Defining Critical View of Safety During Laparoscopic Cholecystectomy: The Preoperative Predictors of Failure.

Background Defining critical view of safety (CVS) is one of the most crucial steps during laparoscopic cholecystectomy (LC). This study aimed to determine the preoperative predictors of failure to achieve CVS during LC. Methods All patients undergoing LC from December 2020 to July 2022 were prospectively included. Results There were 180 females and 93 males. CVS was achieved during LC in 238 (87.2%) patients. Conversion to open surgery was performed for 11 patients. Bile leak occurred in three patients which resolved spontaneously. No patient developed bile duct injury. On univariate analysis, age, male sex, American Society of Anaesthesiologists (ASA) grading, Murphy's sign, emergency surgery, neutrophil percentage, lymphocyte percentage, gallbladder wall thickness > 3mm, and impacted gallstone on abdominal ultrasound were predictors of failure to achieve CVS. On multivariate analysis, neutrophil and lymphocyte percentages were independent predictors of failure to achieve CVS. Patients in whom CVS could not be achieved had significantly longer operative time, higher blood loss, complications, and hospital stays. Discussion Inability to achieve CVS during LC can be predicted preoperatively using various parameters including neutrophil and lymphocyte percentages. Such cases must be operated by senior surgeons or referred to experienced general or hepatobiliary surgeons for cholecystectomy to avoid bile duct injury. The proposed algorithm can help in intraoperative decision-making in difficult cases.

Laparoscopic treatment of postpartum pre-sacral haematoma.

Postpartum retroperitoneal or pelvic haematomas are rare after vaginal delivery. The clinical presentation can vary from being an incidental finding to the development of life-threatening bleeding. Due to their rarity, there are no established guidelines for the management of these postpartum haematomas. The reported treatments vary from watchful observation to emergent laparotomy. We report a case of postpartum pre-sacral haematoma after uneventful vaginal delivery managed successfully by laparoscopic drainage after the failure of conservative treatment.

A Case of Pneumatic Rectal Perforation Caused by Compressed Air.

Rectal perforation is a rare cause of acute abdomen. The most common cause of rectal perforation is trauma. Barotrauma due to the injection of compressed air in the rectum is an extremely rare cause of rectal perforation. We report a case of extensive pneumoperitoneum with abdominal compartment syndrome caused by rectal perforation secondary to the forceful injection of compressed air through the perineum. The patient was successfully managed by immediate relief of abdominal compartment syndrome by needle decompression followed by surgical repair of rectal perforation.