Dr Mohinder Singh's blog

25-28 October

Attended ICS-IS conference at Agra.

Very poorly attended conference.

acquired viral fever there too.

29.10.07

Out of 3 lap choles, had to convert 2 to open:

In the first one, after the gallbladder had been removed, bleeding continued alarmingly, could not be located. On opening up, the bleeding was found to be from the liver bed, which was sutured with catgut.

In the second one (60 years old female, mother of a class IV employee here),  there was a CCD (cholecystoduodenal fistula) at the fundus of the gallbladder. Laparoscopic dissection had led to a tear in duodenum. On conversion to open surgery, the fistula was divided and repaired, besides repairing the iatrogenic injury too. She presented 2 weeks later with epigastric pain, S Alk Phos > 700 units. The plan of an ERCP was deferred for some time due to the repaired duodenum. However, in May 2008, at ERCP, 2 stones were extracted from the bile duct.

2.11.07

A congenital diaphragmatic (Bochdalek) hernia (CDH) in a 10 days old male child was repaired with prolene sutures. Its contents included a lot of small bowel loops, the splenic flexure of colon as well as the spleen.

50 F with previous vertical upper abdominal midline incision (for hepatic hydatids, done many years back)

Now had gall stones and pain and repeatedly raised alkaline phosphate values, so ERCP was done; this however revealed CBD to be clear and so we proceeded to lap chole. At operation, very dense adhesions were encountered right in front of the telescope starting from just above the umbilicus right to the top to xiphoid and extending to all of RUQ. All of these adhesions were lysed, taking about 45 minutes. Only then it was possible to  introduce the subxiphoid port, and other two working ports. The distal stomach’s adhesions with the liver were then sharply divided. The gall bladder was still hardly visible. A little further dissection under the liver revealed that the subcostal port was actually in the fundus of the supposed gall bladder. This was reintroduced properly and the liver was then freed from the abdominal wall and made a little mobile so that the gall bladder now could be flipped over.

After this the calots triangle was rather easy.

Drained.

4.10.07

A submandibular sialadenectomy for ch sialadenitis.

 Excision and marsupialisation of a recurred pilonidal sinus.

5.10.07

Big ovarian mass 50 F (Dr Jagga’s case). Investigated in PGI. Mass stuck firmly in pelvis, and adherent with UB, sigmoid and ureter, causing hydronephrosis. Ureter released and mass excised with difficulty, along with TAHBSOP.

Bx – undifferentiated cystadenocarcinoma.

Later sent  for chemo.

6.10.07

Wrong diagnosis. 50 M (Dr Pawan’s case) – CT diagnosis – appx abscess (CT attached).  Pt had fever and leucocytosis too. At surgery, actually a hard mass in cecum firmly fixed to parietes in the paracolic gutter. Also had deposits in right half of omentum. Right hemicolectomy with removal of omentum (right half) performed.

Bx – Adenocarcinoma.

 

8.10.07

1. A cirsoid aneurysm in a 30 years old female. Excised with great difficulty. Bled like hell despite prior ligation of both superficial temporal arteries (photos).

2. A lap varicolectomy for oligospermia in a 30 years old male.

11.10.07

TG cyst was the wrong diagnosis –  30 F with a small cystic swelling in the midline of neck. At operation, while removing the supposed hyoid bone just above the swelling opened up the trachea. Repaired the trachea with vicryl sutures. Retrospectively decided the diagnosis must have been a thyroid cyst arising from the thyroid isthmus.

An 82 years old lady (mother of Raj Dhanetha)  with GOO, visible peristalsis and palpable mobile lump in the distal stomach. UGIE (Dr Parmod Mittal) reported a malignant looking ulcer and complete obstruction; but biopsies came out to be negative.

CT suggested a 3.5 cm tumor distal stomach; no mets.

An easy and quick resection of distal stomach, duodenal stump closed and GJ done.

4th POD – had dehiscence of the abdominal wound which was resutured.

5 lap choles one after the other

Assisted a pyelolithotomy for multiple kidney stones and 26% function on DTPA scan ( NFK on IVU); one stone in upper calyx could not be taken out by the senior resident. Being easily palpable through the thinned out cortex of the kidney, it was taken out through nephrolithotomy route

 4.9.07

Femoral hernia after a long time. An old lady 65 years of age presented with obstructed hernia; at operation, the obstructed loop of ileum was found to be dusky in colour but recovered. A Low repair (Lockwood) was performed; only sutures, no mesh. The postoperative Ileus persisted for 4 days

6.9.07

Lap chole, an expectedly easy one, became difficult. A 35 years old rural male patient; thick walled GB; wide neck and cystic duct endlooped twice with vicryl. Drained. Next morning had severe upper abdominal pain, and distension and fever with TLC 17900. LFTs normal. US normal. X-ray no free air, but distended colon and minimal bilateral pleural effusion. Became rapidly normal by 2nd and 3rd postoperative day. Discharged on 4th POD. What happened? possibly  ?? pancreatitis.

13.9.07

Another femoral hernia in a 70 years old asthmatic lady from Rajpura. Another low operation (Lockwood) was performed. Contents only omentum, easily reduced; small onlay mesh to bolster sutures.

       

 

30.8.07

MRM for a 3X2 cm ca invasive ductal

pt preference

1. routine looking lap chole; 50F from MKH (had kidney stones too)

dissection immediatiely presented a clear cystic artery right in front of the camera and seen nicely dividing into 2 branches. After clipping it, dissection under could not define the junctional anatomy; looked like a wide duct or neck and so a sessile gall bladder. This neck was ligated with vicryl and divided. While dividing a lot of stones present in it aroused second thoughts of a lower lying cystic artery which was found later after some further dissection.

2. horrible empyema with thick walled gall bladder. took more than 2 hours and left the posterior wall of gall bladder intact and cauterised it 

transverse loop colostomy done 3 months back  (for a faecal fistula after TAH at Malerkotla; found at exploration to have leak from injured sigmoid and extensive faecal soiling); splenocolic ligament high and in the pelvis sigmoid colon had extensive adhesions); took nearly 3 hours. In the end a satisfactory colorectal anastomosis  

21.8.07  –  35 thin female, with h/o previous TAH at which time a mass in sigmoid was palpable; had no bowel symptoms then

at operation palpable mass in sigmoid excised with 10 cm proximal and 5 cm distal margins and EEA colorectal constructed manually

cut section of specimen showed an ulcerating lesions involving all circumference