Cholecystectomy

Ans.D. All of above

Contraindications to laparoscopic cholecystectomy include

• Coagulopathy
• Severe chronic obstructive pulmonary disease
• End-stage liver disease
• Congestive heart failure
• Currently, the major contraindication in completing a laparoscopic cholecystectomy is the inability to clearly identify all of the anatomic structures.

• Symptomatic gallstones are the main indication for cholecystectomy.

• Absolute contraindications for the procedure are uncontrolled coagulopathy and end-stage liver disease.

Prof Dr Erich Muhe of Boblingen, Germany, performed the first laparoscopic cholecystectomy in 1985. First laparoscopic appendectomy was performed in 1980 by Kurt Semm

Propofol has a rapid onset of action.

Awakening from a single bolus dose is also rapid due to a very short initial distribution half-life (2–8 min).

Most investigators believe that recovery from propofol is more rapid and is accompanied by less “hangover” than recovery from

methohexital, thiopental, ketamine, or etomidate.

This makes it a good agent for outpatient anesthesia.

Propofol’s shorter duration of action after infusion can be explained by

its very high clearance, coupled with the slow diffusion of drug from the peripheral to the central compartment.

Ref: Butterworth IV J.F., Mackey D.C., Wasnick J.D. (2013). Chapter 9. Intravenous Anesthetics. In J.F. Butterworth IV, D.C. Mackey, J.D. Wasnick (Eds), Morgan & Mikhail’s Clinical Anesthesiology, 5e.

Surgical wounds can be divided into three categories based on the amount of bacterial contamination.

Clean wounds are those in which no part of the respiratory, gastrointestinal, or genitourinary tract is entered.

Examples include herniorrhaphy and breast surgery.

Clean-contaminated wounds encompass those cases in which the above systems are entered, but without evidence of active infection or gross spillage.

Examples include elective cholecystectomy or elective colon resection with adequate bowel preparation.

Contaminated wounds are those in which there is active infection (perforated appendicitis with abscess) or gross spillage (gunshot wound with large or small bowel injuries).

While contaminated and clean-contaminated wounds require perioperative antibiotics, clean wounds need not be treated with prophylactic antibiotics.

Cholecystectomy is the definite line of treatment for patients with acute cholecystitis.

Early cholecystectomy performed within 2-3 days of presentation is preferred over interval or delayed cholecystectomy.

Surgical treatment of gallbladder carcinoma depends on tumor stage.

Simple cholecystectomy is recommended for patients with carcinoma stage T1a. 

Radical cholecystectomy is indicated in carcinoma stage T1b, T2 and T3. In this technique along with gallbladder, liver surrounding gall bladder fossa, and portal lymph nodes are resected.

Prof Dr Erich Muhe of Boblingen, Germany, performed the first laparoscopic cholecystectomy in 1985. 

Mucocele of gallbladder is one of the complication of gallstones and is caused due to obstruction of the stone at the neck of the bladder.

In course of time the bile is absorbed and replaced by the mucous secreted by the gallbladder epithelium.

Due to this gall bladder may become distended and palpable.

Cholecystectomy is done early otherwise complications like empyema, perforation and gangrene of gallbladder can occur.

Ref: Bailey & Love 24/e, Page 1106; Harrison 17/e, Page 1996.

• With the finding of carcinoma following cholecystectomy, subsequent treatment depends on the depth of penetration of the gallbladder wall and surgical margins.
• With T1a lesions, in which the carcinoma penetrates the lamina propria but does not invade the muscle layer, simple cholecystectomy should suffice for therapy.

Cholecystectomy is indicated in the treatment of mucocele of the gallbladder as empyema, perforation or gangrene can complicate this condition.

Ans:B.) Splenectomy

Howell–Jolly bodies

• They are histopathological findings of basophilic nuclear remnants (clusters of DNA) in circulating erythrocytes.
• Howell–Jolly bodies are seen with markedly decreased splenic function. Common causes include asplenia (post-splenectomy)or congenital absence of spleen.
• Other causes are radiation therapy involving the spleen, such as that used to treat Hodgkin lymphoma.
• Howell–Jolly bodies are also seen in: amyloidosis, severe hemolytic anemia, megaloblastic anemia, hereditary spherocytosis, heterotaxy with asplenia and myelodysplastic syndrome.

Ans. is ‘b’ i.e., Cholecystectomy 

• Mucocele of the Gall bladder ‑

It is one of the complications of Gall stones.

Caused due to obstruction of the stone at the neck of the bladder.

In course of time the bile is absorbed and replaced by the mucus secreted by the Gall bladder epithelium. Due to this the Gall bladder may because distended and palpable.

• Treatment

The t/t is early cholycystectomy.

–  If early t/t is not done following complications can occur‑

– Empyema

Perforation

– Gangrene

Answer is ‘d’ i.e. 55 year old with an asymptomatic gallstone

• In asymptomatic gallstones, “Prophylactic cholecystectomy is not warranted.”
• Patients with symptomatic gallstones are always candidates for cholecystectomy.
• About Gall bladder polyps:

Polyp of Gall bladder includes ‑

–             Cholesterol polyps.

–             Adenomyomatosis.

–             Benign adenomas or

–         Malignant adenocarcinoma. (Adenoma and adenocarcinoma are usually larger than 10 mm)

• Risk factors associated with malignancy in gall bladder polyps include:

–             Old age (>60 years).

– Coexistence of gall stones.

–             A documented increase in size.

–             Size greater than 10 mm.

• Management
• Cholecystectomy is done in

–                All patients with symptomatic polyps.

–                Asymptomatic polyps with any of the listed risk factors for malignancy.

Asymptomatic polyps without any of the risk factors should be monitored with follow up ultrasound studies.

• Also know
• Indications of cholecystectomy in asymptomatic gallstones.

1)       Large stone, >3 cm in diameter (because of increased risk of malignancy).

2)       Multiple small stones (more chances of passing into CBD and causing obstruction)

3)       Stone associated with polyp.

4)       Calcified gall bladder (Porcelain gall bladder).

5)       Congenitally anomalous gall bladder.

6)       Gall stones with diabetes (because emphysematous cholecystitis is common in diabetics with gall stones).

7)       Immuno compromised patients (because complication rate is high).

8)       Transplant patients (because they are on immuno suppressants).

• Few authorities are now also recommending routine cholecystectomy in all young patients with silent stones.

Ans. is ‘c’ i.e. Laparoscopy cholecystectomy immediately

Management of Acute cholecystitis

• IV fluids, analgesics and antibiotics are given initially in a pt. presenting with acute cholecystitis.
• Cholecystectomy is the definitive treatment.
• The timing of cholecystectomy was a matter of debate in the past.
• Early cholecystectomy performed within 2 to 3 days of presentation is preferred over interval or delayed cholecystectomy that is performed 6 to 10 weeks after initial medical therapy. Several studies have shown that unless the patient is unfit for surgery, early cholecystectomy is done as it provides a definitive treatment in one hospital admission & quicker recovery time.
• Laparoscopic cholecystectomy is the preferred approach
• Conversion to open cholecystectomy is made if the inflammation prevents adequate visualization of important structures. The conversion rate to open cholecystectomy is higher in the settings of acute cholecystitis than with chronic cholecystitis.
• If a patient presents late, after 3 to 5 days of illness, or in unfit for surgery, he is treated with analgesics, antibiotics and laparoscopic cholecystectomy is scheduled for approximately 2 months later. But if the patient fails to respond to initial medical therapy he would then need a surgical intervention. Laparoscopic cholecystectomy could be attempted, but the conversion rate is high and some prefer to go directly for an open cholecystectomy. For those unfit for surgery, a percutaneous cholecystostomy or an open cholecystostomy under local analgesia can be performed.
• Acute cholecystitis may progress to complications like empyema of the gall bladder, emphysematous cholecystitis, or perforation of the gall bladder despite antibiotic therapy.

Emergency cholecystectomy is the procedure of choice for these complications, if the patient can safely withstand an anesthetic. Laparoscopic cholecystectomy could be attempted, but the conversion rate to open procedure is high and some prefer to go directly for an open cholecystectomy. Occasionally, the inflammatory process obscures the structures in the triangle of Calot, making dissection and ligation of the cystic duct unsafe. In these patients, partial cholecystectomy, cauterization of the remaining gall bladder mucosa, and drainage avoid injury to the CBD. If a patient is too unstable to tolerate a surgery, percutaneous cholecystostomy (or an open cholecystostomy) under local analgesia can be performed to drain the gall bladder. Delayed cholecystectomy can then be done once the inflammation has resolved.

Answer is ‘a’ i.e. Cholecystectomy 

• Elective Laparoscopic cholecystectomy is the treatment of choice for chronic cholecystitis. Patients should be advised to avoid dietary fats and large meals while awaiting surgery.
• But diabetic patients with chronic cholecystitis should have a cholecystectomy promptly as they are at higher risk for acute cholecystitis or even gangrenous cholecystitis.
• Pregnant women with symptomatic gallstones who cannot be managed expectantly with diet modifications can safely undergo laparoscopic cholecystectomy during the r^d trimester.

Ans. is ‘a’  i.e. Symptomatic gallstones 

• The options in themselves are incomplete as explained below
• Management of GB polyp depends on various factors discribed in previous question.

Asymptomatic GB polyp without any associated risk factors is followed up

Symptomatic GB polyp or those > 1 cm in size, or associated with other risk factors undergo cholecystectomy

• Asymptomatic gall stones are usually followed up, but there are indications for cholecystectomy in asymptomatic gallstones as mentioned in a previous question.
• Asymptomatic strawberry gallbladder does not require cholecystectomy.

Strawberry gallbladder or cholesterosis is caused by the accumulation of cholesterol in macrophages within the gallbladder wall. These submucosal deposits produce a fine yellow reticular pattern on a red background of mildly inflammed mucosa, providing an appearance like a strawberry. Some of the cholesterol deposits protrude like polyps and can be detected on ultrasound. There is no well defined symptom complex linked to this entity. Although frequently an incidental finding at postmortem, it is sometimes associated with vague dyspeptic complaints, the irritable bowel syndrome or recurrent rt. upper quadrant pain.

Answer (a) Cholecystectomy with choledocholithotomy done at same sitting

Management of suspected or proven CBD stones associated with gall bladder stones

• For gallstones – laparoscopic cholecystectomy is the procedure of choice.
• For CBD stones two things can be done:

1) If the surgeon is experienced in laparoscopic techniques of CBD stone removal then both cholecystectomy and choledocholithotomy is done in the same sitting.

– CBD stones are first confirmed by an intraoperative cholangiogram

– then the stones are removed laparoscopically via the cystic duct or by choledochotomy.

2) If the surgeon is not experienced with laparoscopic methods of CBD stone removal, preoperative endoscopic sphincterotomy with stone removal and later laparoscopic cholecystectomy is done.

• Laparoscopic cholecystectomy with choledocholithotomy in the same sitting is the preferred technique (provided the surgeon is experienced)
• But one must keep in mind here that

“for elderly, poor-risk patients with gallstones and CBD stones some have recommended ERCP and sphincterotomy as the sole treatment, leaving gallbladder and stones in situ”. – Maingot’s 10/e Usually the gallstones in these patients remain asymptomatic and if need arises can be managed by cholecystectomy

Ans. is ‘c’ i.e., Radical cholecystectomy 

• Cholecystectomy should be performed for all gallbladder polyps greater than 1 cm.
• Radical en bloc resection that may include segmental or extended hepatectomy, bile duct resection, and regional lymphadenectomy should be considered in selected patients.
• For transmural disease, a radical en bloc resection of the gallbladder fossa and surrounding liver along with the regional lymph nodes should be performed.

Ans. is ‘a’ i.e. Shrunken liver

Ans. is ‘b’ i.e. Stomach

Ans. is ‘c’ i.e. 10-14 days

Ans. is ‘b’ i.e. Decreased incidence of bile duct injuries 

Ans. is ‘a’ i.e., Laparoscopic cholecystectomy 

Ans. is ‘b’ i.e., Tube cholecystostomy 

• Many of these patients are critically ill and would not tolerate the physiologic insult of laparotomy and there is an increase in morbidity.
• Accordingly, percutaneous drainage of the distended and inflamed gallbladder is carried out in patients unable to tolerate a laparotomy.
• The cholecystostomy tube used to drain the gallbladder can be placed by ultrasound or CT guidance.
• Approximately 90% of patients will improve with percutaneous drainage and the tube can eventually be removed.
• So, if patients are unfit for surgery, percutaneous, ultrasound-guided, or CT guided cholecystostomy is the treatment of choice.

Ans. is ‘a’ i.e., Elective open cholecystectomy for cholelithiasis 

Ans. is ‘a’ i.e., Just before operation 

• Preoperatively, vitamin K and fresh frozen plasma should be administered to lower the prothrombin time to less than 14-15 seconds.
• If thrombocytopenia is present, platelet infusions should be given liberally.

Ans. is ‘D’ i.e., Laparoscopic cholecystectomy operation 

• BDI may occur after gallbladder, pancreas and gastric surgery, with laparoscopic cholecystectomy responsible for 80%-85% of them.
• Patients usually complain of diffuse abdominal pain, nausea, fever, and impaired intestinal motility.
• The two most frequent features are bile leak and bile duct obstruction.
•  BDI during laparoscopic cholecystectomy is twice as frequent compared to injuries during an open procedure.

Answer is C (Most common mode of inheritance is Autosomal Recessive)

Presence of numerous Spherocytes in the blood together with a family history of Splenectomy suggests a possible diagnosis of Hereditary Spherocytosis. The most common mode of inheritance in Hereditary Spherocytosis is Autosomal Dominant (Classical Inheritance). Autosomal Recessive inheritance however may also be seen but is less common.

Coomb’s test is important to distinguish Hereditary Spherocytosis from Autoimmune haemolysis which is another common cause of Spherocytosis in the peripheral blood picture. Hereditary Spherocytosis is a coomb’s negative haemolytic anemia (non-immune mediated) while Autoimmune haemolysis is Coomb’s Positive

Hereditary Spherocytosis is characterized clinically by anaemia, jaundice, splenomegaly and pigment gall stones. Cholecystectomy is often required in patients with HS due to repeated episodes of cholecystitis from pigment bile stones. Splenectomy remains the treatment of choice for moderate to severe cases of Hereditary Spherocytosis (Since Spleen is the primary site of destruction of red blood cells and transit through the splenic circulation makes them more spherocytic thereby accelerating their death.

Answer is D (55 year old with an asymptomatic gallstone):

Prophylactic cholecystectomy is not warranted in an asymptomatic patient.

Ans. C i.e. Clean & contaminated

The recovery of tensile strength results from the excess of collagen synthesis over collagen degradation during the first 2 months of healing, and, at later times, from structural modifications of collagen fibers (cross-linking, increased fiber size) after collagen synthesis ceases.