Knowledge of relevant anatomy is important for the safe execution of any operative procedure. Specifically, in the context of a cholecystectomy, it has been recognized since long that misinterpretation of normal anatomy as well as the presence of anatomical variations contribute to the occurrence of major postoperative complications especially biliary injuries. Such injuries in turn can cause significant morbidity and occasionally even mortality. They are also one of the commonest causes of litigation against abdominal surgeons in the developed world. There is now a fair amount of data to suggest that the acceptance of laparoscopiccholecystectomy (LC) as the standard procedure, has led to an increase in bile duct injuries. This seems partly related to the different anatomical exposure of the area around the gallbladder especially the Calot's triangle during the laparoscopic procedure as opposed to the open procedure.
Albeit generally regarded as a safe procedure, cholecystec- tomy may result in adverse outcomes with non-negligible morbidity and occasional mortality. Compared to traditional opencholecystectomy, laparoscopy minimised the periopera- tive mortality and duration of hospitalisation and allowed for an earlier return to normal activities with cosmetically accept- able results. A large Italian series including over 13,600 pa- tients (86.1% of them operated laparoscopically) reported 2.1 and 2% rates of medical and surgical 30-day complications, respectively; the advantage of laparoscopy was consistent across age groups, severity of gallstone disease and previous surgeries, and insignificant for emergency admissions and systemic complications in the elderly . In other studies, compared to the 7.7% overall complication rate after opencholecystectomy, the laparoscopiccholecystectomy- associated morbidity ranged from 1.9 to 6.5%. The risk of developing postoperative adverse events is independent from surgeon and hospital volume, and is related to emergency conditions and to patient factors, such as advanced age, male gender, comorbidities (including obesity and cirrhosis), biliary inflammation and fibrotic gallbladder. Also, in patients with acute cholecystitis, the postoperative morbidity, mortality and
It is a prospective observational study done at SCBMCH, Cuttack a tertiary care hospital. Any patient for primary laparoscopiccholecystectomy who got converted to opencholecystectomy is included in this study .The total no. of patient in this study is 50 patients. The exclusion criteria are patient primarily operated with open method, patient not fit for lap. Cholecystectomy, done as a part of other surgery, age< 18, any patient not consenting for participation. Institutional ethics committee clearance was taken. Patient’s informed consent was taken. A scoring system is formulated for prediction of conversion from laparoscopic to opencholecystectomy taking different criteria into consideration.
I Dr. P.J. GOKULAKRISHNAN solemnly declare that the dissertation titled “ INCIDENCE OF BILE DUCT INJURIES IN LAPAROSCOPIC Vs OPENCHOLECYSTECTOMY - A REVIEW OF METHYLENE BLUE INJECTION TECHNIQUE TO PREVENT BILE DUCT INJURIES IN LAPAROSCOPICCHOLECYSTECTOMY ” has been prepared by me. I also declare that this bonafide work or a part of this work was not submitted by me or any other for any award, degree, diploma to any other University board either in India or abroad.
Gallstone disease is one of the most common surgical encounters. According to world literature, it occurs among 3-20% of the world population (1). A gallstones survey suggested that the incidence of gallbladder (GB) stones is 7 times more common in Northern Indian than in Southern Indian population. Laparoscopiccholecystectomy (LC) is accepted as the gold standard treatment for this disorder (1). Surgery for cholelithiasis is more common in elderly patients as the incidence of gallstones increases with age. The use of a laparoscopic approach in aging patients may pose problems because the comorbid conditions that are concomitant with advanced age thereby increasing the post-operative LC complications and the frequency of conversion to open surgery (2). Cholecystectomy is the most frequent abdominal operation, and its employment in the elderly varies between 8.3% and
Cholelithiasis (presence of stones in the gall bladder) for which I have been informed about the necessity for surgery by the treating doctor. The surgery which shall be performed is LaparoscopicCholecystectomy. In case the surgery cannot be perfomed laparoscopically, I provide consent for the surgery to be performed by open technique(OpenCholecystectomy). I also understand that certain complications such as bleeding, reactions related to anaesthesia, wound infection, bile leak, lengthy recuperation period etc may occur. Having
mortality,opencholecystectomy does carry a risk of potential complications. Traditionally, the complication rate for this procedure has been reported to be in the range of 6-21%, Though this has likely decreased in the current era patients with Child-Pugh class A or B cirrhosis who are undergoing cholecystectomy for symptomatic cholelithiasis, laparoscopiccholecystectomy has decreased complication rates and increased recovery as compared with open cholecyestectomy.
To determine the frequency of conversion from laparoscopiccholecystectomy to open cholecystec- tomy, this retrospective cross sectional study was conducted in surgical department of Northwest General Hospital and Research centre Peshawar. All the cases were performed by a single experienced general and laparoscopic surgeon. All patients who underwent Lap- aroscopic Cholesystectomy (n =531) from September 2012 to April 2018 were identified from the medical records maintained in the Health Information and Management Systems. Patient-specific characteristics that were retrieved included age, sex, co-morbidities and a history of prior abdominal surgery. All patients over 20 years of age with diagnosis of choletithiasis is and having no contra-indication for general anesthesia were included and Patients data with pathologically detected malignancies or gallbladder polyps, Cirrhosis, massive ascites and bleeding diathesis were excluded from the study. Patients were admitted through out-pa- tient clinic, preoperative fitness assessment was done before surgery. All routine laboratory tests including complete blood count, Blood Sugar random, Liver Function Tests, renal profile, and Hepatitis B and C virology were performed. Ultrasound abdomen and pelvic was performed in all patients and used as a tool for exclusion criteria done in every patient to confirm gallstones and to assess the common bile duct (CBD) diameter. In addition ECG and Chest X-ray were also carried out inall patients above forty.
Introduction : Gall bladder disease is the most common curable disease in female of middle age .Laparoscopiccholecystectomy has rapidly become the choice of elective surgery for the treatment of Cholecystitis even though OpenCholecystectomy remains the main modality of surgery in many centres in India. But to become an alternative to open method, it should be safe, less morbid and it should have the possibility of early return to work better than that of open the procedure. This study compares the open
been described earlier . Primary outcomes were costs and health related quality of life, reported in the current paper, and pain. Secondary outcomes were complica- tions within 30 days, operative time, length of hospital stay, conversion rate, frequency of ambulatory surgery and readmissions within 30 days, which together with pain have been reported earlier . In short, SIOC was performed via a transverse incision over the right rectus muscle and laparoscopiccholecystectomy with a four- trocar technique. If the SIOC incision exceeded 8 cm, the operation was classified as an opencholecystectomy as this was the cut-off in the Swedish registry for gall- stone surgery (GallRiks) . Two hospitals participated in the trial, Umeå University Hospital and Lycksele County Hospital. The study was designed as a rando- mised pragmatic expertise-based trial [12, 14], where participating surgeons were asked to join one of two teams, performing either SIOC or LC, according to their personal preferences. Team members performed their specific method (SIOC or LC) as a first-choice oper- ation, but converted to OC when necessary, and even began the operation using OC when neither LC nor SIOC were considered possible.
In bivariate regression models the training group, conver- sion of LC to open surgery was associated with inexperi- ence of the surgeon, history of previous laparotomy, history of smoking, higher body temperature, WBC count, alkaline phosphatase, and positive sonographic findings (Table 2). Multivariate analyses showed that among all, experience of surgeon, previous history of laparotomy, CBD stone, body temperature, WBC, bilirubin, and alka- line phosphatase levels were correlated to conversion independent of other variables (Table 2). The prevalence of conversion of LC to opencholecystectomy increased over the training time (Figure 1), whoever, the conversion rate decreased in validation group (2006).
In our CMCH we are doing both open and laparoscopiccholecystectomy. This study is done between January 2004 to February 2006. In this period I have selected 25 cases of laparoscopiccholecystectomy to compare with 25 cases of opencholecystectomy. Common indications for surgery were chronic calculous cholecystitis, acalculous cholecystitis, cholelithiasis, biliary colic and acute cholecystitis.
The laparoscopic technique has been remarkably improved and understood with the passage of time and with experience, thus making the conversion rate remarkably low of 1-6%  . In our study, the conversion to open procedure was required in 6 patients with conversion rate of 12%. This rate is comparable to results of most international studies that were published in early years of laparocscopic cholecystectomy (2-15%) [6,55,76,94-97] , but remains some what higher than those results recently reported in last five years (1-6%)  . This may be due to the fact that there is differences in the institutional and individual practice as well as experience of operating team. Difficult anatomy at the Calot's triangle accounted for more than half of conversions (66.6%); the reasons for obscured anatomy were due to acute inflammation causing dense adhesions (50%) and aberrant anatomy (16.6%).Ibrahim et al , Al Salamah  and Bingener et al  also found difficult anatomy as the most common reason for conversion to open procedure observed in 41.5%, 48.5% and 50% of the patients respectively. According to our study we observed that individual anatomy was obscured primarily due to dense adhesions (50%) and aberrant anatomy (16.6%) .
“Conversion to opencholecystectomy has been associated with increased overall morbidity, surgical site and pulmonary infections, and longer hospital stays. The ability to accurately identify an individual patient’s risk for conversion based on preoperative information can result in more meaningful and accurate preoperative counselling, improved operating room scheduling and efficiency, stratification of risk for technical difficulty, may improve patient safety by minimizing time to conversion, and also helps to identify patients in who a planned opencholecystectomy is indicated 12 .”
There were 4 (2%) cases who had empyema GB but were easy to detach from the liver bed. A gall bladder may be congenitally partially or completely embedded in the liver parenchyma or may become buried due to recurrent episodes of inflammation. The problem relating to this abnormality is an inability to grasp the fundus of the gall bladder and an absence of avascular plane of dissection between the gall bladder and liver parenchyma, which makes it technically a challenging task (Malik et al., 2007). Malik et al (13) on LC in empyema Gall bladder found that the difficulty level in performing surgery is not as high as stated in literature if the surgery is done by experienced surgeons; they successfully completed LC in 80.59% of patients with empyema GB. Thick gall bladder along with large stones can be difficult to remove, thereby preventing its excision hence fascial incision is extended to facilitate its removal (Palanivelu, 2005). Out of 70 difficult cases there were 21 (30%) patients in which extraction of GB from anterior abdominal wall was difficult. Maximum difficulty in this particular step of LC was seen in stone packed gallbladders 8 (38.09%). Out of 70 difficult LC maximum conversion to opencholecystectomy was seen in patients with acute cholecystitis and abnormal callot's anatomy 31.8% each. Maximum conversion was seen in patients who presented after 72 hrs of attack of cholecystitis. There were 7 cases of acute cholecystitis in which conversion took place. Out of these 7 cases 4 cases also had abnormal anatomy at callot's, in one patient there was small and contracted GB in addition to abnormal callot's, 1 patient had history of post ERCP cholangitis and 1 had billiary pancreatitis associated with cholecystitis.
particular attention has been paid to the introduction of air peritoneum and the insertion of trocar, since their incorrect positioning can also give rise to significant complications. Before starting the gallbladder dissection, it is fundamental to find the triangle Of Calot; If it is not located within 20 minutes, you opt for a conversion. Once the Calot triangle is delimited, the surgeon locates the cystic duct, the biliary and the vascular structures; In cases of anomalous presentation, the question arises whether to continue the operation in a videoaparoscopic method, or if an open reconversion is required. Same procedure for the detection of important adherence phenomena. In the case of misinformation, not seen by previous imaging examinations, the patient underwent intraoperative cholangiography in order to provide a clearer anatomical framework. In the case of possible operative complications, reconversion necessarily presents a higher chance of successful intervention than a laparoscopic approach; The surgeon's decision came from A careful assessment that included the degree of injury, the state of the operating field, the technical-instrumental repair option, the general clinical condition of the patient, and, above all, a sincere analysis of their technical capabilities (25,26,27,28). Another important aspect is the monitoring and management of the post-operative course, it is Drainage if placed. The positioning of the drainage level at the liver lobe if we decide the attachment was maintained for 24-48 hours, in our experience so we can also report the minimum leakage within that timed window, optimal for a better repair result in case Of complications. Depending on the extent of the leak loss from bile duct drainage. There can be a history
BACKGROUND: To study and compare between single incision laproscopic cholecystectomy and conventional laproscopic cholecystectomy. MATERIALS AND METHODS: 50 patients of gall bladder disease in whom Single Incision LaparoscopicCholecystectomy (SILC) and conventional laproscopic cholecystectomy was conducted in the department of General Surgery at Sir Sayajirao General Hospital and Medical College Baroda from November 2012 to October 2013. And all patients were divided in two groups. In Group 'A' , 20 patients were included which were operated by Single Incision LaparoscopicCholecystectomy (SILC) and in Group 'B', 30 patients were included which were operated by conventional laproscopic cholecystectomy. And all the patients were assesed with Intra operative difficulties, Operative Time, Conversion rate from SILC to either Conventional laparoscopic surgery or Open surgery, Post operative pain, Post operative complications, Cosmetic outcome. RESULTS: Average operative time in Conventional laparoscopiccholecystectomy is 85±9.733SD minutes and in single incision laparoscopiccholecystectomy is 111.83±20.53SD minutes. Conversion rate is 20% in SILC and 3.33% in conventional cholecystectomy. Early post operative pain is more in conventional laparoscopiccholecystectomy than single incision laproscopic cholecystectomy. 16 out of 20 (80%) patients was satisfy with single incision laproscopic cholecystectomy according to likert scale and 4 patients of SILC were not satisfy due to wound infections. 3 out of 30 (10%) patients were satisfy with conventional laproscopic cholecystectomy. Surgeon was satisfy with 18 out of 20 (90%) in SILC and 21 out of 30 (70%) in conventional surgery. Post operative wound related complications are more in single incision procedure than conventional surgery. CONCLUSION: Comparison between two procedures in my study concludes that single incision laparoscopiccholecystectomy is better with respect to post operative pain, cosmetic outcome than conventional laparoscopiccholecystectomy. But complication rate is more in single incision procedures due to incision length as well as Operative time and conversion rate is more in single incision procedures due to long learning curve and intra operative technical difficulties. But this learning curve difficulty will be overcome in nearby future with widely acceptance of minimally access surgery concept.
mechanism involves temporary elevation of pancreaticductal pressures, causing a secondary inflammation of the pancreaticparenchyma. Even a temporary elevation of intraluminal pressurecan cause significant injury to the pancreas. As opposed to the gallbladder, in which relief of the obstruction is accompaniedby pain resolution, the symptoms in pancreatitis continue in spiteof passage of the stone. With the diagnosis of pancreatitis in whichthe cause is unclear, ultrasound will help identify gallstones andmay show choledocholithiasis or a dilated bile duct. The offendingstone usually passes spontaneously but may still cause severe pancreatitis.In most cases of gallstone pancreatitis, the pancreatitis isself-limited. If, by clinical assessment, the pancreatitis is severe,early ERCP to remove a stone that may not have passed is indicatedand has been shown to reduce the morbidity of the episodeof pancreatitis.To prevent a future episode of gallstone pancreatitis, a laparoscopiccholecystectomy is warranted; this is generallyrecommended during the same hospitalization, just beforedischarge. Given the suspicion of choledocholithiasis, intraoperativecholangiography should be performed if no other imaginghas been performed to confirm the passage of the gallstone.
Laparoscopiccholecystectomy not only is the corner- stone of management of biliary disease and cholecystitis but is one of the commonest operations in both elective and emergency surgery. It offers an unquestionable ad- vantage over opencholecystectomy to the patient and the health care system . It is essential therefore that simple metrics can be applied to understanding the course of surgery and its outcome. While completion of the operation laparoscopically is not a proven quality in- dicator, analysis of surgical performance needs greater scrutiny [2–4]. Outcomes from cholecystectomy, par- ticularly in terms of operative approaches and findings, use of intra-operative cholangiography, conversion from laparoscopic to open, length of surgery and morbidity, in- cluding readmission to hospital, vary. There are many var- iables in the management of cholecystitis, requiring a tailored approach due in part to the large heterogeneity of the patients and the actual state of the gallbladder at sur- gery. Interpreting the cause of and reducing this variability is a key to advancing outcomes following laparoscopiccholecystectomy.9 Conversion to opencholecystectomy is itself not only occasionally a necessity but a safer op- tion than proceeding laparoscopically. Surgeons, with far greater exposure to laparoscopic technique, may opt for different damage control procedures rather than conversion to open, including various forms of bailout techniques .