INTRAOPERATIVE DIFFICULTIES IN LAPAROSCOPIC CHOLECYSTECTOMY (Abstract): INTRODUCTION:Laparoscopic surgery has certain technical limitations like loss of three-dimensional perception, a relatively limited and fixed view of operative field, indirect contact with intraabdominal structures, and limited tactile feedback during dissection and manipulation of tissues. This makes operation difficult sometimes and leads to conversion to open cholecystectomy. AIM: The aim of the study was to study the intraoperative difficulties in Laparoscopic Cholecystectomy. MATERIAL AND METHODS: This is a prospective study over a period of 12 months in the Department of General Surgery at Himalayan Institute of Medical Sciences, HIHT University, Dehradun, Uttarakhand, India. Difficult Laparoscopic Cholecystectomy was defined in those procedures which exceeded 90 minutes in duration and or converted to open procedure. Per operative difficulties were classified and studied in the following steps during the procedure: 1) Creation of the pneumoperitoneum; 2) Separation of all adhesions; 3) Skeletonization, ligation and division of cystic artery and cystic duct; 4) Excision of Gall Bladder from the gall bladder fossa of the liver bed; 5) Extraction of Gall Bladder. RESULT: 200 patients who underwent Laparoscopic Cholecystectomy presenting to our hospital from March 2011 to February 2012 were included in this study. Out of 200 laparoscopic cholecystectomy (LC) 130 (65%) were easy and 70 (35%) were difficult. Out of these 70 difficult cases 12 (6%) required conversion to open cholecystectomy. The conversion rate was higher in the age group of > 60 years. The maximum difficulty occurred while separating the adhesions 75.71% out of 70 cases. Maximum difficulty while performing this step of LC was found in patients with Previous Abdominal Surgery 8 (50%). Maximum number of adhesions and difficulty separating them was seen in patients with acute cholecystitis 22 (41.50%). Out of 70 difficult cases there were 39 (55.71%) cases in which skeletonization, ligation and division of cystic artery and duct was difficult. Maximum difficulty in this step of LC was seen in patients with abnormal callot's anatomy 20 (51.28 %). Maximum conversion rate was seen with patients having abnormal callot's anatomy 35%. CONCLUSIONS : Previous abdominal surgery, intrahepatic gallbladder, multiple large calculi, very thick walled gallbladder, acute cholecystitis and abnormal callot's anatomy are the difficult factors to operate upon and increases the operating time. Acute cholecystitis and abnormal callot's anatomy are the two conditions in which the conversion rate is higher.

There are three major components of vomit reflex, the emetic detectors, integrative mechanism, and motor output. The main sensors of somatic stimuli are located in the gut and chemo-receptor trigger zone (CTZ). The emetic stimuli in gut are detected by two types of vagal afferent fibers. Mechanoreceptors They are located in the muscular wall of the gut and are activated by contraction and distension of the gut, on physical damage and manipulation during surgery.

Background: Laryngoscopy and endotracheal intubation are associated with an increase in blood pressure (BP) and heart rate (HR). The present study was conducted to evaluate the role of gabapentin in attenuation of these hemodynamic changes. Methods: Forty patients undergoing elective laparoscopic cholecystectomy under general anesthesia with standardized premedication and anesthetics were randomized to receive gabapentin or a matching placebo. The patients of Group I received gabapentin 600 mg orally 2 hrs before surgery and patients in Group II received a matching placebo. Patient's HR, systolic BP (SBP), diastolic BP (DBP), mean BP (MBP), were monitored before and after 1, 2, 5, and 10 mins of endotracheal intubation. Results: Comparison of SBP, DBP, and MBP at 1, 2, 5 and 10 mins after endotracheal intubation showed statistically significant attenuation in the gabapentin group when compared to placebo. Changes in the HR were not significant. Conclusion: Gabapentin 600 mg, given 2 hrs before induction is effective in attenuating the pressor response to laryngoscopy and tracheal intubation.

Aim:To compare the role of single intravenous (IV) bolus of lignocaine and dexamethasone on pain score and quality of recovery score (QoR40) after laparoscopic cholecystectomy.Setting and Design:The study was conducted at the postoperative recovery area, This was a double-blind randomized controlled study.Materials and Methods:Seventy patients 18–60 years of age, American Society of Anesthesiologists physical status Class I and II, who underwent elective laparoscopic cholecystectomy, were enrolled in this study after approval from the Institutional Ethics Committee. Patients were randomly allocated to two groups. Group 1 received: 2 mg/kg lignocaine diluted to 10 ml with normal saline, and Group 2 received 0.1 mg/kg IV dexamethasone diluted to 10 ml with normal saline. Global QoR-40 is a 40-item questionnaire that provides a global score and subscores across five dimensions: psychological support, comfort, independence, pain, and emotions. It was assessed on a preoperative day as baseline to assess patient's basic quality of life and at 24 h postoperative. Visual analog scale (VAS) static and dynamic, total analgesic consumption in a day, nausea and vomiting, and antiemetic per day were assessed.Statistical Analysis Used:Student's t-test, Chi-square test, Fisher's exact, Levene's test were used for statistical analysis.Results:Dexamethasone group had higher Global QoR-40 than lignocaine group 187.94 versus 182.85. Among dimensions of QoR-40, dexamethasone had statistically better physical comfort, physical independence, and pain relief as compared to lignocaine. Dexamethasone group had lower VAS compared to lignocaine group. Similarly, there was less fentanyl consumption in dexamethasone group (364.08 ± 127.31) in the postoperative period when compared to the lignocaine group (412.31 ± 147.8).Conclusions:Preoperative administration of a single dose of dexamethasone enhanced QoR after laparoscopic cholecystectomy as compared to lignocaine bolus dose.

Background:Peritonitis is inflammation of peritoneum and peritoneal cavity. This study was aimed at predicting morbidity and mortality in patients with peritonitis due to hollow viscous perforation by using APACHE II Scoring system.Methods: This study was conducted in patients admitted as a case of perforation peritonitis in Tertiary centre Dehradun, over the period of 18 months. APACHE II score was calculated and correlated with their symptoms and clinical outcomes regarding morbidity and mortality.Results:In present study APACHE- II significantly predict the morbidity and mortality with p value < 0.001. It showed perfect correlation of APACHE-II score and predicted death risk (r = 0.96, P = 0.001).Conclusions: The APACHE-II scoring system can be used to assess group outcomes in patients with peritonitis due to hollow viscous perforation. However, it does not provide sufficient confidence for outcome prediction in individual patients.