Browsing by Author "Joshi, M R"
Now showing 1 - 3 of 3
Results Per Page
Sort Options
Publication Biliary Complications after Laparoscopic Cholecystectomy(Nepal Health Research Council, 2011) Koirala, U; Subba, K; Thakur, A; Joshi, M R; Thapa, P; Singh, D R; Sharma, S KBackground: The reported prevalence of biliary tract disruption following laparoscopic cholecystectomy has ranged from 0% to 7% in early reports. Bile leaks are the most common biliary complication of laparoscopic cholecystectomy. Methods: Total 530 patients who had undergone laparoscopic cholecystectomy from January 2004 to November 2006 at Kathmandu Medical College Teaching Hospital were studied for biliary complications after laparoscopic cholecystectomy. Results: We reviewed 500 laparoscopic cholecystectomies performed at our institution and found 13 cases of bile extravasation and/or biloma formation and/or bile duct injuries (prevalence, 2.6%). One bile duct transection was acutely recognized and treated with hepaticojejunostomy. Three lateral bile duct injuries were also acutely recognized, two of them were managed with primary repair of CBD without T tube and the other was managed with repair and T-tube drainage. Two patients had postoperative generalized biliary peritonitis, one of whom was undergone exploratory laparotomy and found to have lateral injury on CBD which was managed with repair and T-tube drainage, whereas the other was undergone diagnostic laparoscopy with clipping of duct of Lushka. Two patients presented within seven days with biloma, one was treated with percutaneous drainage alone, the other treated with percutanous drainage was found to be complete transection of CBD on subsequent ERCP and managed with late hepaticojejunostomy. One patient with continued bile leak from surgical drainage tube for more than one week was managed with ERCP, diagnosed to be bile leak from duct of Lushka, managed by sphincterotomy and bile duct stenting. One patient presented with obstructive jaundice 6 months after laparoscopic cholecystectomy was found to have Bismuth type II bile duct stricture and was undergone hepaticojejunostomy. The remaining three had bile leak from surgical drainage which resolved within one week without further complication. Conclusions: Laparoscopic cholecystectomy appears to be associated with a higher incidence of bile duct injury than previous reports of open cholecystectomy. Possible explanations include variant anatomy plus failure to obtain an operative cholangiogram, inadequate dissection, injudicious use of cautery or clip placement, inherent limitations of the procedure, or the learning curve associated with a new technology. Key words: biliary tract, laproscopic cholecystectomy.Publication Laparoscopic Primary repair of Common Bile Duct: Does the Suture Size Matter?(Nepal Health Research Council, 2011) Joshi, M R; Sharma, S KBackground: Laparoscopic common bile duct exploration and primary closure is being popular method of management for common bile duct stone. As the standard method of procedure is yet to be established, we have compared the outcome of using different size suture for the closure of choledochotomy wound. Methods: Prospective cross-sectional study was conducted where patients were categorized in two groups. Those with 3-0 suture were grouped “A†and those with 5-0 in“Bâ€. Outcome regarding the suturing time, cost, postoperative bile leak and hospital stay were compared between two groups. Results: Total 42 cases were included, twenty-one in. Mean age in group A is 38.6yrs and in group B is 44.24yrs. The sex ratio is comparable. Mean time taken for suturing is almost same (34.4 mins Vs 32.6 mins). The Post-operative bile leak is significantly for shorter duration in 5-0 group than 3-0 group. But there is no difference in overall hospital stay. Conclusions: Post-operative bile leak is significantly less when common bile duct is sutured with thinner needle and suture. This does not increase the cost, does not prolong the operating time and is not associated with other complications. Although the overall hospital stay is same. Further large scale study is needed. Keywords: bile, choledocholithisis, laparoscopiccholedocholithotomy, suturePublication Use of Ureterorenoscope as Choledochoscope(Nepal Health Research Council, 2010) Joshi, M RBackground: Flexible Choledochoscope is used to remove the stones using accessories during exploration of the common bile duct and its use reduces the incidence of retained stones. The choledochoscope and accessories are expensive and not available in many General Hospitals. In comparison to this, semi-rigid ureterorenoscope is easily available in many minimally invasive centres and accessories are more useful to remove even the impacted stones. We have used this for exploration of the CBD and tried to analyse its efficacy and safety.  Methods: All the patients who underwent Ureterorenoscopic intervention by single surgeon for common bile duct stones during 2007-2010 are included. The usefulness, efficacy and safety of the procedure are analysed.  Results: There were total 71 patients. Age ranges from 10 years to 69 years. Forty one (57.7%) patients had undergone open procedure where as 30 (42.2%) underwent laparoscopic procedure. Most of them were females (69%) and majority had multiple stones (59%). Twenty five (35%) patients required the use of different accessories like dormia basket, forceps etc. Pneumatic lithotripsy was used in 3 patients to fragment large impacted stones. In one (3%) patient of laparoscopic group scope could not be negotiated. In 4 cases mild common bile duct tear observed and in one patient duodenal laceration occurred. In two patients (2.8%) there were retained small stone fragments which passed spontaneously within two weeks post-operatively.  Conclusions: SemirigidUreterorenoscope is easily available, safe and effective instrument. It is useful even for large impacted stones.