Medical Journal of The Islamic Republic of Iran (MJIRI)

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Torsion of the gallbladder with gangrene is a rare condition which is generally due to an abnormal anatomical variation of the organ i.e., loss of fixation of the organ to the inferior margin of the liver and the presence of a long meso cyst. The case considered is a seven year old boy who presented with acute abdominal pain. He underwent laparotomy 36 hours after having sustained blunt abdominal trauma. Operation was limited to cholecystectomy and removal of a gangrenous gallbladder which had undergone torsion. The postoperative course was uneventful.

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 Abstract

 Acute inflammation of the gallbladder can occur without gallstones. Acalculous cholecystitis typically develops in critically ill patients in the intensive care unit. Patients on parenteral nutrition, with extensive burns, sepsis, major operations, multiple organ trauma or prolonged illness with multiple organ system failure are at risk for developing acalculous cholecystitis. The association of acalculous cholecystitis with Mirizzi syndrome is very unusual. Mirrizzi syndrome, which is an unusual cause of obstructive jaundice, is most commonly caused by a stone impacted in Hartmann’s pouch, exerting pressure over the common bile duct (CBD) with subsequent erosion into the CBD. The case we are presenting is a case of Mirrizi syndrome type-1 due to acalculous cholecystitis in a 13- year-old girl that presented with intermittent jaundice and RUQ abdominal pain and fever. Intraoperative finding showed Mirizzi syndrome type- 1 without gallstones. The cause of jaundice was only pressure of the gallbladder on the CBD and cholecystectomy with intraoperative cholangiography was performed. At post operative follow-up, the patient became anicteric and all symptoms and signs disappeared.

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 Backgrounds: There are controversies among surgeons about prophylaxis of deep vein thrombosis (DVT) in laparoscopic cholecystectomy. The aim of this study was the assessment of patients’ condition after laparoscopic cholecystectomy without any prophylactic measure.

 

Methods: 100 cases of laparoscopic cholecystectomy without DVT prophylaxis were followed by duplex scanning in the first postoperative day and by physical examination and patient history at the first to second postoperative week however no clinical sign was found for DVT.

 Results: Only one case of partially thrombosis (1%) was found by duplex scanning which was managed conservatively.

 

Conclusion: Laparoscopic cholecystectomy may consider as a low-risk procedure and routine prophylaxis may not be justified in the absence of other risk factor.

 

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    Background: Given the importance of patients’ pain after laparoscopic surgeries, this study was conducted to compare the effectiveness of intraperitoneal bupivacaine, acetazolamide, and placebo on pain relief after laparoscopic cholecystectomy surgery.
   Methods: Patients admitted to Rasool Akram hospital with physical status I or II, based on the American Society of Anesthesiologists (ASA) system, who were candidates for laparoscopic cholecystectomy surgery due to gallstones, were included in this study. Patients were divided into 3 groups (each group containing 20 patients) using block randomization with foursome blocks. Group 1 received bupivacaine, group 2 acetazolamide, and group 3 intravenous saline as placebo. After surgery, pain score was assessed by visual analogue scale, and shoulder pain and analgesic doses were also measured. The mentioned parameters were assessed at 1, 4, 8, 12, and 24 hours after surgery.
   Results: In this study, 60 patients were included in 3 groups. The mean pain recorded (VAS) at 1, 4, and 8 hours after surgery was not significantly different between acetazolamide and bupivacaine groups, but their score was significantly lower than the placebo group (p<0.05). However, the score recorded at 12 and 24 hours after surgery was not significantly different between the 3 groups (p>0.05). Mean of pain reliever (acetaminophen) injected to the patients when needed was not significantly different among the 3 intervention groups (p<0.05). The highest prevalence of shoulder pain (70%) belonged to the placebo group and the lowest (25%) to acetazolamide (p<0.05). Mean heart rate, systolic blood pressure, diastolic blood pressure, and the respiratory rate were not significantly different among intervention groups in 1, 4, 8, 12, and 24 hours after surgery (p>0.05).
   Conclusion: According to the results, acetazolamide and bupivacaine injection reduced pain in early hours after laparoscopy. However, pain intensity was not different between intervention groups and the control group after 12 hours, so re-prescription seems to be appropriate at this time. Acetazolamide injection significantly reduces shoulder pains after surgery.
 
 

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Background: Low pressure laparoscopic cholecystectomy has been advocated due to reduction in postoperative pain, ventilation problems, hemodynamic complications, and potential for reduction in surgical events. No reported data have been found focusing on the effects of low-pressure laparoscopic cholecystectomy on intracranial pressure (ICP). The aim of this study was to investigate the effect of low-pressure laparoscopic cholecystectomy on intracranial pressure measured by optic nerve sheath diameter (ONSD) in Imam Hossein Medical Center, Tehran, Iran.
   Methods: The patients classified as American Society of Anesthesiologists physical status I or II undergoing elective laparoscopic cholecystectomy due to benign gallbladder disease were randomly assigned to low-pressure laparoscopy (LPL) group or normal pressure laparoscopy group (NPL). ONSD was measured at 3 different times: (1) before induction of anesthesia; (2) after initiation of gas insufflation; and (3) after the termination of gas insufflation. The collected data were entered into SPSS software (V 24). Data were demonstrated with frequency (percentage) or mean ± standard deviation. We used the Mann-Whitney test to compare the means of continuous variables. The Friedman test was used to compare the mean of variables over time in each of the 2 groups. The significance level in all analyses was considered at ˂0.05.
   Results: ONSD after the termination of gas insufflation was significantly lower in the LPL group with the mean of 4.97±0.83 mm than the NPL group with the mean of 5.62±1.32 mm (p=0.018).  ONSD before induction of anesthesia or immediately after gas insufflation did not differ significantly between LPL and NPL groups. Duration of anesthesia and surgery, mean arterial pressure, the total dose of propofol (p=0.600), and fentanyl (p=0.201) did not show significant differences between the 2 groups.
   Conclusion: ONSD was lower with low-pressure laparoscopic cholecystectomy after the termination of gas insufflation, which emphasized the neural protective effect of low intraperitoneal pressure. Further studies are needed to evaluate this diagnostic tool in different populations, especially in patients with increased ICP undergoing laparoscopic interventions.