5.8.10

One of the most difficult lap choles so far, worth remembering. A 40 years old man had been admitted two weeks before with acute cholecystitis, treated conservatively and recovered to be sent home. However, he was admitted again as he felt he had never been really free from pain. Ultrasound revealed distended gallbladder and pericholecystic fluid. LFTs within normal range. At lap chole, dense omental adhesions had to be removed diligently before the gall bladder became visible. A grasp at the fundus tore the gall bladder to reveal thick pus which was aspirated, and along with this came out a cast of a fibrinous wall of the abscess. Slow dissection led to the big Hartmann pouch the grasping of which was impossible due to the big stone stuck in it. This was opened up, the stone retrieved, broken into pieces to remove it piecemeal, and then only the neck of the gall bladder became clear. Further dissection of the area was deemed dangerous, and the neck was ligated  with vicryl 1 twice with extracoporeal knots. Thereafter, separating the wall of the gall bladder from the liver bed was another difficult task, so some of the wall was left behind with the liver, and cauterised. Removal of the big thickwalled gallbladder was not possible in one piece, so it was divided in steps into 4 pieces, each one being removed separately. The whole procedure took nearly 4 hours, but in the end was a satisfying one. Next day the patient was smiling but the surgeon aching all over.

6.8.10

Anothe difficult lap chole, but not like yesterday’s. Male patient again.

AndersonHynes pyelopasty in a young (25) female, big hydronephrotic right kidney, with 29% function on DTPA scan.

A perianal fistula, starting from under the urethra with three openings and ending near the anal verge blindly. All tracks excised.