Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
Difficult Laparoscopic Cholecystectomy-When and Where is the Need to Convert?Apollo Hospitals
Laparoscopic cholecystectomy has now become the treatment of choice for the gall bladder stone. With increasing experience, surgeon has started to take more difficult cases which were considered relative contra indications for laparoscopic removal of gall bladder few years back.
We conducted this study at our hospital and included all laparoscopic cholecystectomy done from May'08 to January'10. Total time taken in surgery, conversion rate and complication rate were analysed. Factors making laparoscopic cholecystectomy difficult were also analysed. We defined difficult laparoscopic cholecystectomy when we found -dense fibrotic adhesions in and around Callot's triangle, gangrenous gall bladder, empyma, large stone impacted at gall bladder neck, contracted gall bladder, Mirrizi's syndrome, h/o biliary pancreatitis, CBD stones, acute cholecystitis of <72 hrs duration.
Out of 206 cases done during above period, 56 cases were considered difficult. Only two cases were converted to open.
With growing experience and technical advancement surgery can be completed in most of the difficult cases. This is important because recently it is shown in literature that laparoscopic cholecystectomy is associated with less morbidity than open method irrespective of duration of the surgery.
PowerPoint presentation on Choledochal Cysts, also known as biliary cyst, uploaded by Dr. Vaskar Humagain, first presented in 31st December, 2013. This presentation contains all the information about Choledochal Cysts, the original and revised Todani classification of choledochal cysts, pathogenesis, other associated congenital anomalies, clinical features in infant and adult, management of choledochal cysts. Comments are highly welcome :)
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
etiology ,classifications of gall stones & causes,risk factors,presentations, clinical examinations ,investigations including radiological (role of ERCP and MRCP ) and serological ,treatment including surgical and non surgical ,post cholecystectomy syndrome and its management ,Iindicatrions for cholecystectomy and cholecystotomy & when to perform ,complications of gall stones ,preventions of gall stone disease
gall stone disease, etiology , pathogenesis , risk factors ,types of gall stones,clinical feature, diagnosis , medical and surgical treatment of gall stones , prevention of gall stones
In these slides we will go through the surgical anatomy of the gut,pathophysiology of intestinal obstruction, clinical presentation and management. Also we will discuss specific types of intestinal obstruction.
chronic pancreatitis , from its etiology, types, etiopathology, clinical features to management including surgical and pancreatitic enzymes supplementation. particularly the pain and surgical management are highlighted with pictures.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
5. Classfication
First – Alonso-Lez 1959
Type 1 – fusiform/saccular dilatation of CHD/CBD
Type 2 – supraduodenal diverticulam of CBD/CHD
Type 3 – intraduodenal diverticulam of distal CHD /
Choledococele
(not included intrahepatic cysts)
Caroli – 1958 described multiple intrahepatic cysts
9. Defect in maturation with ductal plate
formation
Primarily to Caroli disease
AR>AD
Ductal plate – development of intrahepatic progenitor cells
that are in contact with mesenchyme of portal vein and
then remodelled into mature duct
Defective remodelling – inflammation and ulceration of
biliary epithelium of large bile ducts – segmentally dilated –
cysts
10. Bile duct obstruction / distension in
prenatal / neonatal period
Stricture/ web / sphincter of oddi dysfunction
Distal biliary obstruction
Reflux of pancreatic juice into bile dict
Chronic inflammation and increased bile duct
pressure - dilatation
11. Pancreaticobiliary maljunction
M/C proposed theory
57-96% of choledochal cyst
Extramural junction of pancreatic and bile duct beyond the
sphincter
Long common channel outside sphincter >1.86cm(nomal
<0.46cm)
Reflux of pancretic juice – biliary cyst
12. Others
Incomplete / partial pancreatic divisum
Oligoganglionosis of neck of cyst (Hirshsprungs of colon)
Congenital biliary cysts may be diagnosed prenatally and
can be associated with biliary atresia .
Fetal viral infection may also have a role; reovirus RNA has
been isolated from biliary tissue of neonates with infantile
biliary obstruction and choledochal cysts
13. Clinical features
Vast variety of symptoms
Classical triad – female child
Jaundice
Abdo pain
RUQ mass
Infants – conjugated hyperbilrubinemia(70%) ,
faolure to thrive, abdominal mass(30%)
Adults – mimics calculous cholecystitis
16. Imaging
USG abdomen
m/c first imaging
Noninvasive , accurate for type 1 and type 5 disease
Limited to choledococeles
Type 1
Irregular hypoechoic
segmental dilated
extrahepatic bile duct
Caroli disease
Multiple cysts adjacent to
intrahepatic bile ducts
17. MRCP
Noninvasive and investigation of choice
Defines the PBMJ
Extent of cyst
Stones within pancreatic and biliary duct
Polypoid filling defects – malignancy
18.
19. ERCP
Invasive
Focussed view of PBJ through ampulla
Extraction of intracystic stones
Biopsy / brush cytology of intracystic mass
Visualise stomach and esophagus – portal
hypertension
Endoscopic papillotomy for type 3 cyst
PTC
Proximal anatomy
Obstruction to ERCP
20. Other investigation
CBC, LFT, Amylase , coag profile
Preoperative investigations
CT abdomen
Assess hepatobiliary and pancreatic anatomy
Evaluate possible biliary malignancies
Metastatic disease
Vascular encasement
21.
22. Associated hepatobiliary conditions
1. Cystolithiasis
2. Hepaticolithiasis
3. Calculous cholecystitis
4. Pancreatitis
5. Cholangiocarcinoma
6. Intrahepatic abscess
7. Cirrhosis with portal hypertension
8. Spontaneous perforation and bleeding from
erosion of adjacent vessels
23. Cystolithiasis
Most frequent
2-72% prevalence in adults
Soft earthy pigmented stones
Viscous bile - forming bile duct / cyst casts
Follows stricture at previous cystoenterotomies / cyst
remnant in head of pancreas(incomplete excision )
Cause recurrent pancreatitis
24. Hepaticolithiasis
Follows complete or partial stricture at
cystoenteric anastomosis
Proximal migration of intracystic stones
>80% of type 4 – membranous / septal stenosis
of major lobar bile duct
25. Gallbladder disease
Acute / chronic cholecystitis/ cholilithiasis
Denovo/ after treatment
Gallbladder not excised during primary surgery
for bile cysts
26. Pancreatitis
2-70% prevalence in adults
Mild and acute, often relapsing presentation
Cause
Anomolous PBJ Type II
Cysto/cholelithiasis
Mucus by metastatic epithelium of cyst
28. Cholangiocarcinoma
26% incidence
Age related with cysts disease
Early 2nd decade – 2.3% risk
30-40yrs – 14.6%
Older age – 75%
Type I, IV and V.
Hyperplasia – dysplasia – carcinoma sequence
Bile stasis and intrabiliary carcinogens
29. Treatment
Principles
Complete cholangiographic definition of extent of
cystic process and associated ductal pathology
Control of biliary infections – antibiotics >drainage
Long term follow up
30. Midline incision
Exploration to rule out
mets
Cholecystectomy and
complete cyst excisionj
Reconstruction –
mucosa to mucosa
Hepatico jejunostomy
Hepatico duodenostomy
31.
32.
33. Type I cyst
Cholecystectomy + cyst excision +
Roux en Y hepaticojejunostomy
35. Type II cyst
Cholecystectomy + Complete cyst excision
Defect needs to be closed tranversely with or
without T tube
36. Type III cyst
Unusual and lower overall rate of malignancy
Surgical excision is uncommon
ERCP with unroofing of choledochocele and
sphincterotomy of CBD
Surgery – difficult sphincterotomy / suspecting
malignancy
Transverse dudodenotomy thro 2nd or 3rd part of
duodenum
37. Type IV cyst
Cyst excision of extra hepatic cyst and Roux En Y
Hepaticojejunostomy (as type I)
IVA cysts with complicated intrahepatic bile ducts
Hilar/intrahepatic bile duct strictures
Intrahepatic stones/ abscess
Requires abnormal hepatic segment resection
IVA cysts with intraheptic cysts of both lobes liver/
cirrhosis --Transhepatic stents needs to be placed
38. Caroli’s disease
Depends on extent and presence of congenital hepatic
fibrosis , cirrhosis, and portal hypertension.
m/c localised to left ductal system
Limited to one lobe –
Without concurrent cirrhosis / fibrosis , hepatic resection
with Roux en Y cholangiojejunostomy
If not feasible – Roux en Y intrahepatic
cholangiojejunostomy to intrahepatic cyst
39. Diffuse Carolis disease
Recurrent cholangitis ,portal hypertension with
variceal bleeding and liver failure
Long term medical therapy with antibiotics,
analgesics and litholytic agents may improve
Long term transhepatic stents – recurrent
cholangitis
Hepatic transplant is the treatment of choice
40. Advantages
Magnified view
Less pain
Fast recovery
Disadvantages
Lengthy opeartion
time
Steep learning curve
Costly instruments
Laparoscopic Choledochal cyst
excision
41.
42. Summary
Choledochal cyst disease is uncommon
Most common in children , increasing in adult population
Diagnosis by cross sectional imaging promarily CT and
MRCP
Risk of malignancy in untreated patients
Majority cases can be treated with Cholecystectomy ,
cyst excision and biliary reconstruction
Long term followup surveillance for cancer cholangitis
,intrahepatic stones are necessary
43. References
Surgery for liver, biliary tract and pancreas – L H
BLUMGART
MAINGOT,S abdominal operations 12ed
SABISTON Tectbook of surgery 20th ed
Editor's Notes
In extrahepatic cyst 1 and 4a
Stenosis of major heatic ducts should be sought in hepaticolothiasis patients
Complicates further intrahepatic dilatation / abscess
Denovo leading to incidental discovery of bile duct cysts / can evolove after treatment of bileduct cyst
Type 1 - major pancreatic duct joins CBD
Type 2 – major CBD joins pancreatic duct