PubMed · 9142085
The source did not provide an abstract. Follow the original record for more information.
Explore connections, maps & timelines
R Matz. 1997-05-03. Laparoscopic surgery.. https://doi.org/10.1016/s0140-6736(05)62537-8
Cite the original work for its findings. Save a collection to share your selection of sources.
KEEP EXPLORING
Gallstones are common and occur asymptomatically or symptomatically with or without complications. Treatment is only required for symptomatic gallstones and complications in gallstones. Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones and is performed with an increasing frequency. One may fear, that the indications for cholecystectomy have changed, and surgery is now undertaken for a lesser degree of morbidity. Cholecystectomy does not increase life expectancy, and 20-30% of patients cholecystectomized for symptomatic gallstones complain of abdominal pain of unknown origin after the operation. New valid parameters in order to predict which patients will benefit from cholecystectomy are therefore necessary. Symptoms specific to gallstones are not precisely known, and greatest success in treatment seems to be related to the occurrence of severe, often steady pain, of hours' duration, often located in the epigastrium or upper right quadrant, with or without radiation and/or vomiting. Dyspepsia alone is not an indication for cholecystectomy. Psychological vulnerability may predict a poor outcome after cholecystectomy and should lead to reconsideration of the indication for surgery.
Laparoscopic cholecystectomy began to gain ground in the late eighties. The smaller incision led to less postoperative pain and faster recovery. By now, the method has become a matter of controversy: the laparoscopic operation took more time than the 'minilaparotomy'. This criticism can be refuted: laparoscopy gives faster recovery than the conventional large incision and a better view than the 'minilaparotomy'.
We report a rare case of spontaneously developing generalised gas gangrene with massive rhabdomyolysis after a cholecystectomy and drainage of a hepatic abscess. On preoperative physical examination the patient appeared severely ill and was icteric and oliguric. Laboratory evaluation showed signs of systemic inflammation, elevated lactate levels, evidence of disseminated intravascular coagulation (DIC), and increased levels of serum creatine kinase (CK) activity. Abdominal ultrasound and endoscopic retrograde cholangiography showed a gallbladder perforation and a hepatic abscess. Cholecystectomy and drainage of the abscess was performed immediately and without technical problems. After postoperative admission to the intensive care unit, the patient showed evidence of generalised myonecrosis with subcutaneous gas formation and acute renal failure. Initially, there were few other signs of systemic toxicity; the patient was not hypotensive and the pulmonary gas exchange was normal. Within hours diffuse swelling of his right leg developed with cutaneous gangrene and a compartment syndrome. After fasciectomy and extensive surgical debridement, uncontrollable bleeding due to DIC developed from the fasciectomy site, which finally required exarticulation of the leg at the hip joint. At this point, multiple organ failure including severe adult respiratory distress syndrome was present. Two days after cholecystectomy, the patient died from hypoxic cardiocirculatory failure. Clostridium perfringens was repeatedly isolated from the wounds. Besides gas gangrene, the differential diagnosis of such infections includes localised clostridial cellulitis, nonclostridial anaerobic cellulitis caused by mixed aerobes and anaerobes, and type I or type II necrotising fasciitis. Patients with systemic necrotising infections should be treated with broad-spectrum antimicrobial regimens (penicillin G, 3rd generation cephalosporins, clindamycin, and aminoglycosides). An otherwise unexplained elevation of serum CK activity in the presence of acute cholecystitis may suggest haematologic spread of an aggressive myolytic agent and the beginning of myonecrosis. This should prompt immediate surgical exploration after establishing broad-spectrum antibiotic coverage. The role of hyperbaric oxygen treatment in this situation remains to be established. If hyperbaric oxygen is to be employed, it should neither delay surgical exploration nor jeopardize the patient with the hazards of an interhospital transport.