Indexing Title: JPingul’s Medical Anecdotal Report 06-04

Date of Medical Observation: October 12, 2005

TITLE: Surprise! 

Narration: 

I was doing a cholecystectomy, assisted by a consultant, on a 44 year-old male. The last severe attack was last year where he sought consult at another hospital, where he was given pain relievers.   The recurrent abdominal attacks prompted him to seek consult with a private physician, who requested for an ultrasound of the gallbladder and biliary tree.  The ultrasound resulted to a finding of a stone in the gallbladder.  This prompted the patient to seek consult in this institution, where he was eventually scheduled for an operation.

The patient was scheduled for the first case, and when we opened up, we saw a distended gallbladder that had a lot of adhesions.  The dissection was very difficult, there were even areas of fibrosis, the consultant theorized a probable previous perforation.   

Later in the operation, we suctioned the contents of the gallbladder with a trocar, and saw that the material was purulent, brownish, and foul-smelling.  It was an empyema of the gallbladder!  When I finally freed the attachments, the structures were so dilated that I was not able to identify the cystic duct.  Instead, I proceeded with releasing the gallbladder from the liver.  Much to my surprise, it was very bloody, there were areas where the gallbladder was avulsed from the liver bed, which was bleeding. 

In my mind, I was in a state of panic.  With a difficult anatomy, plus a bloody field, I was afraid to hit major vascular structures.  I was instructed by my consultant to pack the field, he helped me identify the cystic duct and artery, and eventually get the gallbladder out. 

After the specimen was taken out, re-examination of the liver bed showed several bleeding points.  We started with hemostasis, which was alternated with washing of the blood and some of the spilled bile and pus.  Again we packed the liver bed and waited for five minutes.  After five minutes, the pack was carefully removed, and the bleeding was gone.  But the sponge was stained with yellowish material coming from the liver bed. 

Upon investigation, the yellowish material was coming from an inferior part of the liver bed.  By placing a dry peanut-sized sponge, the consultant was able to identify the source, and ligated and sealed it with chromic sutures.  Several more checks, then we decided to put a penrose drain and closed the incision site. 

The next post-operative days was very uneasy, there were days when the drain gave an output of 50 ml per day of bilous mucoid liquid.  Upon follow-up with the consultant, we planned of re-opening the wound and do an intra-operative cholangiogram, to locate the source of the discharge.   

One day prior to the re-operation, the discharge lessened, and lessened, and the patient was eventually sent home.     

INSIGHTS: (DISCOVERY, stimulus, reinforcement), (physical, psychosocial, ETHICAL) 

As surgeons, the abdomen of our patients are like a box of unknowns, no matter how many times we had done a procedure, each patient will present differently.  There are cases of easy and sometimes there are difficult ones.  We must always prepare for the worst, but hope for the best. 

Taking into account a rational and structured step-wise management of patients, we can never be 100 per cent certain of our diagnosis.  And when the treatment comes, the floor becomes swept off our feet, to our surprise.   

The challenge for us is to do the best of the situation presented to us, to minimize or avoid any complications, to ask for help from someone who has more experience and skill, and to pray hard. 

It will take discipline for a surgeon to make a decision intra-operatively which will be best for the patient.