It was a gynecologist who introduced the so called ‘endoprocedures’ in the field of surgery, his name was Kurt Semm, a German national who used his instruments for the removal of ovaries and myomas in 1970s. Only after a successful laparoscopic appendicectomy by Semm in 1982 the general surgeons realized the importance and started applying these instruments in the field of general surgery. The German surgeon Eric Muhe while pioneering cholecystectomy came to know that a modification of the instrument is needed for gall bladder removal. Since then rest of the world started doing laparoscopic cholecystectomies but, this was the time when abdominal open surgeries were becoming extensive operations with the concept of ‘bigger problems need bigger incisions’ and laparoscopic technique was criticized by many as “a futureless technique, circus surgery, the mediatized show of a
This study was carried out over a period of 12 months from March 2011 to February 2012, at Himalayan Institute of Medical Sciences, HIHT University, Dehradun, Uttarakhand, India on 200 patients by Sahu S. K. The aim of the study was to study the intraoperative difficulties in LC. They concluded that previous abdominal surgery, intrahepatic gallbladder, multiple large calculi, very thick walled gallbladder, acute cholecystitis and abnormal Calot’s anatomy are the difficult factors to operate upon and increases the operating time 46.
was assumed that SIOC would take 16 min less com- pared to LC, based on three previous studies [19–21]. The calculation was made for 90% power, 5% signifi- cance level and an anticipated data loss of 25%. With these assumptions, it was calculated that the study should consist of at least 350 patients. The sample size was estimated to be sufficient for detecting significant differences of routine costs, but not for comparing rela- tively rare complications between groups. All analyses were made with the intention-to-treat principle. Quanti- tative results were presented as median values, 25 and 75 th percentiles whenever the distribution of the data was skewed. A non-parametric Mann-Whitney U test was used for statistical tests of significance. AUC (Area Under Curve) values up to 1 year were calculated using the EQ-5D-3L scores at five different postoperative time points and the assumption that the change between time points was linear. Missing EQ-5D-3L values were impu- tated if the case had at least two registered genuine EQ- 5D-3L values at different time points, otherwise the case was excluded from AUC calculation. We used the principle to add (or subtract) the mean change between specific time points for the group (LC or SIOC) to the last genuine value to generate the value for the next time point if it was missing. In all, 128 imputations for miss- ing values were added to the 1372 genuine values. Thirty-three cases were excluded because of more than three missing EQ-5D-3L scores. The EQ-5D-3L scores and AUC values were calculated from raw data using Microsoft® Excel for Mac version 14.2.3 (Microsoft Corporation, Redmond, Washington, USA), and Stata® software release 13.1 (StataCorp LP, College Station, Texas, USA) was used for statistical calculations.
Postoperative complications treated without re-operation were noted in 12 patients. In one patient calculi in the common bile duct stones had to be removed with sphinc- terotomy and temporary endoprosthesis (IIb); another patient was erroneously administered low molecular weight heparin intra-operatively and developed multiple intra-abdominal haematomas, which resolved spontane- ously (II b). Wound infections were identified in 10 patients (grade I in eight patients and grade IIa in two patients). Patients with wound infection were older than those without wound infection, mean 67 versus 54 years, but they did not differ significantly from patients without wound infection with respect to emergency indication (30% versus 38%) or BMI (mean 27.3 versus 28.2).
This retrospective study included patients admitted from 2012- 2017 (5 Years) in the Department of General Surgery at Government Medical College Amritsar, Punjab, India. All the patients who underwent LC presenting in the hospital were included in this study. A sample size of 200 was included in the study. Exclusion criteria includes preoperatively proven gall bladder malignancy, refractory coagulopathy, severe cardio-pulmonary disease, as these patients cannot tolerate CO2pneumoperitoneum and patients unfit for general anaesthesia due to any other reason. Total duration of surgery from the insertion of veress needle to the closure of port site and conversion to opencholecystectomy, if any and the cause of conversion were also studied. Surgeons with experience of more than 100 laparoscopic cholecystectomies did all the surgeries in this study. Difficult LC was defined in those procedures which exceeded 90 minutes in duration and or converted to open procedure.
RESULTS: A total of 39 patients underwent partial cholecystectomy with 280 laparoscopic and opencholecystectomy operations. The majority of the patients treated were female: 40 (95%) and 2 (5%) patients were male. The age range was 35-80 (mean 47). Acute cholecystitis in 26 (62%) patients, bile duct empyema in 7 (16.5%) patients, bile duct mucocele in 4 (9.5%) patients and gallstone pancreatitis in 5 (12%) patients. Tube cholecystostomy was used in two patients and opencholecystectomy was performed after a 12-week follow-up. In our study, 29 (69%) had diabetes mellitus, 20 (47.5%) had hypertension, 12 (28.5%) had ischemic heart disease and 16 (30%) had DM and HTN. The patients are followed up every three months and they are transferred to the home by telephone or in writing every six months. Liver function tests and ultrasound examination were performed at each visit. None of the patients had postoperative
for progression to transcystic clearing or stenting of the common bile duct; in many cases clearing can be accomplished with simple measures such as administration of glucagon and flushing with saline. In terms of detecting bile duct stones, 2-12% of patients will have choledocholithiasis on routine intraoperative cholangiogram, and recent studies suggest as many as 10% of these are unsuspected prior to operation. A meta-analysis performed in 2004 revealed that the incidence of unsuspected retained stones was 4% with only 15% of these going on to cause clinical problems. The conclusion from that study was that a selective policy should be advocated, though creating a reliable algorithm for predicting the presence of stones and thus the need for selective cholangiogram has been unsuccessful.
Cholecystectomy was completed laparoscopically in 28 patients. Only two cases were converted to opencholecystectomy. In the first patient severe inflammation and adhesions were present at the gallbladder area. Because of the intense adhesions at the Calot’s triangle we decided to convert the operation to opencholecystectomy with open CBD exploration (Figure. 3.). In the second patient, laparoscopiccholecystectomy was initiated and during dissection the cystic duct was avulsed from its attachment near the bile duct. We decided to perform an open CBD exploration with successful extraction of the stone. Gallbladder removal was completed with closure of the CBD over a T-tube. Only five patients had complications in the form of biliary leak from cystic duct stump in one case, two postoperative bleeding and two wound infection (Table 3).
monitored closely for signs of complications in the postoperative period. The trocars can lacerate blood vessels in the abdominal wall.so before removal, trocar should be visualized from the peritoneal aspect using the laparoscope. If significant hemorrhage is seen, it usually can be controlled with cautery, intraoperative tamponade with a Foley catheter, or a through-and-through suture on each side of the trocar insertion site. Most complications occur early in the surgeon's experience. In a multivariate regression analysis of 8839 laparoscopic cholecystectomies in which there were 15 bile duct injuries, the only significant factor associated with an adverse outcome was the surgeon's experience with the procedure (Moore & Bennett, 1995). The regression model predicted that a surgeon had a 1.7% chance of a bile duct injury occurring in the first case and 0.17% chance of a bile duct injury in the 50th case.
There is a report that postoperative analgesia require- ments for the LC with needlescopic instruments, which has smaller ports, were 70% lower than for the conven- tional LC . It is expected that a slightly bigger wound to construct multichannel port for DILC caused strong pain, but our study showed a different result. The effect of number or size of ports on postoperative pain remains an open question.
Present prospective study included ultrasonographically proved 50 patients of symptomatic cholelithiasis and were posted for elective cholecystectomy. These patients were admitted in Surgical Wards of Indira Gandhi Medical College, Shimla .SILC were performed on 25 (50% of patients) and cLC were conducted in rest of 25 (50%) patients. The patients were selected randomly. Relevant history, clinical examination and investigations were recorded. SILC was done by infra umblical incision and cLC was done by three /four Trocar Technique. Patients with acute cholecystitis /pancreatitis, choledocholithiasis jaundice / hypoproteinemia/malignancy, conversion of cLC to opencholecystectomy , patients on oral contraceptive pills/pregnancy , intra operative injury to adjacet organs/structures etc. are excluded from study .
BACKGROUND: Paramaters defining cholecystectomy as „difficult‟: peritonitis in right hypochondrium, difficult identification and isolation of cystic artery/duct, scarring of Calot‟s triangle, inflammation, abundant adipose tissue and difficult dissection of GB from liver. Removal of GB by laparoscopy is considered “difficult” due to high risk factors which can be known preoperatively or intraoperatively. Objective: 1. To assess various factors predicting difficult laparoscopiccholecystectomy. 2. To study methods to deal with difficult laparoscopiccholecystectomy. 3. Find conversion rate from laparoscopic to opencholecystectomy in case of difficult laparoscopiccholecystectomy(LC). MATERIALS AND METHODS: Cases of elective LC of SSG Hospital from May 2010 to November 2012 are included; total 309 cases. Inclusion Criteria: Either sex patients posted only for elective LC. Exclusion Criteria: Factors precluding conversion from laparoscopic to opencholecystectomy like instrument/power failure,etc. RESULTS: 309 patients included in study with mean age of 44.96 years [11-85], consisting of 69 males [22.33%] & 240 females [77.67%]. Of 309 patients, conversion to opencholecystectomy was necessary in 22 patients with conversion rate of 7.12%. Of 309 patients, 73 (23.62%) were difficult, out of which in 44 (61.11%) cases, routine LC was done, Laparoscopic subtotal cholecystectomy in 7 (8.14%) cases and 22 (30.13%) patients were converted to opencholecystectomy (conversion rate 30.13%) CONCLUSION: Most common risk factor-OBESITY. Conversion rate for all cases is 7.12% and for difficult cases, it is 30.13%. The patients considered “difficult” managed by continuing laparoscopic surgery, coversion to opencholecystectomy or by laparoscopic subtotal cholecystectomy.
Perforation of hollow viscus during trocar insertion. Small bowel most commonly gets injured. Many times this perforation will not be evident intraoperatively, manifests most commonly post operatively as faecal peritonitis and mortality is high in such cases. If bowel perforation is identified intraoperatively then the procedure should be converted into open and bowel suturing should be done.
Laparoscopiccholecystectomy was introduced in 1985 and in very short time became the procedure of choice for surgical removal of the gallbladder. This rising popularity was based on many outcomes, including lower morbidity and complication rate, and a quicker postoperative recovery compared to opencholecystectomy, despite a rise in bile duct injury. It has improved patient satisfaction in terms of both primary and secondary outcome measures. Although it showed early promising results, recent trials show an increase in the incidence of operative complications, especially common bile duct injury. 7
Incidence of bile duct injury in our study was restricted only to opencholecystectomy (2.7%) which was a major transection injury involving common bile duct, way higher than reported in standard literature of about 0.125% (1 in 800). Biliary continuity was restored with Roux-en-Y hepatico jejunostomy electively, months after a emergency laparotomy where in a large bilioma was drained.
RHA, the cystic artery, the cystic lymph node (of Lund), connective tissue, and lymphatics. Occasionally it may contain accessory hepatic ducts and arteries as discussed previously. It is this triangular space, which is dissected in a cholecystectomy to identify the cystic artery and cystic duct before ligation and division. In reality, it may be a small potential space rather than a large triangle making the dissection of its contents without damaging the bordering structures the most challenging step of a cholecystectomy. In addition the space may be obscured and shrunken by various mechanisms. The left (or medial) boundary of the triangle formed by the common hepatic duct is the most important structure, which needs to be safeguarded.
Background: Gallstone disease is a global health problem. The incidence is 10–20% of the whole adult population. The most common infectious disease of the Gallbladder (GB) is the acute cholecystitis (AC). Objectives: evaluate the safe technique of surgery in patients with acute cholecystitis, to highlight the better method in which patient can be prevented from complications, to analyze the clinical features and surgical outcome of LC for AC, to develop a new criterion for the therapeutic strategy used for AC, especially for late AC. Patients & Methods: The present study shows that the operation time among the studied cases ranged from 90 to 120 min with mean 105.34 min. Out of 24 LC cases 5 patients (20.8%) were converted to opencholecystectomy. These patients had unclear anatomy during LC dissection, wherein 3 patients (12.5%) had bile duct injury and 2 patients (8.3%) had bleeding. Results: Observed that the mean total hospital stays as a result of repeated readmission and recurrent attacks biliary pain were higher for patient groups with significant distribution. Therefore, the overall patient’s satisfaction regarding surgical outcome, recurrent attacks biliary pain, repeated readmission, and the length of hospital stay was in favor of patients with early surgical intervention. Our results concerning patient’s preference and satisfaction came in concordance with other published results of the same interest. Conclusions: The conversion rate is related to operators’ surgical experience. Regarding the postoperative outcomes, financial costs and length of hospital stay, it is more helpful than LC beyond 72 hours.
This study suffers from certain limitations. First of all, the data collection of the training group was performed in a retrospective fashion. This method naturally fails to be as accurate as prospective data collection; however, data of the validation group, which were collected prospectively, corresponded reasonably with that of the training group. Secondly, our study bears the flaws of single centered studies. Third, we regarded a surgeon as experienced after performing 50 LCs. This seems to be a relatively rough cri- terion to determine the level of experience of a surgeon. Forth, the robustness of the results may be damaged by the differences of characteristics of validation and test groups (i.e. surgeon skill and prevalent emergency surger- ies) in particular for discriminant regression analyses. Interestingly, the ANN approach is explicitly appropriate
Purpose: Single-fulcrum laparoscopiccholecystectomy (SFLC) is a variant type of single incision and multi-port technique that does not use specialized one-port de- vices or articulating instruments. We retrospectively compared perioperative out- comes of SFLC with those of conventional laparoscopiccholecystectomy (CLC). Materials and Methods: Between March 2009 and December 2010, SFLC was performed in 130 patients. Among them, 105 patients with uncomplicated gallblad- der disease (no inflammation or no clinical symptoms) and another 105 patients who underwent CLC were selected for this study. Results: There was no open con- version. In comparison with CLC, SFLC was performed more often in young (46.4±12.2 years vs. 52.5±13.6 years, p=0.001) female patients (80/25 vs. 62/43, p=0.008). The total operation time was longer in SFLC (56.7±14.1 min vs. 47.5±17.1 min, p<0.001), but pain scores immediately after operation and at dis- charge time were lower for SFLC than for CLC (3.1±1.3 vs. 4.0±1.9, p<0.001, 2.0±0.9 vs. 2.4±0.8, p=0.002). Total cost was lower for SFLC than for CLC (US $ 1801±289.9 vs. US $ 2003±617.4, p=0.004). There were no differences in hospital stay or complication rates. Conclusion: SFLC showed greater technical feasibility and cost benefits in treating uncomplicated benign gallbladder disease than CLC.
Postoperative pain was assessed by visual analogue scale. The pain scores were significantly lower in the three port group as compared to the four port group in early postoperative period as well as late postoperative period at first and second weeks. The mean visual analogue scale (VAS) score for pain was 2.88 at 1 hour, 4.24 at 24 hours and 2.34 at 48 hours in the three port group and 3.18 at 1 hour 4.70 at 24 hours and 2.84 at 48 hours in four port group. This difference was statistically significant (P <0.05). Mean VAS score was 0.162 at 1 week and 0.08 at 2 weeks in Group 1. In Group 2, mean VAS score was 0.44 at 1 week and 0.24 at 2 weeks. This difference in VAS scores at late postoperative period was also statistically significant. Manoj Kumar, et al reported similar findings in their study. 12 In their study the VAS