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.
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
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.
In this study equal number of patients (60) underwent LC and OC. Majority of the cases were females (F: M=5.3) and in the age group 40 to 60 years. The operating time for LC was more as compared to O C in most cases and more than 2 hours in 19 cases due to various reasons like dense tough adhesion around Calott’s triangle (in 6 patients), bleeding (in 3 cases), perforation of GB (in 6 cases), CBD injury (in 1 case) and technical hardware challenges (in 3 cases). The mean operation time for laparoscopiccholecystectomy was more than for opencholecystectomy. The operative time for laparoscopiccholecystectomy was 55-155min (mean: 102.50min) and 40-105min (mean: 72.50min) for opencholecystectomy (p <0.001). The operation time for laparoscopiccholecystectomy became shorter as the period of study elapsed and the team became more experienced. The following table shows the operation duration for both the groups (Table 2).
In our study the majority of cases (88%) of OC group felt moderate to severe pain and late recovery as compare to LC group where 31% felt mild to moderate pain (p=0.005) with quick re- covery and early mobilization and therefore was less need of postoperative analgesia in LC group. In other studies laparoscopiccholecystectomy have minimum surgical stress, less postoperative pain, fast recovery 25 and early gut motility and feed-
This is consolidated report on a comparativestudy of OPEN VS LAPAROSCOPICCHOLECYSTECTOMY based on the cases treated at CMCH Coimbatore during the period of 2004 – 2006. This is submitted to THE TAMILADU DR.M.G.R MEDICAL UNIVERSITY CHENNAI in partial fulfillment of rules, regulations of M.S Degree Examination in general surgery to be held on September 2006.
Opencholecystectomy induces an inflammatory response in which pro inflammatory cytokines such as IL6, IL8, IL 1B, TNF alpha and C reactive proteins are released which is responsible for increased pain and late recovery. There is also suppression of cell mediated immune system transiently which alters the functioning of lymphocyte, monocyte and other immune cells. 17
Gastro-intestinal surgery has undergone a revolution in the recent years by the introduction of laparoscopic techniques. The concept of “keyhole surgery” created an immediate disparity between the potential of the new technique and training of surgeons to perform it. Now modern surgical methods are aimed at giving cure along with minimal invasive techniques with patient in mind, safety never being compromised. Cholelithiasis, which continues to be one of the most common digestive disorders encountered, was traditionally being dealt by conventional or opencholecystectomy. With the introduction of laparoscopiccholecystectomy, the surgical community witnessed a revolution in basic ideology and the importance of minimal access surgery.
Anterior approach onlay mesh tension free prosthetic repair of the inguinal canal was first demonstrated by Irving Lichtenstein in 1984 which has revolutionized the way hernia repairs have been conducted with very low recurrence levels. Ralph Ger was the first in 1982 to report a transabdominal closure of an inguinal hernia defect during a laparoscopy for other reasons. Years later, in 1989, the gynaecologist S.Bogojavalensky showed a video demonstrating the laparoscopic intra abdominal incision of the peritoneal hernia sac, subsequently closing the visible muscular defect with a rolled-up piece of polypropylene mesh. Thereafter in 1990 Ger, Shultz, Corbitt, etc. demonstrated laparoscopic hernia repair after conducting a series of trials and studies. Laparoscopic hernia repair is similar to the open preperitoneal approach and can be performed via a transabdominal or totally extra peritoneal route.
The cost of anesthesia while surgery is a factor to consider while selecting patients for surgery and cost of operation is increased when general anesthesia is used. We did not consider cost factor in this study because of Shree Krishna Hospital is an affiliated with charutar arogya mandal and pramukh swami medicalcollege which provide cheap and affordable health care like a trust hospital. Additionally, we are using autoclavable reusable instruments which also helps in cost cutting. The study comparing the cost of TEP and open inguinal hernia repair revealed that cost for TEP is $852 more as compared to open hernia repair. However, this study did not show the cost saving arising from the faster recuperation and early re-entry into the workforce . Operating cost can also be reduced by avoiding the use of disposable instrument .
I declare that this dissertation entitled” P rospective study comparing early versus delayed laparoscopic/opencholecystectomy for Cholecystitis ” is a record of work done by me in the Department of General Surgery, Stanley MedicalCollege, Chennai, during my Post Graduate Course from 2015-2018 under the guidance and supervision of my unit chief PROF.DR.T.SIVAKUMAR M.S. It is submitted in partial fulfillment for the award of M.S. DEGREE EXAMINATION – BRANCH I (GENERAL SURGERY) to be held in May 2018 under the Tamilnadu Dr.M.G.R. Medical University, Chennai. This record of work has not been submitted previously by me for the award of any degree or diploma from any other university.
Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, American Academy of Orthopaedic Surgeons, American Association of Critical Care Nurses, American Association of Nurse Anesthetists, American College of Surgeons, American College of Osteopathic Surgeons, American Geriatrics Society, American Society of Anesthesiologists, American Society of Colon and Rectal Surgeons, American Society of Health-System Pharmacists, American Society of PeriAnesthesia Nurses, Ascension Health, Association of perioperative Registered Nurses, Association for Professionals in Infection Control and Epidemiology, Infectious Diseases Society of America, Medical Letter, Premier, Society for Healthcare Epidemiology of America, Society of Thoracic Surgeons, Surgical Infection Society. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases 2004;38:1706
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 MedicalCollege 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.
The study Three port vs four port laparoscopiccholecystectomy: a prospective comparative clinical study was conducted prospectively in the department of surgery SKIMS Medicalcollege Bemina Srinagar from July 2015 to March 2017. The study was performed on all adult patients with ultrasound documented cholelithiasis, gall bladder Polyposis or gall bladder adenomyomatosis admitted in the Department for elective surgeries. The study comprised of 100 patients which were randomly taken for a three port (Group 1,50 patients) or four port laparoscopiccholecystectomy (Group 2, 50 patients). Patients which were excluded from the study included patients with acute cholecystitis, patients with surgical jaundice associated cholidocholithiasis, carcinoma of gall bladder and patients who had undergone endoscopic retrograde cholangio pancreatography graphy (ERCP) less than three weeks before.
In our study, extraction of the gall bladder was seen to be difficulty in 16% of the subjects. Difficulty in extraction refers to the necessity for extension of the port site, or for decompression of the gall bladder in order to remove the specimen. A statistically significant association was observed between time taken to extract the gall bladder and gall bladder wall thickness( p value 0.001), with size of the stones( p value 0.022) and with prediction by ultrasonography( p value 0.023). Difficulty in extraction of the gall bladder specimen was seen in patients with a calculus size greater than 1 cm by Sharma S K et al 38 , Sahu et al 46 Nachnani et al 37 . Extraction of gall bladder from abdomen was found to be more difficult with a thickened gall bladder wall according to Kyung Soo Cho 76
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
the training group. The preoperative data of patients were extracted from archived data sheets. The data included the following health characteristics and operation conditions: sex, age, history of previous laparatomies, concurrent sys- temic illnesses (chronic obstructive pulmonary disease, ischemic heart disease, hypertension, chronic renal fail- ure, and diabetes), history of smoking and alcohol use, the surgery setting (emergency or elective) and the sur- geon's expertise. Surgeons were considered to be inexperi- enced in their first 50 LC and experienced afterward. In addition, admission values of body temperature, white blood cell (WBC) count, serum total bilirubin, and serum alkaline phosphatase concentrations, as well as sono- graphic findings, including gallbladder wall thickness, pericholecystic fluid, CBD stone, and CBD diameter, were collected. The conversion to open surgery and duration of hospital stay was also determined. All the above men- tioned data were gathered prospectively for the first 100 LC operations performed since March 2006 in the same department to compose the validation group. The study protocol was approved by the ethics committee of the uni- versity and confidential data handling regulations were employed.
Background: Open abdominal hysterectomies was one of the most common and traditional surgical procedure for the removal of uterus in women for the treatment of benign gynecological disease. Laparoscopic hysterectomy results in less blood loss than abdominal surgeries and is also more achievable in nulliparous and obese women. Laparoscopic hysterectomy (LH) rates recently increases, but traditional open approach is still used in predominance. Most studies now prefer the laparoscopic approach for hysterectomy for the known benefits of minimal access surgery Aim of the Study: the study aimed to compare the outcome of laparoscopic total hysterectomy with its open counterpart in terms of some intraoperative and postoperative selected parameters. Patients and Methods: this prospective randomized controlled trial performed on 50 patients who underwent LH (group 1) compared to 50 patients who underwent AH (group 2). The mean age of the cases, body mass index (BMI), duration of operation, estimated blood loss (EBL), rate of complications, post-operative hospital stay and convalescence time were compared for two groups. Results: LH was associated with a significantly longer operating time (90+-12 minutes vs. 75+-15minutes P 0.004). Regarding the intraoperative complications there were no difference between both groups, but there is statistically significant difference regarding blood loss In LH group the pain score and analgesia requirements in post- operative period were significantly less with only few patients' required post-operative opioid analgesia. There was a highly significant difference between groups in postoperative wound related complications which were higher in AH group. LH was also associated with a significantly shorter hospital stay (1.6+-1 vs. 3+-2 days P= 0.001) and earlier returned to daily activities (9+-3.2 vs. 23.4+-11days P<0.001). Conclusion: total laparoscopic hysterectomy is safe and feasible procedure in treatment of benign uterine tumors and other pathologies with less postoperative pain, rate of wound complication, shorter hospital stay.
Gallstone disease is the pathologic state of stones or calculi within the gallbladder lumen and biliary tree. This is a common digestive disorder worldwide, with occurrence varying from 6- 20%.  The definitive management of symptomatic gallstones is surgical. The two surgical approaches are conventional and laparoscopic. First successful removal of gallbladder was done by Carl Langenbuch in 1882 for stone disease.