22.5.24

A twenty five years old tall (just more than 6 feet) young man from the local jai jawan colony had acute calculus cholecystitis, was treated with antibiotics for a week, and recovered.

At operation, found to have a very thick walled empyema, which took nearly 4 hours to complete laparoscopically.

Difficulties as usual: the omental adhesions took half an hour to clear the gall bladder. Then the fundus grasp being impossible, the gallbladder was opened up by a vertical bisection, and all stones removed from within it including the one impacted in the H pouch – picking up and removing all these stones one by one. All this took more than one hour. The grasp now being possible at fundus and H pouch, the thick walls of the big gallbladder were removed from both sides (to make it more manageable), and the gallbladder transected just above the H pouch. Dissecting behind the pouch now it was possible to make space behind it so as to pass a no 1 vicryl suture behind and ligate it just below the H pouch. As all this is done very slowly and carefully, it consumed more than one hour. The remaining gallbladder was now removed leaving some of the posterior wall alone.

Post-operatively the patient recovered very nicely and quickly and sent home in the evening.

To contrast with this, in the similar case (4 hours) done last month (19.4.24), it was not possible to make a safe space behind the gallbladder/H. pouch to pass a ligature; the fibrosis of the area was so dense (the real frozen Calot’s triangle). Hence, the case was converted to open, and a right-angle clamp used to make that space, resulting in a close shave with the underlying CBD, exposing its mucosa. Bile leak continued through the drain for nearly 3 weeks and then dried up.