Intraoperative Difficulties in Laparoscopic Cholecystectomy

Abstract

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.

Preoperative Prediction of the Difficulty of Laparoscopic Cholecystectomy

“…Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures worldwide is accepted as the gold standard in the treatment of symptomatic gallstones [1]. Preoperative assessment of complexity factors is needed for frequent procedures such as (LC) in order to avoid complications and delays and to guarantee an efficient course of surgery [2].…”

“…In case of laparoscopic cholecystectomy, preoperative complexity estimation helps surgeons deciding whether to proceed with a minimally invasive approach, perform an open procedure or make a referral to a more experienced surgeon. It may also be useful for explaining the various risks of laparoscopic and open procedures [1]. Although laparoscopic cholecystectomy has generally a low incidence of morbidity and mortality and of conversion rate to open surgery, its outcome is particularly affected by the presence and severity of inflammation, advancing patient's age, male sex and greater body mass index [3].…”

Assessment of clinical, hematological, radiological parameters for prediction of difficult laparoscopic cholecystectomy at a tertiary health care centre

“…24 However, according to previous studies, maximum difficulty in performing LC was faced in patients having abnormal Calot's anatomy in turn resulting in maximum rates of conversion. 24 LC has been considered as the ideal treatment for acute cholecystitis.…”

“…24 However, according to previous studies, maximum difficulty in performing LC was faced in patients having abnormal Calot's anatomy in turn resulting in maximum rates of conversion. 24 LC has been considered as the ideal treatment for acute cholecystitis. While most of the previous studies were conducted retrospectively and evaluated various risk factors in terms of conversion to OC, this prospective study analyzed various risk factors as pre-operative predictors on the basis of clinical evaluation and ultrasonographic parameters.…”

Prediction of difficulties during laparoscopic cholecystectomy by preoperative clinical examination and ultrasonography

“…Laparoscopic cholecystectomy (LC) has gradually replaced open cholecystectomy (OC) in the treatment of symptomatic gall stone disease and accepted as the gold standard. 3 Better cosmetic results, short hospital stay, early recovery and return to physical activity and work, all have contributed to the popularity of this technique. [4][5][6] In the beginning, patients with acute cholecystitis, empyema, gangrenous gallbladder, cirrhotic patients and Mirizzi syndrome, previous upper abdominal surgery, and morbid obesity were considered as contraindications for carrying out LC.…”