Dr Mohinder Singh's blog

18.10.20

An interesting encounter with gall stone disease: A 55 years old female (mother of Neetu, worker in OT of Shalley hospital), obese and diabetic and hypertensive was known to be carrying gall stones for many years. She landed up in septic shock (cholangitis) and severe pancreatitis and jaundice. Was luckily resuscitated and survived. An urgent ERCP (dr Atul) and stone extraction and stenting the bile duct followed. She reported passing her stent per rectum about 3 weeks later. Luckily the subsequent lap chole was not very difficult.

28.11.20

Another lesson in lap chole: an apparently easy lap chole (as per dr Jagga’s opinion) in a 55 years old female turned out to one of the most difficult and took more than 3 hours. First of all, the duodenum was adherent high up to the fundus which was very thick walled. This was carefully dissected safely. Next the cystic duct was thick walled and friable and the vicryl ligature cut through. Luckily the stump then could be clipped with two large clips. Thirdly, when beginning the dissection of the gall bladder it appeared as if the infundibulum was actually below where the cystic duct had been clipped. But by careful further dissection a safe plane behind the gall bladder could be created and what looked like the infundibulum was actually an large cystic lymph node (fallacy of perception).

27.7.20

Open cholecystectomy and CBD exploration after 4 failed attempts to clear the duct endoscopically, including two in the PGI.

5.9.20

An unusual encounter with a a femoral hernia in 60 years old male (s/o old retired laundry incharge RHP) who had been diagnosed as irreducible inguinal hernia. It actually turned out be not inguinal but femoral and mesh repair could be done through the inguinal incision itself.

7.10.20

A lap chole in a 45 years old male had to be converted due the the thick and big omental cake inseparably adherent to the thick walled gall bladder and duodenum. Even at open surgery, the procedure turned out to be very difficult due to dense adhesions around the Calot’s triangle.

16.10.20

Huge bilateral sliding inguinal hernias in an elderly gentleman (related to dr KD Singh, ex-principal GMC Patiala) who was carrying these hernias for more than 10 years. Took more than 2 hours for the bilateral mesh repair.

11.6.20

Called by dr Vikram while operating for right undescended testis in a 25 years old male but unable to find the testis in the inguinal canal.

The testis was easily located in the abdomen laparoscopically and removed laparoscopically through the inguinal incision already made.

22.7.20

An apparently easy lap chole became difficult due to two unforeseen problems – firstly due to the gall bladder being intrahepatic and secondly due to the small stones stuck in the fibrosed neck above which the gall bladder apparently narrowed down to the calibre of the cystic duct.

The first problem (the intrahepatic gall bladder) led to difficult and bloody dissection of the cystic artery which was eventually controlled. The second problem caused a fallacy of perception giving the appearance of the cystic duct to the infundibulum of the gall bladder. The dissection here too became very difficult and led to a tear in what was taken to be the cystic duct. A reappraisal of the thought process led to some dissection very low down and deep down to eventually find the real cystic duct just below the fibrosed neck of gall bladder with small impacted stones in it.

Just another example of visual fallacy of perception that so often causes trouble in lap chole.

15.5.20

A 50 years old male with a history of recurrent abdominal pain was diagnosed with gallstones and multiple lipomas in the terminal ileum on CT scan. After lap chole by Dr Vikram, a lower limited laparotomy was performed to discover an ileoileal intussusception and the segment of terminal ileum was excised. Cut specimen showed multiple benign looking masses.

16.3.20

A 12 years old male child was operated in the left groin on the suspected diagnosis of a hematoma (history of trauma and diagnosed on ultrasound). Actually turned out to have a nice encysted hydrocele of the cord which was excised, after disconnecting its connection with the processus vaginalis. Dr Jagbir’s case.

15.11.19

A 50 years old male presumably with a popliteal cyst in the left popliteal fossa turned out to have a neurofibroma actually.

A big lipoma of the thigh resected at GSMCH in a 55 years old man.

3.12.20

A spigelian hernia in the left lower abdomen just above the previously repaired inguinal hernia, repaired with mesh – the patient a 70 years old man Narinderpal singh. Previously operated also for similar right sided spigelian hernia by me some 7 or 8 years back, that side also having had a previous inguinal hernia repaired more than 20 years back. Thus this unfortunate man had 4 lower abdominal and inguinal hernias all of which had to be repaired.

27.1.20

An MRM of the left breast was performed for multicentric lobular carcinoma in a 45 years old female. Dr Jagbir’s case.

17.8.19

A routine lap chole in a 55 years old female turned out to be unexpedtedly difficult, resulting in considerable bleeding from the liver bed. This was controlled with cautery and pressure with gauze, and several pieces of gelfoam were later pressed into the area. Discharged the next day, had to be readmitted on 19.8.19 with abdominal distension. Treated as ileus with IV fluids and recovered by 21.8.19.

2.9.19

Another lap chole case had to be readmitted on 4th PO day for severe abdominal pain, possibly pancreatitis. resolved with conservative treatment in 2 days.

23.9.19

Another lap chole landing up in trouble. A young 30 years old male underwent a very difficult lap chole due to the frozen Calot’s triangle and a very thick walled gall bladder. Postoperatively had a bile leak which was 200 cc on the first postoperative day and then continued to decrease in amount gradually drying up in 18 days. MRCP shown below reported a small collection and a ? kink and narrowing at the site of cystic duct-CBD junction. Was it a cystic duct blow-out?

24.9.19

Cystogastrostomy and cholecystectomy in a 65 years old female who was admitted more than 2 months back in ICU for severe pancreatitis. Had developed a big pseudocyst which continued to persist and cause pressure symptoms.

A lot of necrotic debris was also removed from the depth of the pseudocyst cavity.

9.10.19

An attempted lap chole in an 85 years old man (Dr NP Singh’s case) was abandoned, due to dense adhesions and the liver being very hard and cirrhotic with innumerable nodules on its surface.

13.4.19

An atypical Fournier’s gangrene had resulted in perianal sepsis. The patient, a 50 years old male, first presented with pain and tenderness in the scrotum. There was a palpable crepitus in the scrotum – pneumoscrotum. CT scan showed a lot of gas in the scrotum.

The patient was treated with antibiotics and the pneumoscrotum gradually resolved but the patient developed a soft urethral stricture which was dilated.

Also he developed a perianal abscess which was drained. However, this eventually ended up in a complex horse-shoe fistula which was excised.

22.4.19

A supposed hydrocelectomy had to be converted into orchiectomy. Dr jagbir’s case. Hard testicular tumor with necrotic areas.

6.6.19

Called for strangulated right inguinal hernia in a 70 years old male Dr Vikram’s case). REEA of about 6 inches length of gangrenous ileum had to be done.

21.6.19

A huge recurred dermatofibrosarcoma of the left thigh in an elderly female was excised followed by skin grafting of the defect.

25.6.19

Sacrocolpopexy for vault prolapse. Previously had laparoscopic hysterectomy 20 years back at Doraha. (Dr Arora’s case).

26.6.19

Nephrectomy for non-functioning left kidney (due to stones of many decades standing) in a 68 years old female from himachal pradesh.

18.7.19

Sigmoid colon cancer resected with colorectal anastomosis. the adherent ileal loops as well as the adherent part of anterior abdominal wall excised too along with the colon cancer. A colorectal anastomosis and an ileo-ileal anastomosis had be made.

19.7.19

Laparotomy for recurrent episodes of small bowel obstruction in a 58 years old man. At operation, a stricturing tumour of the ileum was found. This was excised and EEA performed. Biopsy report was GIST.

8.4.19

A hefty tall 55 years old with opium addiction and depression (on treatment with anti-depressants) was hospitalized with acute abdomen and was found to have acute cholecystitis and a big distended thick walled gallbladder with a huge stone (around 5 cm) in it. He also had fecal impaction which was treated with enemas. Laparoscopic cholecystectomy was not considered and an open operation was planned. Even then, the big empyema and the difficult dissection of the Calot’s triangle took more than 2 hours.

Photos clicked by Dr Jasleen.

13.4.19

A similarly hefty and tall male patient, also an opium addict, underwent a similarly difficult procedure. However, the gall bladder and the stone were not so big and so the laparoscopic cholecystectomy was comparatively an easier option. Also, this patient was not depressed and psychotic like the previous patient  and so was not difficult to manage postoperatively.

6.4.19

A young fit man (had been obese and now into fitness programme) with big bilateral gynecomastia. Excised like bilateral mastectomy under GA.