Background A left‐sided gallbladder (LSGB) is a rare anatomical anomaly that is often not discovered until surgery. Two cases of LSGB managed with laparoscopic cholecystectomy (LC) stimulated this systematic review. The aims of this study were in LSGB to define the rate of pre‐operative detection, variations in biliary anatomy, laparoscopic techniques employed and outcomes of surgery for symptomatic gallstones. Methods A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta‐Analyses principles. Results Fifty‐three studies with 112 patients of which 90 (80.4%) had symptomatic gallstones. Pre‐operative imaging was performed in 108 patients (96.4%) with an LSGB reported on imaging in 32 (29.6%) patients. The remainder of LSGB were discovered at surgery. Ultrasound detected an LSGB in three (2.7%) patients. Five variants of cystic union with the common hepatic duct (CHD) were identified. The most common (67.8%) was union on the right side of the CHD after a hairpin bend anterior to the CHD. A cholecystectomy for gallstone disease was performed in 90 patients, 23.3% open and 76.7% LC. Common variations in LC technique were different port site placement and techniques related to the falciform ligament to improve exposure. Common bile duct injury occurred in four (4.4%) patients. Conclusion LSGB is a rare anatomical variation that in patients with symptomatic gallstones is usually discovered at surgery. Cholecystectomy is associated with a higher incidence of common bile duct injury.
Synchronous primary anorectal melanoma and colorectal adenocarcinoma is extremely rare, with only 5 cases reported in the literature. Here, a case is reported and the currently available literature is summarized. A 72-year-old white male presented with changes in his bowel habits and unintentional weight loss. Colonoscopy revealed a polypoid mass in the distal rectum extending to the anal verge anteriorly and a circumferential polypoid mass in the distal sigmoid colon. Biopsies were taken, which revealed poorly differentiated melanoma of the anorectal mass and moderately differentiated adenocarcinoma of the sigmoid mass with nodal involvement. Computed tomography of the abdomen showed liver metastasis. An extended abdominoperineal resection was undertaken for palliation, relief of symptoms, and definitive histology to guide further management. Consequently, a resection of the hepatic metastasis was attempted; however, macroscopic deposits were discovered on 7 of 8 liver segments perioperatively. He was subsequently referred to medical oncology for palliative chemotherapy. Synchronous primary anorectal melanoma and colorectal adenocarcinoma is rare, this being the sixth report found in the literature. In summary of the available cases, all synchronous cancers were located in the rectosigmoid and had very similar presentations. Most presented relatively late and were generally treated with abdominoperineal resection, which appears to be the best treatment option. Overall, prognosis appears to be dismal. General and colorectal surgeons should always be aware of the possibilities of simultaneous primary cancers because this can affect treatment modalities and prognosis for the patient.
The instillation of local anaesthetic agents into surgical wounds has been reported to be an effective method of reducing pain and narcotic requirements, using both local injection'.* and topical application' techniques. We performed a double-blind trial to test the value of the long-acting local anaesthetic, bupivacaine, in this role.Eighty patients undergoing elective cholecystectomy were entered into the study. They were divided into 2 groups of 40 patients to compare a local injection technique with a topical application technique. For each route of application. 20 patients received a test solution containing 0.25% plain bupivacaine, and 20 received 0.9% NaCl as a control. Postoperative analgesia in the form of intramuscular pethidine (1-I .5 mg/kg) was made available to all patients on request.The degree of postoperative pain was assessed using three criteria: the time from operation to the first request for analgesia, the total dose of postoperative pethidine required during the first 3 postoperative days and the patient's rating of pain on a lOcm linear analogue scale at 24 h and 72 h.There was no statistically significant difference between the degree of postoperative pain experienced by patients receiving bupivacaine and those receiving NaCI, when assessed by any criterion. There was also no significant difference found between patients receiving bupivacaine by local infiltration and those receiving the drug topically. It is concluded that the local application of bupivacaine to the wound is not an effective analgesic technique following laparotomy for cholecystectomy .
A gelatin-sealed knitted Dacron vascular graft was prepared by passive impregnation with rifampicin and implanted in the common carotid artery of 10 merino sheep. Another 10 merino sheep had an untreated graft inserted. The graft was topically inoculated with 1 mL of 10' colony forming units per mL of Staphylococcus aureux before wound closure. The grafts were harvested at 3 weeks and cultured. All untreated grafts and surrounding tissues became infected. One of the 10 grafts treated with rifampicin became infected (P = 0.0002) and 4 sheep with rifampicin-treated grafts had surrounding tissue infection. No bacteria cultured from the rifampicin-treated sheep developed resistance to rifampicin.
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