PDF (5 MB) - Jurnalul de Chirurgie

150 Sahu SK. et al.Jurnalul de Chirurgie (Iaşi), 2013, Vol. 9, Nr. 2Dr. Eddie Reddick reported 100 casesof laparoscopic cholecystectomy in 1989.The classical four port technique of LC asdescribed by Reddick became the mostwidely adopted technique. LC wasconsidered by most to be at its zenith sinceits inception in the early 1990s and is alsonow done by 2 and 3 ports. When LC wasstarted, only simple gall stone disease wasconsidered as indication. With increasingexpertise and introduction of newerinstruments, acute cholecystitis has alsobecome one of the indications for LC. Nowany type of calculus cholecystitis can bemanaged by laparoscopic method. The skillof the surgeon, experience in laparoscopictechniques and thorough knowledge of therisk factors are important for laparoscopicmanagement of gall stone disease indifficult situation without increasing themorbidity. [1]Laparoscopic surgery has certaintechnical limitations like loss of threedimensionalperception, a relatively limitedand fixed view of operative field, indirectcontact with intraabdominal structures, andlimited tactile feedback during dissectionand manipulation of tissues. This makesoperation difficult sometimes and leads toconversion to open cholecystectomy. Thedefinition of “difficult laparoscopiccholecystectomy (LC)” is inconsistent. Theterm difficult cholecystectomy refers tomultiple technical intra-operative difficultiesthat increases the risk complications andsignificantly prolongs operation time. [2, 3]The aim of the study was to study theintraoperative difficulties in LC.MATERIAL AND METHODSThis study was carried out over aperiod of 12 months prospectively in theDepartment of General Surgery atHimalayan Institute of Medical Sciences,HIHT University, Dehradun, Uttarakhand,India. All the patients who underwent LCpresenting to our hospital were included inthis study. A sample size of 200 wasincluded in the study. Exclusion criteriaincludes preoperatively proven gall bladdermalignancy, refractory coagulopathy, severecardio-pulmonary disease, as these patientscannot tolerate CO 2 pneumoperitoneum andpatients unfit for general anaesthesia due toany other reason. Total duration of surgeryfrom the insertion of veress needle to theclosure of port site and conversion to opencholecystectomy, if any and the cause ofconversion were also studied. Surgeons withexperience of more than 100 laparoscopiccholecystectomies did all the surgeries inthis study.Difficult LC was defined in thoseprocedures which exceeded 90 minutes induration and or converted to open procedure.Per operative difficulties wereclassified and studied in the following stepsduring the procedure:1) Creation of the pneumoperitoneum;2) Separation of all adhesions;3) Skeletonization, ligation and divisionof cystic artery and cystic duct;4) Excision of gall bladder (GB) from thegall bladder fossa of the liver bed;5) Extraction of GB.Overlapping of these intra operativedifficulties were recorded and consideredwhile doing the statistical analysis. The datacollected was represented in the form of bardiagram and pie diagrams. The results havebeen analysed by using unpaired t-test.RESULTSThis study was carried out over aperiod of 12 months from March 2011 toFebruary 2012, prospectively in theDepartment of General Surgery atHimalayan Institute of Medical Sciences,HIHT University, Dehradun, Uttarakhand,India. 200 patients who underwent LCpresenting to our hospital were included inthis study.Out of 200 LC, 130 (65%) were easyand 70 (35%) were considered as difficult.Out of these 70 difficult cases 12(6%) required conversion to opencholecystectomy.All those cases which were convertedfrom laparoscopic to open cholecystectomywere included in the difficult laparoscpic