Dr Mohinder Singh's blog

15.7.24

A difficult lap chole had to be performed in a 17 years old young man with acute cholecystitis. At operation, thick pus had to be aspirated to grasp the fundus, and thereafter the stone had to be disimpacted to make dissection easier. Even then the cystic duct junction with the bile duct could not be defined. The gallbladder neck was just ligated under the H. pouch and gallbladder removed.

13.6.24

A 65 years old female (Labh Kaur c/o Gurmukh Singh, ex employee RHP) presented with pain in the upper abdomen and fever for the last 15 days, and a tender palpable gallbladder. Her TLC was 16800 with 82% neutrophils. Recovered with antibiotics. LFTs were within normal limits. US and CT showed a dilated gallbladder and dilated EHBD system with CBD of 20 mm diameter, with circumferential thickening of its wall. The CT also reported a narrow intrapancreatic CBD. Suspecting an obstructive pathology (Ca head of pancreas), she was referred to PGI where she was investigated extensively. The pancreas did not have any tumor, and the CA 19.9 was 5.2 (within normal limits). The MRCP reported proximally dilated (16 mm diameter) CBD with short segment of tapering at the level of its junction with pancreatic duct. The junction of PD and BD was seen outside the duodenal wall in the head of pancreas, with the formation of a common channel of length 1.8 mm suggesting pancreaticobiliary maljunction. The common channel was also reported to be prominent in caliber (8 mm diameter). Since her symptoms had already resolved with a short course of antibiotics, she was sent home, to be just observed in the future for any recurrence of symptoms.

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.

4.5.24

An elderly patient (c/o Gurmukh Singh, ex-employee, gynae), 70 years of age, presented with epigastric and RUQ symptoms, with previous history of open cholecystectomy 2 years back at Malerkotla civil hospital through a small incision (so-called mini-lap).

The ultrasound scan, however, still showed a smaller rounded gallbladder.

An MRCP was obtained for local biliary anatomy.

At lap chole, dense omental and colonic adhesions took time to safely dissect off the top of the gallbladder which came into view only at the middle of the gallbladder fossa.
Thereafter, the going was easy. It was a small rotund residual gallbladder, suggesting the upper half had been removed (partial cholecystectomy).

2.4.24

A 45 years old lady presented with a big painful swelling below the umbilicus which was diagnosed clinically as PUH, possibly obstructed. At operation instead, the swelling turned out to be a chronic abscess full of thick pus. Further exploration showed a foreign body emerging out of a small hole in the rectus sheath, and on enlarging the opening in the sheath, a full sized abdominal pack could be pulled out (gossypiboma), possibly retained during TAH on 9.11.23. The drain continued to drain thick pus for 3 weeks and then dried out, with full recovery.

19.4.24

Lap chole in a 50 years old female turned out to be very difficult due to dense fibrosis in the Calot’s triangle. She had a very big stone (34 mm on US) impacted in the neck of gallbladder, the stone was disimpacted and removed. Still no safe progress could be made in dissection of the area due to dense fibrosis, and the case was converted to open after 2 hours.
At open operation, the thick mass at the neck of gallbladder could be separated from the underlying bile duct which however was denuded to expose the mucosa which appeared to be intact. The drain, however, continued to drain bile for a little more than 3 weeks and then dried out.

8.3.24

A 38-year-old lady (Dr Rajni’s patient) presented with a long-standing (more than 6 months duration as per history) inflammatory mass in the left breast – never actually resolving despite prolonged antibiotic treatment and diagnosed clinically as an antibioma. This mass (along with a sinus which had developed recently) was excised under general anesthesia. The biopsy report surprisingly came out to be tuberculosis.

Was referred to TB hospital for medical treatment of tuberculosis. There she was put on anti-tubercular drugs, starting with 4 drug combination for first two months.

22.12.23

A 35-year-old female presented with features of pyloric stenosis/GOO (gastric outlet obstruction) due to chronic peptic ulcer, confirmed on endoscopy, for which a retrocolic gastrojejunostomy was performed. Also, her chest x-ray revealed eventration of diaphragm, for which the diaphragm was plicated with running layers of 1-0 prolene sutures.

25.1.24

A very difficult lap chole was done in a 60 years old male, with history of choledocholithiasis (ERCP showed a meniscus sign) too, for which ERCP clearance had already been done. The procedure took 3 hours, the Calot’s triangle was all fibrotic. Fundus first dissection up to the neck of gallbladder was done and the neck ligated below it with vicryl.

27.9.23

A 28 years old male patient (related to an employee of saket hostpital) presented with torticollis since childhood, with severe deformity of neck and face. The neck X-ray revealed scoliosis, making intubation for anesthesia difficult.

A bipolar sternocleidomastoid tenotomy was performed, and a cervical collar given.

21.10.23

During dissection for a big right inguinal hernia, it was found that the big omentocele was adherent to the testis and appeared to be going into the testis. And indeed, the capsule of the testis had to be incised to deliver the omentum from within the testis.

28.11.23

During a difficult dissection in a lap chole, cautery dissection lower down on the Hartmann pouch resulted in a tiny perforation which resulted in a bile leak for a week.

19.6.2023

RIH indirect hernia repaired in an obese 50 years old male patient. The indirect which was ligated and excised as usual. Also had a big lipoma in the canal quite free from the cord – unusual. This was excised too.

20.6.23

Urethral caruncle in an elderly 65 years old female had caused urinary obstruction and stricture of the distal urethra. Was catheterized after excision of the caruncle and urethral dilatation.

30.6.23

Mesh removal in a 67 years old male (brother of Cheema Sahib Singh) following meshalgia and a chronic sinus developing after a hernia repair in 2022. The mesh was removed with difficulty. The wound developed a hematoma and infection for which the nonhealing wound was laid open on 16.7.23. After this, the wound gradually healed.

9.7.23

A difficult lap chole in a diabetic and hypertensive 55 years old male took more than 2 hours but was eventually successful when the gall bladder was emptied of the big stones first, and the big Hartmann pouch was lifted high up to reveal a fibrotic calot’s triangle. Dissection starting higher up from the left could achieve a plane of dissection behind the neck of gallbladder, at which level it was ligated with vicryl. Earlier attempts at dissecting from the right on the H. pouch were not successful.

19.5.23

A 76 years old rural lady had undergone brain aneurysm clipping at PGI in 2010, when the craniectomy bones were kept in a subcutaneous pocket in the thigh. She never reported back there for removal of these bones from the thigh, and forgot about them. Now after 13 years she presented at TNH with a large palpable swelling over the thigh with a discharging sinus. The bones were removed and the wound which had a large collection of serosanguinous fluid cleaned and debrided of several areas of inflammatory granulations, drained and sutured.

27.5.23

A large paraumbilical hernia (supraumbilical) repaired with mesh in a 62 years old hypertensive, diabetic and obese lady (w/o Ranjit S Bhullar). The incarcerated omentum looked like gut loops, eventually dissected out completely and excised. Drain removed after 5 days, but the wound continued to discharge and took exactly a month (till 27 June) to dry up.

An attempted APR (case of Dr Sukhpreet) was abandoned in favour of palliative sigmoid loop colostomy in a 60 years old male patient, who had a big mass in the rectum diagnosed as GIST (spindle cell type) on biopsy. At exploration, the mass was found to be immobile, with vascular angry-looking surface; and the resection was abandoned. The sigmoid colon was found to be large and fixed in the right side; so had to be mobilised and and a loop colostomy made in the RIF.