Wednesday, November 24, 2010

CASE : Eventration of diaphragm with Gastric Volvulus (stomach and spleen herniated via defect )

40 yrs female
with chronic epigastric pain and full ness.
Unfortunately got operated before 2 days for Lap. Appendectomy.
presented with persistent vomiting and severe epigastric pain

CECT reveled : Eventration of diaphragm with Gastric Volvulus (stomach and spleen herniated via defect )

1. De rotation of stomach.
2.  Plication of diaphargm
3. Seromascular GJ ( Pseudo GJ: for fixation was done)

Thursday, November 18, 2010

Open Pancreatic Necrosectomy in the Multidisciplinary Management of Postinflammatory Necrosis

Hepatobiliary Surgical Unit, †Department of Radiology, and ‡Critical
Care Unit, Manchester Royal Infirmary, Manchester, United Kingdom.

Objective: To examine clinical outcome in a consecutive cohort of patients undergoing open necrosectomy for postinflammatory necrosis. Background Information: The last decade has witnessed major developments
in the surgical management of pancreatic necrosis. Minimally invasive approaches have become established. However, there are limited data from contemporary open necrosectomy, in particular where multidisciplinary care and aggressive interventional radiology are used. This report provides data on outcome from open necrosectomy in a tertiary referral Hepatobiliary unit over the last decade.
Methods: During the period January 1, 2000 to July 31, 2008, 1535 patients were admitted with a final discharge code of acute pancreatitis. Twenty-eight (1.8%) of all admissions underwent open surgical necrosectomy. Twentyfour (86%) were tertiary referral patients.
Results: The median APACHE II score on admission was 10.5 (5–26). Median logistic organ dysfunction score on admission was 3 (0–10). Median LODS score after surgery was 2 (0–8). Twenty patients (71%) underwent radiologically guided drainage of collections before surgery. Thirty-day mortality occurred in 2 (7%), 4 further deaths occurred in patients after discharge from intensive care resulting in a total of 6 (22%) episode-related deaths.
Conclusions: Modern open necrosectomy can be performed without the procedure-related deterioration in organ dysfunction associated with major debridement. Multidisciplinary care with an emphasis on aggressive radiologic intervention before and after surgery results in acceptable outcomes in this cohort of critically ill patients. Newer laparoscopic techniques must demonstrate similar outcomes in the setting of stage-matched severity before wider acceptance.

    (Ann Surg 2010;251: 783–786)

Sunday, November 14, 2010

CASE: Abdominal tuberculosis with blown out appendicular stump

Past history: 60 Yrs male operated once for minimal peritonitis in  third week of oct (out side surat).---developed burst abdomen 1 week later---operated for closure of burst... ------went well  started on orals ....passing stool....

Once again developed features of peritonitis and respiratory distress... Rt sided ICD was kept and drained 1.5 liters of fluid... CECT abdomen showed gross free gas
and TLC was rising ...

It was decided to operate up on and found to have mesenteric thickning and multiple peritoneal nodules.... (probably missed in previous surgery) + free gas...pus pockets and bilio enteric  leakage....gross adhesions in abdomen as it was third surgery in 18 days...for a 100 kg fatty man.

I found appendicular stump blown out----- transfixed and proxymal diverting loop ileostomy done along with mesenteric noduler biopsy....

pt on venti for 5 days ---- now on oral diet in room...walking.. talking.. Ileostomy functioning healthy...AKT started. patient ready for home care in few days...

Histology: suggestive Caseating Granuloma s/o TB

IFT going through appendicular stump

Tuesday, November 2, 2010

CASE: Retro peritoneal per cutaneous approach for Pancreatic necrosis

necrosis from splenic hilum to pelvis


Follow Up CT with
minimal residual collection

drainage tube
minimal amount of collection
 after 5 days on follow up CT
thats what patient is caring now at home .
no other incision

Current status of minimally invasive necrosectomy for
post-inflammatory pancreatic necrosis
Benoy Idicula Babu & Ajith Kumar Siriwardena
Hepatobiliary Surgical Unit, Manchester Royal Infirmary, Manchester, UK
Objective: This paper reviews current knowledge on minimally invasive pancreatic necrosectomy.
Background: Blunt (non-anatomical) debridement of necrotic tissue at laparotomy is the standard
method of treatment of infected post-inflammatory pancreatic necrosis. Recognition that laparotomy may
add to morbidity by increasing postoperative organ dysfunction has led to the development of alternative,
minimally invasive methods for debridement. This study reports the status of minimally invasive necrosectomy
by different approaches.
Methods: Searches of MEDLINE and EMBASE for the period 1996–2008 were undertaken. Only studies
with original data and information on outcome were included. This produced a final population of 28
studies reporting on 344 patients undergoing minimally invasive necrosectomy, with a median (range)
number of patients per study of nine (1–53). Procedures were categorized as retroperitoneal, endoscopic
or laparoscopic.
Results: A total of 141 patients underwent retroperitoneal necrosectomy, of whom 58 (41%) had
complications and 18 (13%) required laparotomy. There were 22 (16%) deaths. Overall, 157 patients
underwent endoscopic necrosectomy; major complications were reported in 31 (20%) and death in seven
(5%). Laparoscopic necrosectomy was carried out in 46 patients, of whom five (11%) required laparotomy
and three (7%) died.
Conclusions: Minimally invasive necrosectomy is technically feasible and a body of evidence now
suggests that acceptable outcomes can be achieved. There are no comparisons of results, either with
open surgery or among different minimally invasive techniques.

DOI:10.1111/j.1477-2574.2009.00041.x HPB 2009,

Monday, November 1, 2010

CASE: Choledochal cyst(CDC) type 4 a--> excision and Hepatico Jejunostomy 1.11.10

post op

Choledochal cyst type IV a
with dilatation in Rt ductul system

CDC disection, diameter of CDC was 2.6 cm
with classical intra pancreatic tapering

dissection till the lower tapering

2.6 cm size CDC looped

lower end divided in intrapancreatic
portion and closed

single layer hepatico jejunostomy
after division at the upper end at hilum