19.10.22

lesson 1. Gallbladder tightly packed with small stones is better emptied of all its stone burden to make dissection easier and safer:

A 55 years old lady was admitted for lap chole after a 3 days hospitalization in some other hospital for acute pancreatitis from which she had recovered. The fact that the gallbladder was tightly packed with stones was not apparent by the look of the gallbladder, but the dissection of the cystic duct and its clipping took a long time due to small stones in it which had to be milked up repeatedly. During dissection of the gallbladder from its liver bed, its wall ruptured spilling hundreds of stones, and when all stones were removed, it was realized if we could have done that intentionally before dissection of the cystic pedicle, it would have made the procedure more safe and easy, and perhaps taking lesser time than it took otherwise.

lesson 2. A Kocher clamp with stout teeth can be very helpful in breaking big hard stones:

A lap chole in a 60 years old lady was rather easy as far as the dissection was concerned, but the single big stone (2.7 cm) caused problems in taking out the gallbladder through the epigastric port. It could not be broken into pieces with the usual ovum forceps or the bigger clawed instruments, but then the scrub nurse suggested to use the long Kocher clamp’s sharp teeth, which were eventually able to break the stone into pieces, so as to remove it without enlarging the port.