvant and adjuvant radiochemotherapy. As with other diseases, the use of radiotherapy and chemotherapy before and after surgery may be a potential future treatment.

Our experience of laproscopic cholecystectomy with associated complications and their treatment: a study of 200 cases

Background: The aim of this study was to evaluate the intraoperative and postoperative complications of laparoscopic cholecystectomy along with their treatment. Methods: The study was conducted in a tertiary care government teaching hospital in central Gujarat, India. And conventional laparoscopic cholecystectomy was performed after all relevant investigations. Results: In our analysis of 200 cases of planned laparoscopic cholecystectomy, we have found that the median age of patients undergoing operation was 47 years. In our study, 140 (67%) of the patients were female and 60(33%) male cases. It is noted that there were more complications in male patients (OR=2.95, CI 95%, 1.42-4.23, p<0.001). The total number of complications were 60 (30%) out of which 45 (22%) were found to be intraoperative complications and rest were post operative complications. In our study, most common complication encountered was iatrogenic perforation which caused spillage of stones or bile 35 (17.5%) followed by bleeding from gallbladder fossa 12 (6%). CBD injury which is one of the most dreaded complications of laparoscopic cholecystectomy occurred in only 1 patient (0.5%). Among the post operative complications bleeding from abdominal cavity 12 (6%), bilioma 7 (3.5%) and infection of surgical wounds 4 (1.5%) were common. There was a total rate of 5% conversions to open surgery. Conclusions: Adopting laparoscopic cholecystectomy as a new technique for treatment of cholelithiasis, introduced a new spectrum of complications. Major biliary and vascular complications are life threatening, while minor complications cause patient discomfort and prolongation of the hospital stay. It is important recognizing IOC complications during the surgery so they are taken care of in a timely manner during the surgical intervention.

Active biloma and the use of hepatobiliary specific MR contrast agent.

We present a case of a woman in her 70s, with right upper quadrant pain and jaundice, who underwent laparoscopic cholecystectomy 14 days, previously. The ultrasound and computer tomography scan revealed a fluid lesion in the gallbladder fossa with intrahepatic extension. At this point a wide differential diagnosis was possible. In order to reach a definitive diagnosis, a magnetic resonance imaging exam with a biliary excretion contrast agent - gadoxetate disodium (hepatobiliary specific paramagnetic gadolinium-based contrast) was obtained, which showed a lesion with delayed, but important contrast enhancement, 4 hours after contrast injection, demonstrating leaking of bile reaching the final diagnosis of biloma. Our patient was successfully treated with ultrasound-guided percutaneous drainage.

Gallbladder fossa nodularity in the liver as observed in alcoholic liver disease patients: Analysis based on hepatobiliary phase signal intensity on gadoxetate-enhanced MRI and extracellular volume fraction calculated from routine CT data.

The purpose of this study is to further verify the concept utilizing signal intensity on hepatobiliary phase (HBP) of gadoxetate-enhanced MRI and extracellular volume fraction (ECV) calculated from CT data. Between Jan 2013 and September 2018, consecutive ALD patients who had both quadruple phase CT and gadoxetate-enhanced MRI within six months were retrospectively recruited. Those who had any intervention or disease involvement around gallbladder fossa were excluded. All images were reviewed and ECV was measured by two experienced radiologists. GBFN grades, and their HBP signal intensity or ECV relative to the surrounding background liver (BGL) were analyzed. There were 48 patients who met the inclusion criteria. There were GBFN grade 0/1/2/3 in 11/15/18/4 patients, respectively. The signal intensity on HBP relative to BGL were iso/slightly high/high in 30/15/3 patients, respectively, and ECV ratio (ECV of GBFN divided by that of BGL) was 0.88 ± 0.18, indicating there are more functioning hepatocytes and less fibrosis in GBFN than in BGL. The GBFN grades were significantly correlated to relative signal intensity at HBP (Spearman's rank correlation, p < 0.01, rho value 0.53), and ECV ratio (p < 0.01, rho value -0.45). Our results suggest GBFN in ALD would represent liver tissues with preserved liver function with less fibrosis, as compared to BGL, which are considered to support our hypothesis as shown above.

Gallbladder fossa lymphangioma encasing the common bile duct: a case report and review of the literature

Introduction: Lymphangiomas are rare low-flow lymphatic vessel malformations mostly diagnosed in childhood. Among the abdominal lymphangiomas, the gallbladder lymphangioma is a rare presentation, and only a few cases have been reported till date, of which majority were cystic lymphangiomas. Case presentation: The authors present a case of a 48-year-old female with abdominal pain and normal physical examination and laboratory findings. On the performed imaging, a multiloculated cystic lesion, located in the gallbladder fossa, was found. The patient underwent open cholecystectomy, and surprisingly, the cyst extended to the common bile duct, which was separated cautiously. The cyst was resected, and the histopathological findings confirmed cystic lymphangioma. Conclusion: The cystic lymphangioma of the gallbladder can be asymptomatic, although most of the literature has reported abdominal pain. The diagnosis of lymphangioma is complicated, especially when intra-cystic hemorrhage happens. Ultrasonography, computed tomography, and magnetic resonance imaging are usually performed. The surgical excision of the cyst and the gallbladder is the treatment of choice. Although bile duct involvement is extremely rare, it should be considered during the surgery.

Comparison of age-stratified survival outcomes of gallbladder cancers in an Indian population

BackgroundGallbladder cancers (GBCs) occur a decade earlier in India in comparison to the global occurrence, limiting the applicability of existing literature on age adjusted outcomes. MethodsPatients who underwent surgery between 01.01.2010 and 31.12.2020 for GBC were analyzed. Patients were divided into three age groups: group 1(≤40 years), group 2(41–60 years), group 3(>60 years) and their outcomes were compared. ResultsTotal of 6190 patients were treated for suspected or diagnosed GBC with a median age of 57 years. Curative resection was performed in 749 (67.9%) patients, of whom 114 (16.2%), 471 (62.9%), and 164 (21.9%) patients were in groups 1, 2, and 3, respectively. 5-year disease-free survival (DFS) [46.8% vs. 58.5%, p = 0.031] and overall survival (OS)[53.5% vs. 66.6%, p = 0.05] of group 3 were significantly lower than group 1. Patient age (HR 1.021), AJCC stage (HR 6.413), pathologic residual disease in the gallbladder fossa (HR 2.44), and extranodal tumor deposits (HR 1.762) were identified as independent predictors of poor OS. ConclusionsGallbladder cancers in the Indian population show poorer outcomes with advancing age. Higher proportion of males in the elderly group with a more advanced stage at presentation are plausible reasons for poorer outcomes.

Intraperitoneal instillation versus port-site infiltration or subcostal transversus abdominis plane block for post-operative analgesia following laparoscopic cholecystectomy

Background Although pain after laparoscopic surgery is less compared with open cholecystectomy, pain management in the first 24 to 72 h in the postoperative period is tricky and most patients complain of pain with cough, breathing and mobilization during the initial hours. The aim of this study was to evaluate the most efficacious route of analgesia in patients following laparoscopic cholecystectomy by comparing port-site wound infiltration, intraperitoneal infiltration and subcostal transversus abdominis plane block in providing post-operative analgesia following laparoscopic cholecystectomy. Methods This was an observational study performed on patients who underwent elective laparoscopic cholecystectomy at a tertiary care hospital in Mangalore. Group A received bupivacaine instilled in gallbladder fossa after removal of gall bladder before closure. Group B received Bupivacaine as an infiltration into the skin incision site (fascia, muscle, preperitoneal space) at each of the four port sites based on the length of the skin incision before closure. Group C received bupivacaine as subcostal transversus abdominis plane block under ultrasound guidance immediately postclosure. Collected data was entered in Microsoft Excel 2007 and analyzed using SPSS version 22.0 to find frequency, Mean and SD. Significance was assessed using Kruskal–Wallis test, χ 2 test and ANOVA for repeated measures. Results Hemodynamic parameters, i.e. the heart rate and mean arterial pressure were comparable at the end of 2 h and 4 h. At 6 and 8 h postoperatively however, visual analog scale was significantly better in group C compared with groups A and B. Time until the first analgesic request in group C was 359.35±45.55 min which was significantly lesser than the other two groups. Only three patients from group B had shoulder tip pain which was not seen in the other two groups. Conclusion Infiltration of bupivacaine at port sites is helpful in providing effective analgesia for upto 2 h post operatively whereas intraperitoneal instillation is both effective at meeting analgesic requirements as well as preventing shoulder tip pain. However, the substantial finding of our study is in providing further evidence to existing data that Subcostal transversus abdominis plane block can produce effective analgesia for laparoscopic cholecystectomy, effectively reduces analgesic requirement, and ensures faster recovery.

Gallstone-Associated Histopathological Changes in Liver: A Prospective Observational Study.

To assess the effect of gallstone disease on liver parenchyma and the prevalence and extent of liver pathology in cholelithiasis in our population at the Department of General Surgery, Indira Gandhi Institute of Medical Science (IGIMS), Patna. The present prospective observational study was conducted on 100 either-sex patients scheduled for open or laparoscopic cholecystectomy. In all the patients, laboratory and radiological investigations were performed. An undamaged portion of the liver edge around the gallbladder fossa was selected and held by atraumatic forceps. Using sharp scissors, around 1 cm of the liver edge was taken out and sent for histopathological examination. The mean age of the patients was 39.28 ± 13.73 years. The majority of patients were females (69%). Pain was the predominant clinical feature in 51% of the patients, followed by vomiting (21%), nausea (18%), and indigestion (10%). In 36% of cases, the liver histology was abnormal, including steatosis, fibrosis, cholestasis, portal tract infiltration, and lobular parenchymal infiltration. A significant association was found between the duration of symptoms and abnormal histology findings (P<0.0001). Gallstone disease is associated with notable alterations in liver histology, and these changes tend to be more prevalent in individuals with a prolonged duration of symptoms.

Clinical observation of gastrointestinal function recovery in patients after hepatobiliary surgery.

The liver is an important metabolic and digestive organ in the human body, capable of producing bile, clotting factors, and vitamins. To investigate the recovery of gastrointestinal function in patients after hepatobiliary surgery and identify effective rehabilitation measures. A total of 200 patients who underwent hepatobiliary surgery in our hospital in 2022 were selected as the study subjects. They were divided into a control group and a study group based on the extent of the surgery, with 100 patients in each group. The control group received routine treatment, while the study group received targeted interventions, including early enteral nutrition support, drinking water before gas discharge, and large bowel enema, to promote postoperative gastrointestinal function recovery. The recovery of gastrointestinal function was compared between the two groups. Compared with the control group, patients in the study group had better recovery of bowel sounds and less accumulation of fluids in the liver bed and gallbladder fossa (P < 0.05). They also had shorter time to gas discharge and first meal (P < 0.05), higher overall effective rate of gastrointestinal function recovery (P < 0.05), and lower incidence of postoperative complications (P < 0.05). Targeted nursing interventions (early nutritional support, drinking water before gas discharge, and enema) can effectively promote gastrointestinal function recovery in patients undergoing hepatobiliary surgery and reduce the incidence of complications, which is worthy of promotion.

Incidentally Detected Gallbladder Carcinoma: Can F-18 FDG PET/CT Aid in Staging and Prognostication?

Incidental gallbladder carcinoma (IGBC) is diagnosed in post-cholecystectomy specimens for benign indications, where the role of 2-fluro-2-deoxyglucose positron emission tomography/computed tomography(FDG-PET/CT) is not clearly defined. The present study aimed to assess the benefits of staging and prognosticating with FDG-PET/CT in IGBC. A retrospective observational study from a tertiary-care center from January 2010 to July 2020 was performed. The demographic, clinical, histopathological, and treatment-related histories were collected. FDG-PET/CT-image findings were compared with survival outcomes through telephonic follow-up. The chi-square test was used for comparing frequencies. The univariate and multivariate survival estimates were analyzed using the Kaplan-Meier analysis and the Cox-proportional hazard model, respectively. Log-rank test was used to compare the Kaplan-Meier curves. The study included 280 postcholecystectomy participants (mean age: 52 ± 11years; women: 227) of whom 52.1% had open surgery(146/280). Residual disease in the gallbladder fossa (54.8% vs. 36.6%, p = 0.002) and liver infiltration (32.9% vs. 22.4%, p = 0.05) were seen more frequently in open surgery compared to laparoscopic surgery, while anterior abdominal wall deposits were more common in laparoscopy(35.1% vs. 24%,p = 0.041). FDG-PET/CT changed the management in 10% (n = 28) of patients compared to contrast-enhanced CT. The median survival was 14months (95%CI-10.3-17.7). A higher stage of the disease on the FDG-PET/CT (loco-regional disease-HR 4.86, p = 0.006; metastatic disease-HR 7.53, p < 0.001) and the presence of liver infiltration (HR-1.92, p = 0.003) were independent predictors of poor survival outcomes. FDG-PET/CT detects residual and metastatic disease in patients with IGBC, enabling the institution of appropriate management and acting as a tool for prognostication of survival.

Supragastric lesser sac: an insidious site for surgical exploration during the debulking surgery in advanced ovarian cancer.

Metastases in the supragastric lesser sac (SGLS) are not only occult but are also barriers to complete resection of ovarian cancer. We describe a cohort of patients with SGLS disease undergoing debulking surgery. We identified all patients who underwent evaluation and eventual resection of SGLS disease as part of cytoreductive surgery for stage IIIC-IVB high-grade epithelial ovarian cancer at our institution from January 2018 to August 2022. Thirty-three of 286 patients (11.5%) underwent resection of SGLS disease. Metastases in the SGLS were identified by preoperative imaging in 4 of 33 patients (12.1%). The median peritoneal cancer index score was 22 (range, 9-33). Through surgical exploration, metastases were frequently seen in the right diaphragm (100%), hepatorenal recess (97%), lesser omentum (81.8%), left diaphragm (78.8%), supracolic omentum (75.8%), anterior transverse mesocolon (72.7%), splenic hilum (63.6%), ligamentum teres hepatis (60.6%), and gallbladder fossa (51.5%). The lesser omentum was normal in 6 of 33 (18.2%) patients, despite metastases within the SGLS. A total of 54.5% of patients underwent complex surgery (surgical complexity scores; median, 8; range, 3-14). Complete resections were achieved in 19 (57.6%) patients. No complications were related to the resection of SGLS disease. The median length of progression-free survival was 24.8 months (95% confidence interval=16.6-32.9). Metastases to the SGLS are not uncommon in advanced ovarian cancer, particularly those with widely disseminated disease. Disease in this recess is rarely identified by preoperative imaging and deserves systematic surgical exploration to attain complete cytoreduction.

A RARE CASE OF ADENOSQUAMOUS VARIANT OF GALLBLADDER CARCINOMA

The most prevalent cancer of the extrahepatic biliary tract is gallbladder carcinoma with adenocarcinoma as the most common variant while adenosquamous carcinoma of the gallbladder represents the rare variant of gallbladder cancers. We are presenting the instance of a 61-year-old woman who has complained of abdominal pain from umbilical and epigastric region and radiating towards the back since 7 days. Ultrasonography showed heterogeneously hyperechoic collection in gallbladder fossa and CECT whole abdomen showed a well defined rounded heterogenous enhancing mass lesion arising from fundus of gallbladder with adjacent liver bed suspecting neoplastic etiology. Laproscopic cholecystectomy was done under general anaesthesia. The sample was forwarded to the pathology department for histopathological analysis and diagnosis ofAdenosquamous carcinoma of gallbladder was made.

Magnetic resonance imaging findings in autoimmune hepatitis: how frequent and reproducible are they?

To determine the frequency and interobserver reproducibility of the magnetic resonance imaging (MRI) features considered diagnostic for autoimmune hepatitis. Two abdominal radiologists, blinded to pathology data, reviewed the MRI examinations of 20 patients with autoimmune hepatitis, looking for liver enhancement, lymphadenopathy, portal hypertension, and chronic liver disease. The pattern of liver fibrosis was categorized as reticular, confluent, or mixed. Interobserver agreement was assessed by calculating intraclass correlation coefficients and kappa statistics. The most common abnormal finding on MRI was surface nodularity (in 85%), followed by liver fibrosis with a reticular pattern (in 80%)-categorized as mild (in 25.0%), moderate (in 43.8%), or severe (in 31.2%)-; heterogeneous liver enhancement (in 65%); splenomegaly (in 60%); caudate lobe enlargement (in 50%); and lymphadenopathy (in 40%). The interobserver agreement was almost perfect for surface nodularity (0.83), ascites (0.89), and liver volume (0.95), whereas it was just slight and fair for the degree of fibrosis and for heterogeneous liver enhancement (0.12 and 0.25, respectively). It was also slight and fair for expanded gallbladder fossa and enlarged preportal space (0.14 and 0.36, respectively), both of which are indicative of chronic liver disease. The interobserver agreement was satisfactory for surface nodularity (the most prevalent abnormal MRI finding), ascites, liver volume, and splenomegaly. Conversely, it was only slight or fair for common but less objective criteria.

HPB P59 An evaluation of local 30-day readmissions following laparoscopic cholecystectomy

Abstract Background Laparoscopic cholecystectomy, both elective and acute, is a commonly performed operation in general surgery. Good post-operative outcomes are important for patient physical and mental wellbeing. For example, complications can result in physical harm and abdominal pain can cause distress and anxiety. Patient anxiety can also result from symptoms which may not have a clinically significant or concerning cause. 30-day hospital readmission rates post-surgery are considered by some as a measure of quality of care. This study assessed 30-day readmissions following laparoscopic cholecystectomy at our local hospital and the investigation and management of these. Methods Clinical patient data software was used to obtain the details of all patients undergoing acute and elective laparoscopic cholecystectomy over a 4 month period, from January 2022 to the beginning of May 2022. Pre-, intra- and post-operative data was collated. Post-operative data incorporated the presenting complaints, investigations and management of patients re-presenting within 30 days of discharge from our hospital. Results 150 laparoscopic cholecystectomies were performed over 4 months. There were 12 30-day readmissions (8%), 4 elective and 8 acute patients. Presenting complaints included abdominal and chest pain. Investigations included blood tests (10 patients, 83%), ultrasound abdomen (1 patient, 8.3%), CTAP or CTPA (7 patients, 58.3%), and MRCP (1 patient, 8.3%). CTPA scans were negative for pulmonary emboli. 3 patients (2%) with gallbladder fossa collections were discharged with antibiotics. 2 patients (1.3%) required re-laparoscopy and washout in theatre for bile leak (no CBD injury). 1 patient (8.3%) required ERCP for a distal CBD stone. Overall, 4 patients (2.7%) required inpatient admission. Conclusions This study found that only a third of patients reattending within 30 days required inpatient admission, which was not unexpected. However, although most patients did not require admission, arguably the investigations performed were essential to establish this. For example, although CTPA scans did not reveal pulmonary emboli, this was a necessary investigation in the post-operative obese patient with chest pain. That said, a more effective system of triage, for example face-to-face evaluation by GPs or A&amp;E doctors and avoidance of surgical referral without clinical assessment, is suggested to prevent inappropriate referrals, such as antibiotic skin reactions and wound bruising.

The Role of Hepatobiliary Scintigraphy as the Initial Investigative Modality for Significant Bile Leak following Laparoscopic Cholecystectomy

Introduction: Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak. Methods: We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments. Results: Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients. Conclusions: Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.

Open injury, robotic repair-moving ahead! Total robotic Roux-en-Y hepaticojejunostomy for post-open cholecystectomy Bismuth type 2 biliary stricture using indocyanine green dye.

Hepaticojejunostomy is currently the best treatment for post-cholecystectomy biliary strictures. Laparoscopic repair has not gained popularity due to difficult reconstruction. We present case of 43-year-old-female with Bismuth type 2 stricture following laparoscopic converted open cholecystectomy with bile duct injury done elsewhere. Position was modified Llyod-Davis position and four 8-mm robotic ports (including camera) and 12-mm assistant port were placed. The procedure included noticeable steps such as adhesiolysis, identification of gallbladder fossa, identification of common hepatic duct, lowering of hilar plate etc. Operating and console time were 420 and 350 minutes and blood loss was 100 mL. Patient was discharged on postoperative day 4. Robotic repair (hepaticojejunostomy) of biliary tract stricture after cholecystectomy is safe and feasible with good outcomes.

Cystic lymphangioma of the gall bladder: common disease at uncommon site

BackgroundCystic lymphangiomas are benign vascular malformations of lymphatic differentiation. They usually occur in childhood and are commonly seen in the head and neck region. Lymphangioma of the gallbladder is extremely rare, and only a handful of cases have been reported in the literature.Case presentationA 56-year-old female presented to the outpatient department for evaluation of right upper quadrant abdominal pain which had been bothering her for the past few months. Abdominal ultrasonography revealed an ill-defined septated cystic lesion surrounding the gallbladder (GB) which was initially thought to be a collection. However, contrast-enhanced computed tomography of abdomen showed a well-marginated fluid density lesion in the gall bladder fossa which was insinuating around the gall bladder and was encasing it. No intralesional enhancement was seen after contrast administration. MRI confirmed the well-defined, multiseptated lesion without any solid component in the gall bladder fossa encasing the GB but without any abnormal communication with the biliary tree. Therefore, a final diagnosis of slow flow lymphatic malformation was formulated. The patient underwent exploratory laparotomy, and the mass was resected en bloc with the GB. Histological evaluation was consistent with lymphatic malformation.ConclusionsGB lymphangioma is a rare entity and is difficult to diagnose. While the imaging characteristics are essentially similar to lymphangiomas elsewhere in the body, the location is peculiar and should warrant a thorough evaluation by the means of CT and more importantly MRI.

Agenesis of gallbladder-series of four cases - why it is difficult to diagnose preoperatively?

Agenesis of gallbladder (AGB) is a rare clinical entity first reported by Bergman in 1702. The incidence is about in 10–65 cases/1,00,000 population. It is seen in 1/6th cases of biliary atresia. It is of unknown etiology and is believed to be due to abnormal embryonic development. Nearly 70% cases are sporadic. AGB may be associated with other congenital abnormalities including the biliary system. The majority (nearly 50%) of the patients are symptomatic with misinterpreted signs and symptoms of cholecystitis and lands up to unnecessary surgery. Our series of four cases have male: female ratio of 3:1. Two of the cases underwent laparoscopic surgery. Among the other two, one had biliary pancreatitis due to primary calculous in the common bile duct (CBD) with upstream dilation. Other cases had chronic pancreatitis with dilated pancreatic duct and a proximal calculous close to ampulla causing proximal dilation of CBD. Two operated cases were postoperatively diagnosed by magnetic resonance cholangiopancreatography (MRCP) and the non-operated patients were also diagnosed by MRCP. Symptomatic AGB is often wrongly interpreted as cholecystitis with cystic duct obstruction or as sclero-atrophic gallbladder, therefore leading to pointless surgical interventions. In case of false-positive ultrasonography (USG) of AGB, it has been suggested that either a loop of gas-containing bowel located in the gallbladder fossa or periportal tissue and subhepatic peritoneal folds impersonate a contracted gallbladder containing gallstones. When USG reveals such reports or in cases of non-visualization in other imaging modalities, the need of additional preoperative imaging investigation must be in the surgeon’s mind such as MRCP to avoid surgery which is not at all required.

Do not get stumped: multimodality imaging findings of early and late post-cholecystectomy complications

Cholecystectomy is the most performed intra-abdominal surgical procedure in the US, with 1.2 million performed annually, and is predominantly performed laparoscopically. Although largely safe, laparoscopic cholecystectomy results in higher rates of abdominal symptoms consisting of abdominal pain and dyspepsia, which may persist or recur, collectively known as post-cholecystectomy syndrome. This article aims to (1) provide an overview of post-cholecystectomy syndrome with an emphasis on biliary complications and emergent imaging findings, (2) illustrate the spectrum of imaging findings of early and late post-cholecystectomy complications, (3) enumerate the role of various imaging modalities in evaluating post-cholecystectomy complications and address the role of selective trans-catheter coil embolization in managing bile leaks, and (4) discuss pearls and pitfalls in imaging following cholecystectomy. While common first-line imaging modalities for post-cholecystectomy complications include CT and sonography, ERCP and MRCP can delineate the biliary tree with greater detail. Scintigraphy has a higher sensitivity and specificity than CT or sonography for diagnosing bile leak and may preclude the need for ERCP. Post-operative complications include biliary duct injury or leak, biliary obstruction, remnant gallbladder/cystic duct stones and inflammation, biliary dyskinesia, papillary stenosis, and vascular injury. Subtle cases resulting in lethal outcomes, such as hemorrhage from the gallbladder bed without major vessel injury, have also been described. Cases presented will include biliary complications such as post-cholecystectomy stump cholecystitis, nonbiliary complications such as subcapsular hematoma, and normal post-surgical findings such as oxidized regenerated cellulose. Post-operative biliary complications can cause significant morbidity and mortality, and thus familiarity with the expected post-surgical appearance of the gallbladder fossa and biliary tract, as well as understanding the spectrum of complications and associated multimodality imaging findings, are essential for emergency radiologists and those practicing in the acute care setting to direct appropriate patient management. Furthermore, many of the postoperative complications can be managed by noninvasive percutaneous interventional procedures, from drain placement to cystic artery and cystic duct stump embolization.