ERCP and Removal of Biliary Stent

complicated gallstones may present with dual problems of gallstones and bile duct stones with associated clinical syndromes in both... calculous cholangitis with bile duct stones will require ERCP and stone removal.. after the stones are removed, a biliary stent is frequently inserted to ensure bile drainage in any possible event of retained duct stones.. calculous cholecystitis will require laparoscopic cholecystectomy... following cholecystectomy, ERCP is repeated for the removal of the stent

Laparoscopic Appendectomy performed during Laparoscopic Cholecystectomy

This latest video on the conduct of Laparoscopic Appendectomy.

Laparoscopic Appendectomy is done selectively in patients that will benefit from a laparoscopic approach as compared to the open conventional approach.

This patient has concomitant Cholecystitis and Appendicitis, hence after the performance of Laparoscopic Cholecystectomy, the inflammed Appendix was next removed laparoscopically using the same port sites without additional port.

Are Your Sure Its Appendix Doc?

 Acute Appendicitis is perhaps one of the commonest surgical conditions that present to any busy Emergency Dept. that open a 24-Hr services anywhere in the world.

Most patients are easily suspected from the history of the pain and the typical physical findings. Doctors then will perform some tests to support this suspected diagnosis in order to embark on definitive treatment namely Appendectomy(removal of appendix).

Quite often patients will pose a really good question to the Surgeons;..Doc, are you sure its Appendix? After operating on so many similar cases before, the most likely answer from the surgeons would be "most probably its appendix". That means you are not so sure?

This typical surgeon-patient conversation is so typical when a diagnosis of Appendicitis is made and the consent for Appendectomy is required.

The surgeon's little doubt is not without reason. The clinical pattern of many other possible conditions may mimic Acute Appendicitis especially in female patients. The many pelvic organs like the right ovary, right fallopian tube, right side of the uterus may give rise to many disease states that may present much like Appendicitis. Any experienced surgeon would have come across unsuspected normal pregnancy and the ectopic ones after ultrasonography of patients with a suspected diagnosis of Appendicitis. Very seldom ultrasound will make a positive diagnosis especially in early appendicitis when the appendicular swelling is minimal.

In fact, thats exactly the main purpose of ultrasound in patients with suspected appendicitis, that is to rule out other diagnoses. In philosophical terms, applying the falsifications principle of Karl Popper in sustaining a theory is to falsify the theory. If the theory stands up to the falsification test, then the theory survives. Many surgeons apply this philosophical of science principle without even realising it. Many patients find difficult to grasp that the test(namely the ultrasound) is done for a negative purpose.

This philosophical mismatch between the surgeon and the patient explains the scepticism of both in managing Appendicitis.

Despite these doubts on both parties, consent from patients are usually obtained and the final diganosis of Appendicitis turn out to be correct at operation.

Based in this empirical and historical experience, many surgeons would remove the patient's doubt by quoting the previous similar successful cases.