Neck of the gallbladder has a narrow angulated distal portion called Hartmann's pouch
which is located in the infundibular region.
Level 1-adherent omentum, level 2-oedematous gall bladder wall, level 3-necrotic gall bladder wall, level 4-adherent gut and level 5 - adherent Hartmann's pouch
and oedematous Calot's triangle having no defined planes.
The gallbladder was transected at its neck or Hartmann's pouch
, leaving a remnant gallbladder pouch behind.
The surgical sequel resulted in modified radical hysterectomy, ureterolysis, resection of left and right tubo-ovarian abscess complexes, rectosigmoid resection with end-sigmoid colostomy and Hartmann's pouch
, and ileocolic resection with a primary anastomosis.
In laparotomy stained yellowish green free fluid in peritoneum and a tear over a necrotic area on the neck of the calcified gallbladder near the Hartmann's pouch
Another grasper was introduced through the medial cannula for holding Hartmann's pouch
and for manipulating it.
Laparoscopy revealed a thickened gallbladder with stones impacted in Hartmann's pouch
Colostomy, resection, or even a Hartmann's pouch
are reserved for more severe cases, including those with an obstruction distal to the perforation.
This pouch is variable in size but a large Hartmann's pouch
may obscure the cystic duct and the Calot's triangle.
However, Right-handed surgeon standing on the right side of the patient, either crosses his hands, as in our case, to allow the right hand to operate through the epigastric port, or use the assistant to retract the Hartmann's pouch
from the left side or, as we have described here, use the epigastric port to retract with the left hand, and operate with the right hand through the lateral subcostal port Though laparoscopic cholecystectomy in such patients is technically more demanding, an experienced laparoscopic surgeon can perform it safely.
The Hartmann's pouch
an outpunching of the wall in the region of the neck is recognized more as an outcome of pathology in the form of dilatation or presence of stones.