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Correlation between USG, CT images with FNAC in epigastric port nodules following laparoscopic cholecystectomy: a prospective study in remote area of west Bengal.


Laparoscopic cholecystectomy has now become the procedure of choice replacing open method for almost all gallbladder diseases except a few. With the advent of laparoscopic cholecystectomy, most of the complications are avoided and as well the longer time of stay in hospitals. The total complications rate was 3.6/1000 procedures. (1) and the rate of major complications was 1.4/1000 procedures. (1) Port site complications are very rare amounting 21/100000 procedures. (2) and port site infections accounts for 1.8% of all the complications. (2)

We got a few other port site complications namely metastatic nodules, hernia. We tried in the study to make any correlation if it may between USG, CT images with FNAC of port site nodules at epigastric port and to find out most common cost of port site nodules in this remote area of West Bengal.


The study was conducted for the period from April 2012 to April 2015 over 1400 post cholecystectomy patients, of which 50 patients got epigastric port nodules. We had taken consent from patients or its party for our study. Male-Female ratio in our study is 3:2 and age of patients in the range of 15 to 64 years. This nodules are studied both radiologically (By USG and CT Scan) and pathologically (By FNAC). All the 1400 patients underwent pre-operative USG and following criteria are made for study.

1. No suggestion of USG feature of malignancy.

2. No history of active or old Koch's.

3. No history of immunosuppression.

4. Only epigastric port nodules are included.

We have studied epigastric port nodule by high frequency linear transducer (8-12 Mhz) of standard USG machine and multi-slice CT scan machine. FNAC was done by image guidance (Either by USG or CT). Each patient was included only once in the study.

On HR US, out of 50 epigastric port nodule patients, 30 patients had hypoechoic sinus tract with central hyperechoic contents and grouped as A. Group B patients (8 in nos. in our study) had narrow hypoechoic sinus tract with hypoechoic nodules at port site. Group C patients (8 in nos.) show hypoechoic sinus tract with internal hypoechoic contents and multiple finger like projections in surrounding subcutaneous tissue. Group D patients (4 in nos.) show hypoechoic nodules, having protrusion of omental fat, which increases in size during straining. No intra-peritoneal extension had been seen.

On multi slice CT scanner, A group of patients show iso to hypodense sinus tract with mild-to-moderate contrast enhancement; B Group of patients show moderately enhancing port nodules along minimal enhancement of underlying sinus tract; C Group patients show only enhancement of sinus tract walls; D Group patients show fat density contents (Hu- -5 to -20) without contrast enhancement.

All the above 50 patients underwent FNAC. Among A Group of patients (30 in nos.), 27 had atypical mycobacterial infections and 3 patients had nonmycobacterial infections. Among B Group of patients (8 in nos.), 6 showed metastatic deposits (Adeno-carcinoma), 1 patient had atypical mycobacterial and another 1 had non-mycobacterial infections. Amoung C Group of patients (8 in nos.), 6 patients showed non-mycobacrial infective pathology and 2 patients showed atypical mycobacterial infections. Among D Group of patients, only fatty tissue found in FNAC.

It was revealed in our study that 80% of epigastric port nodules are of infective pathology and atypical mycobacterials infections accounts for 60% of port nodule pathology at epigastric port. Metastatic nodules account for 12% and that of hernia 8% in our study.

Statistical parameter of atypical mycobacteria in epigastric port nodule
Sensitivity  Specificity   PPV   NPV

90%           84.2%         99%    84.21%.

Thus the atypical mycobacteria in our study outnumbered the other causes of epigastric port nodule in this part of West Bengal. P value of the study is found to be <0.05.


Laparoscopic cholecystectomy is a relative safe procedure. Postoperative port related complications and morbidities rather rarer. Port site complications can be due to access related and postoperative complications and have been reported in all age groups and in both sexes. Previous studies showed that obesity is related to increased morbidity in laparoscopic procedures because of thick subcutaneous layer, which need long trocar, larger incision and restricted movements of instruments. Fulter et al. (4) showed that port related complications are more in postcholecystectomy, as these procedures outnumbered the other laparoscopic surgeries. Port related complications in laparoscopic cholecystectomy, apart from obesity, related to gross spillage of infected bile, umbilical stitch sinuses (Wasim Memon et al.). (5) Port site complications increases with increased nos. of ports. (6)

Amongst the port sites epigastric port (88.2%) is more affected than umbilical port (11.7%). (7) Epigastric port is the major site of port site complications in laparoscopic cholecystectomy because gallbladder and associated tissues are expelled through this port and therefore vulnerable to complications. (7) Laparoscopic surgeries have reduced incidence of postoperative complications. (8) however, they can produce morbidity significantly at port site. Necrotizing fascial infections is some times the accompaniment of PS complications. (9) In our study, PSI is much more than standard national level (2.85% versus 1.8%). (1) Our study results comparable with many other studies. Den Hod et al. found the incidence to be 5.3%. (10) Colizza et al. <2%. (11) and Shindholimath et al. found 6.3%. (12) All PSI are superficial involving only the skin and subcutaneous tissues. Among the port site infections atypical mycobacterial outnumbers the other infections. In our study, 80% of PSI are atypical mycobacterial infections with sensitivity of 90% and specificity of 84.2% which are comparable to many previous studies. (13,14,15) Most of PSIs in our study are atypical mycobacterial infection, the contamining source was identified as the rinsing water which used for washing clinically disinfected instruments comparable to previous studies. (13,14) so our study points the lack of stringent sterilization procedures.

The rate of incidence of incisional hernia at port site is very rare. The incidence of hernia is 0.2% in our study and is comparable to other studies (0.02%-1.6%). (16,17) It was revealed that incisional hernia is related to trocar size and larger fascial defects. When port site hernia is identified, it should be repaired to prevent the complications of intestinal obstruction. (17) In recent years, several reports of trocar site metastasis have been published. (18) However, exact mechanism of metastasis is unknown. In our study results metastatic rate is 0.4% and is comparable to other studies. (2)

Most of PSIs in our study are atypical mycobacterial infections. In our study, the concerned patients came from the hospitals using cidex solutions for sterilization of laparoscopic instruments. So there is strong presumption that these are the source of atypical mycobacterial organism in cidex solutions. In one of the previous study. (14) this type of solution got 80% seropositive for Koch's.


In our study, we found that all the port site complications can be diagnosed by imaging confidently. USG can detect the complications in nearly all patients. USG is readily available and cost effective in all the corners of our country, even in the remote areas show early diagnosis and management are possible. Our study also awares the surgeons of possible port site complications, which are related to improper sterilization of laparoscopy instruments. In our study, we found most of the port site complications are due to atypical mycobacterial infections which is related mostly with improper sterilizations of instruments. So activated cidex solutions to be replaced by auto claving and ethiline-oxide gas plant sterilizations for the sterilization of laparoscopic instruments. PS complications can occur even in the best of hands and it is vital that these are recognized and addressed earlier, which imaging can offer to the concerned surgeons earliest.


(1.) Hakki-Siren, Kurki T-A. Nationwide analysis of laparoscopic complications, obstet-gynae :89:108-112; 1997.

(2.) Karthik S, et al. Analysis of laparoscopic port site complications--A descriptive study, J Min Access Surg 2013;9:59-64.

(3.) Fuller J, Ashar BS. Trocar associated injuries and fatalities--J Minm Invasive Gynecol 2005;12:302-7.

(4.) Wasim Memon, et al. Complication of laparoscopic cholecystectomy Pak-J med sci 25(I) 69-73; 2009.

(5.) Neu Decker J. The European association for endoscopic surgery clinical practice guideline on pneumoperitoneum for laparoscopic surgery. Surg Endosc 2006;20:1584-6.

(6.) Waqar Alam, et al. The frequency of port site infection following laparoscopic cholecystectomy; journal of post graduate medical institute 22;01;66-70; 2006.

(7.) Atul K Sharma, et al. Port site infection in laparoscopic surgeries. Indian medical gazette, June 2013.

(8.) Taragaron JE, Kook MM. Laparoscopic surgery and surgical infections, British Journal surgery 2000;87:536-44.

(9.) Losanof JE, Richmann BW. Trocar site hernia complicated by necrotizing fasciitis. Hernia 2003;7:220-3.

(10.) Den Hoed PT, Bruining HA. Infection and bacteriological data after laparoscopic and open gallbladder surgery. J Hosp infect 1998;39:27-37.

(11.) Colizza S, Rossi S, Picardi B, et al. Surgical infections after laparoscopic cholecystectomy: ceftriaxone vs ceftazidime antibiotic prophylaxis. A prospective study. Chir Ital 2004;56(3):397-402.

(12.) Shindholimath VV, et al. Factors influencing wound infection following laparoscopic cholecystectomy. Trop Gastro enterol 2003;24:90-2.

(13.) Vijayraghavan R, Chandrasekhar R. Hospital outbreak of atypical mycobacterium, port site in laparoscopic surgery. J Hospital infect 64(4):344-347; Dec. 2006.

(14.) Leo Francis Tauro, et al. Port site tuberculosis, a rare complication following laparoscopic cholecystectomy. Indian journal of surgery 104-105; 2007.

(15.) Jagadish N, Sameer R. Port site tuberculosis following laparoscopic cholecystectomy. Scand J Infective diseases, 34(12):928-929; 2002.

(16.) Azurin DJ, Kirkland ML. Trocar site herniation following laparoscopic cholecystectomy and the significance of an incidental pre-existing umbilical hernia. Am surg 1995;61:718-20.

(17.) Montz FJ, Munro MG. Incisional hernia following laparoscopic. Obstet Gynaecol 1994;84:881-4.

(18.) Buryene F, Sun J. Incarceration of bowel through opening of 5mm port. J Endourol 2004;18:675-6.

Monojit Chakrabarti [1], Supriya De Ray [2], Md. Abdur Rahaman [3]

[1] Assistant Professor, Department of Radiology, Malda Medical College and Hospital, West Bengal.

[2] Assistant Professor, Department of Anaesthesiology, Malda Medical College and Hospital, West Bengal.

[3] RMO Cum Clinical Tutor, Department of Radiology, Malda Medical College and Hospital, West Bengal.

Financial or Other, Competing Interest: None.

Submission 28-11-2015, Peer Review 29-11-2015, Acceptance 12-12-2015, Published 17-12-2015.

Corresponding Author: Dr. Md. Abdur Rahaman, RMO, Department of Radiology, Malda Medical College & Hospital, Englishbazar, Malda-732101, West Bengal, India.


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Title Annotation:Original Article
Author:Chakrabarti, Monojit; De Ray, Supriya; Rahaman, Md. Abdur
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Date:Dec 17, 2015
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