Port site tuberculosis and retained gall stone after laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy is one of the most common general surgical procedures performed.

Surgical site bacterial infection at port site is common but tuberculosis of port site is very uncommon.^1,2

Most commonly it occurs due to instruments contaminated with mycobacterium tuberculosis due to breach in sterilization. Other causes include tuberculosis of gall bladder or other abdominal organ tuberculosis co existing at the time of procedure.

CASE REPORT

A 36 year old lady presented to our tertiary care center Lady Hardinge Medical College and associated Smt Sucheta Kriplani Hospital, New delhi, India with complain of swelling at mid-clavicular port (Figure 1) and sinus with sero-purulent discharge from epigastric port site (Figure 2), one months after laparoscopic cholecystectomy done outside our hospital. CECT abdomen (Figure 3) show anterior abdominal wall collection with extension till peritoneum and subsequently wide local excision (Figure 4) with primary closure of defect was done and histopathology of excision specimen show feature of chronic inflammation- fibroadipose tissue showing lympho-histiocytic inflammatory infiltrate along with chronic granulation tissue (Figure 5). Patient again develops swelling at scar site (Figure 6) and FNAC from recurrent swelling shows acid fast bacilli on Ziehl Neelsen stain (Figure 7). Previous record shows no histopathological evidence of tuberculosis in gall bladder and no abdominal tuberculosis. Patient was started on Anti tubercular drug therapy. Follow up after 2 months shows healthy stitch line and no discharge or swelling.

DISCUSSION

Port site infections are very commonly seen but tuberculosis at port site is very uncommon. In our case, we first did wide local excision of sinus with swelling and biopsy shows feature of chronic inflammations. Our patient again develops swelling at previous site and FNAC from recurrent swelling reveals features of tuberculosis. Previous studies shows that initial investigations including pus AFB and pus culture were negative and biopsy provide the diagnosis.^1-4

After FNAC our patient was started on anti-tubercular treatment and follow up after two months shows no swelling or sinus or discharge. Previous studies also showed anti-tubercular therapy was the best treatment modality.^5-8 Since in our case there were no signs of tuberculosis in gall bladder and no evidence of other abdominal tuberculosis, we assume that the source of infection was poorly sterilized instruments, which is also seen in previous studies.^6-8

CONCLUSION

Port site tuberculosis in absence of tuberculosis of gall bladder and abdominal is most likely due to contamination of instrument or dressing by mycobacterium tuberculosis due to faulty sterilization technique. FNAC from collection or biopsy or culture helps in achieving diagnosis. Management includes incision and drainage, debridement, wide local excision along with ant tubercular drug therapy.

ACKNOWLEDGEMENTS

Authors would like to thank Department of pathology for providing the histopathological image for this case report.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Cai Y, Venkatachalam I, Tee NW, Tan TY, Kurup A, Wong SY, et al. Prevalence of Healthcare-Associated Infections and Antimicrobial Use Among Adult Inpatients in Singapore Acute-Care Hospitals: Results From the First National Point Prevalence Survey. Clin Infect Dis. 2017;64(2):S61-7.
2. 2. Sasmal PK, Mishra TS, Rath S, Meher S, Mohapatra D. Port site infection in laparoscopic surgery: A review of its management. World J Clin Cases. 2015;3(10):864-71.
3. 3. Taj MN, Iqbal Y, Akbar Z. Frequency and prevention of laparoscopic port site infection. J Ayub Med Coll Abbottabad. 2012;24(3-4):197-9.
4. 4. Siddiqua SS, Khan MAI, Khan MAU, Sayeed S. Port site infections following laparoscopic cholecystectomy. Bangladesh J. Med. 2018;29(2):51-8.
5. 5. Ramesh H, Prakash K, Lekha V, Jacob G, Venugopal A, Venugopal B. Port-site tuberculosis after laparoscopy: report of eight cases. Surg Endosc. 2003;17(6):930-2.
6. 6. Jagdish N, Sameer R, Omprakash R. Port-site tuberculosis: a rare complication following laparoscopic cholecystectomy. Scand J Infect Dis. 2002;34(12):928-9.
7. 7. Chintamani, Kumar V, Singhal V. Port site tuberculosis following laparoscopic cholecystectomy. Trop Doct. 2005;35(1):47-8.
8. 8. Rehman IU, Farooqui F, Waseem S, Lee KY, Mamoon N, Riaz U, et al. Port site tuberculosis a rare post operation entity: A case report. Ann Med Surg (Lond). 2022;78:103703.