Mini-laparoscopic cholecystectomy: evolution of a new technique

Background Since the first laparoscopic cholecystectomy (LC) in 1985, there has been much advancement in laparoscopic surgery in terms of reduction in number and size of ports. We report a new technique of performing mini laparoscopic cholecystectomy using only three ports, 5 mm each. The indications of this procedure include GB polyps, GB dyskinesia, microlithiasis, and idiopathic pancreatitis. Case presentation In this case report, we present a new technique that has been performed safely in a 49-year-old male patient with pancreatitis caused by microlithiasis. This was performed using a novel three port procedure consisting of only 5 mm ports, and he was discharged as a day case without complications. Informed patient consent was obtained. Conclusions The fundamentals of this mini-LC technique remain the same as that of a standard laparoscopic cholecystectomy throughout the procedure. It is a feasible option in selected cases, and it has the potential to further augment the inherent benefits of minimal access surgery namely less analgesia, improved cosmesis and faster recovery. Further trials will help ascertain its potential advantages.

A COMPARATIVE STUDY BETWEEN ROUTINE INSERTIONS OF SUBHEPATIC DRAIN VERSUS NO DRAIN AFTER ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY

Introduction: Laparoscopic cholecystectomy is the mainstay of treatment in symptomatic cholelithiasis. Surgeons are still following the old habit of routine Subhepatic drainage following laparoscopic cholecystectomy (LC). However, routine drainage after LC is still a debatable issue. This study aims at evaluating the effects of Subhepatic drainage after standard laparoscopic cholecystectomy in terms of various post-operative parameters. Materials & methods: The study was conducted at the department of General Surgery, ESIC-PGIMSR, Joka, Kolkata from January 2018 to March 2020. We selected 120 patients with symptomatic cholelithiasis & divided them into 2 groups; each having 60 patients, with drain & without drain respectively. Age & sex distribution of the patients, post-operative abdominal pain & right shoulder tip pain, post-operative wound infection, subhepatic collection (24 & 72 hrs after surgery) & post-surgical hospital stay were measured in both groups. Data were analyzed by appropriate statistical tests. Results: We found the incidence of laparoscopic cholecystectomy was highest in the 5th decade & more common in women. The incidence of post-surgical abdominal pain & subhepatic collection were greater in the group of patients with drain in situ which was statistically significant also. Moreover, inserting drain showed increased incidence of post operative wound infection & hospital stay, though these were statistically insignificant. More patients in the non drain group showed post-operative right shoulder tip pain in comparison to the drain group but that was also statistically insignificant. Conclusion: The decision of inserting drain should be taken judiciously on the basis of individual case scenario. The generalized approach of putting abdominal drain after every standard laparoscopic cholecystectomy is not at all beneficial.

Natural Orifice Transluminal Endoscopic Surgery: Long-Term Experience with Hybrid Transvaginal Cholecystectomies

Objective. To assess outcome and safety of 571 hybrid natural orifice transluminal endoscopic surgery (NOTES) cholecystectomies. Methods. We retrospectively analyzed all consecutive NOTES cholecystectomies performed at our center between June 2009 and January 2018. All procedures were performed using a hybrid transvaginal technique, including an umbilical small-size trocar. End points, calculated at discharge, 30 and up to 90 days postoperatively, included intra- and postoperative morbidity assessed by the validated Clavien–Dindo classification and the Comprehensive Complication Index (CCI). Special focus was held on outcome and necessity of pre- and postoperative gynecological examinations. Results. We performed 571 hybrid NOTES cholecystectomies within 9 years. The vast majority were elective, 9.6% were emergency cholecystectomies. 6.7% of patients developed at least one complication until discharge, most of them minor (≤grade II). 30- and 90-day complication rates were 10.7% and 11%, respectively. Mean CCI at discharge and postoperative days 30 and 90 was 1.45 (±6.4), 2.3 (±7.7), and 2.4 (±7.8), respectively. Major complications (≥grade IIIa) occurred in 1.6% of patients, and 4 patients required emergency reoperation. No mortality was observed. In 9.8%, an additional abdominal trocar was placed. All patients underwent routine gynecological examination, whereof only 5 were rejected for transvaginal access preoperatively. In no case transvaginal access was discontinued intraoperatively due to gynecological disease. Conclusion. Hybrid NOTES transvaginal cholecystectomy represents a safe and feasible alternative to standard laparoscopic cholecystectomy. Preoperative gynecological examination is no longer routinely necessary, as intraoperative assessment is adequate.

Comparative study of standard laparoscopic cholecystectomy and single incision laparoscopic cholecystectomy: outcome and complications

Background: Laparoscopic cholecystectomy (LC) has evolved to be as gold standard treatment for gall bladder disease and is the most common laparoscopic procedure performed worldwide. In recent times, the innovative techniques of Natural orifice Transluminal Endoscopic Surgery (NOTES) and Single Incision Laparoscopic Surgery (SILS) have been applied as a step forward towards scar less surgery with added benefits of less pain and less analgesic requirement, shorter hospital stay, quick return to work.Methods: A retrospective study of 50 patients admitted with gall bladder disease through outdoor for laparoscopic cholecystectomy from November 2018 to January 2019 in Maharishi Markandeshwar Institute of Medical Sciences and Research Mullana (AMBALA) were randomized into two groups of 25 each for Single Incision Laparoscopic Cholecystectomy (SILC) and standard laparoscopic cholecystectomy (LC) comparing the operative time, outcome and complications.Results: 50 patients admitted to MMIMSR Mullana from November 2018 to January 2019 with gall bladder disease were divided into two groups of 25 each who underwent three port SILC and four port laparoscopic cholecystectomy (4PLC). The average intra-operative time in SILC (80.56 mins) was significantly more than standard laparoscopic cholecystectomy. The average length of stay in the hospital for SILC was 1.8 days (1-3 days), was significantly less than in standard four port laparoscopic cholecystectomy. Incidence of Intraoperative complications were more in SILC than standard LC.Conclusions: SILC as the newer novel technique had better outcomes in terms of cosmesis, early discharge, shorter stay at hospital.

Single port laparoscopic cholecystectomy compared to the standard laparoscopic cholecystectomy

Background: Efforts to improve outcomes of laparoscopic cholecystectomy heralded the advent of single incision laparoscopic cholecystectomy. The objective of this study was to evaluate and compare single port laparoscopic cholecystectomy to the standard laparoscopic cholecystectomy with respect to time required for surgery, postoperative pain, morbidity and complications.Methods: This comparative randomized study was conducted in M.L.B. Medical College, Jhansi among 124 patients. 74 patients were included in the three port laparoscopic cholecystectomy group and 50 in the single port laparoscopic cholecystectomy group. Informed consent was taken. All patients were operated under general anesthesia. Statistical analysis was using independent t-test and chi- square test.Results: The mean operative time was slightly longer in SILC (group I) as compared to CLC/SLC (group II). Postoperative pain on VAS scale in group I after 6 hours (1st day score) was 2.44 in group I and 2.73 in group II (CLC/SLC). But on 2nd day in SILC 1.40 and in CLC/SLC it was 1.81. In SILC (group I) 4 patients out of 50 (8%) developed seroma and 2 patients out of 50 (4%) developed Biliary peritonitis due to the slipped dip. And in SLC/CLC (group II) 3 patients out of 74 (4.05%) developed seroma.Conclusions: SILC can be an effective alternative to traditional CLC/SLC, with the added benefit of minimized scarring and a shorter length of stay. This technique can be performed safely for patients with a multitude of gallbladder diseases without resulting in additional complications.

Glisson’s capsule cauterisation is associated with increased postoperative pain after laparoscopic cholecystectomy: a prospective case–control study

INTRODUCTION Postoperative pain after laparoscopic cholecystectomy has three components: parietal, visceral and referred pain felt at the shoulder. Visceral peritoneal injury on the liver (Glisson’s capsule) during cauterisation sometimes occurs as an unavoidable complication of the operation. Its effect on postoperative pain has not been quantified. In this study, we aimed to evaluate the association between Glisson’s capsule injury and postoperative pain following laparoscopic cholecystectomy. METHODS The study was a prospective case–control of planned standard laparoscopic cholecystectomy with standardized anaesthesia protocol in patients with benign gallbladder disease. Visual analogue scale (VAS) abdominal pain scores were noted at 2 and 24 hours after the operation. One surgical team performed the operations. Operative videos were recorded and examined later by another team to detect presence of Glisson’s capsule cauterisation. Eighty-one patients were enrolled into the study. After examination of the operative videos, 46 patients with visceral peritoneal injury were included in the study group, and the remaining 35 formed the control group. RESULTS VAS pain score at postoperative 2 and 24 hours was significantly higher in the study group than control (P = 0.027 and 0.017, respectively). CONCLUSIONS Glisson’s capsule cauterisation in laparoscopic cholecystectomy is associated with increased postoperative pain. Additional efforts are recommended to prevent unintentional cauterisation.