Extraction Of Gallbladder Research Articles

Analyzing the Factors for Pre-operative Prediction of Problematic Laparoscopic Cholecystectomy: A Cross-sectional Exploratory Study

Background: Laparoscopic cholecystectomy is considered as the preferred treatment for symptomatic Cholelithiasis. Though laparoscopic cholecystectomies are considered a common surgical intervention, still 1-13% requires conversion to open cholecystectomy for various reasons. Pre-operative evaluation of such factors would be helpful to establish criteria that would assess the risk of conversion, hence the rationale for this study. Materials and Methods: A cross-sectional study conducted among patients (n=100) reporting with gall bladder disease and requiring cholecystectomy (aged 10-60 years) not having peritonitis, malignancy, pregnancy and/ or a compromised immune system were recruited in the study. Factors of difficult laparoscopic were assessed by Socio-demographic factors, Inspection and Palpation and USG findings (wall thickness, pericholecystic collection, impacted stone and post ERCP status). Following this, the patient was subjected to laparoscopic cholecystectomy and conversion was noted. SPSSv15.0 was utilized for statistical analysis (*p<0.05). Results: Study subjects with GB wall thickness >3mm, presence of pericholecystic fluid, appearance of WES sign, and subjects having multiple gall stones and/ or CBD stone had a significantly higher level of difficulty in gall bladder extraction, as well as higher chances of complicated bleeding. Overall, 13% subjects required a conversion from Laparoscopic Cholecystectomy to Open Cholecystectomy. Conclusion: Pre-operative prediction of difficult laparoscopic cholecystectomy can help the patient as well as the surgeon to prepare better for the intra operative risk and risk of conversion to open cholecystectomy.

Use of retrieval bag in the prevention of wound infection in elective laparoscopic cholecystectomy: is it evidence-based? A meta-analysis

BackgroundSurgical site infections complicate elective laparoscopic cholecystectomies in 2,4-3,2% of cases. During the operation the gallbladder is commonly extracted with a retrieval bag. We conducted a meta-analysis to clarify whether its use plays a role in preventing infections.MethodsInclusion criteria: elective cholecystectomy, details about the gallbladder extraction and data about local or systemic infection rate. Exclusion criteria: cholecystitis, jaundice, concurrent antibiotic therapy, immunosuppression, cancer. A comprehensive literature search of PubMed, Cochrane Library and MEDLINE databases was carried out independently by two researchers, according to the PRISMA guidelines and applying the GRADE approach. Terms used were (“gallbladder”AND(“speciment”OR“extraction”OR“extract”))OR(“gallbladder”OR“cholecystectomy”)AND(“bag”OR“retrieval|”OR|“endobag”OR“endocatch”).ResultsThe comprehensive literature revealed 279 articles. The eligible studies were 2 randomized trials and a multicentre prospective study. Wound infections were documented in 14 on 334 (4,2%) patients operated using a retrieval bag versus 16 on 271 (5,9%) patients operated without the use of a retrieval bag. The statistical analysis revealed a risk ratio (RR) of 0.82 (0.41–1.63 95% CI). Concerning sensitivity analysis the estimated pooled RR ranged from 0.72 to 0.96, both not statistically significant. Harbord test did not reveal the occurrence of small-study effect (p = 0.892) and the funnel-plot showed no noteworthy pattern.ConclusionsThe results of this review highlight the paucity of well-designed large studies and despite limitations related to the low level of evidence, our meta-analysis showed no significant benefit of retrieval bags in reducing the infection rate after elective laparoscopic cholecystectomy. In absence of acute cholecystitis, accidental intraoperative gallbladder perforation or suspected carcinoma their use, to date, may not be mandatory, so that, further studies focusing on complex cases are needed.

Randomized trial of umbilical incisional hernia in high-risk patients: extraction of gallbladder through subxiphoid port vs. umbilical port after laparoscopic cholecystectomy.

IntroductionTrocar site incisional hernia (TSIH) is one of the most common complications of laparoscopic surgery. Using the umbilical port as a common hole for removing the gallbladder in laparoscopic cholecystectomy is more likely to lead to TSIH than other ports. Thus, extracting the gallbladder through other ports may reduce the incidence of TSIH.AimTo ascertain whether extraction of the gallbladder through the subxiphoid port is more beneficial for reducing umbilical incisional hernia than the umbilical port.Material and methodsFrom April 2014 to March 2017, a randomized clinical trial was conducted among patients with high risk of incisional hernia and accepted for three-port laparoscopic cholecystectomy (TLC) in our department. 182 patients with indications of cholecystectomy were allocated randomly to group A (subxiphoid port) and group B (umbilical port). Data collection was carried out on operative time, postoperative pain, hospital stay, wound infection and TSIH in the early postoperative course, and at 1, 10, and 24 months after surgery.ResultsThe incidence of TSIH in group A was lower than that in group B (4.9% vs. 14.6%; odds ratio = 8.02; 95% CI: 2.15–47.6; p < 0.001). The mean operative time of group A was significantly shorter than that of group B (35 ±15.16 min vs. 42 ±14.58 min, p < 0.01). There was no significant difference in wound infection rate between group A and group B (p = 0.068). The data of hospital stay (p = 0.428) and postoperative pain (p = 0.349) of all analyzed patients were similar in the two groups.ConclusionsExtraction of the gallbladder through the subxiphoid port can reduce umbilical incisional hernia in high-risk patients effectively.

Intraperitoneal hydrocortisone for pain relief after laparoscopic cholecystectomy

Background Laparoscopic cholecystectomy (LC) is associated with shorter hospital stay and less pain in comparison with open surgery. The aim of this study was to evaluate the effect of using intraperitoneal hydrocortisone on pain relief following LC. Objectives This study aims to evaluate the effect of using intraperitoneal hydrocortisone after LC in decreasing postoperative pain and other adverse effects. Patients and methods Fifty patients were enrolled in a double-blind, randomized clinical trial. Patients (randomly assigned) underwent ordinary LC or along with the operation received 100 mg of hydrocortisone in 250 ml normal saline after extraction of the gallbladder into the peritoneum. Abdominal pain and shoulder pain were evaluated using the visual analog scale after surgery and at 6, 12, and 24 h postoperatively. The patients were also followed for postoperative analgesic requirements, nausea and vomiting, and return of bowel function. Results Forty-eight patients completed the study. Patients in the hydrocortisone group had significantly lower abdominal pain (10.75 vs. 12.65,P = 0.00) and shoulder pain (5.35 vs. 6.74,P = 0.008) scores than the control group. There were no significant differences regarding analgesic requirements in the recovery room. However, those in the hydrocortisone group required less meperidine than those in the control group (138.55 ± 49.9 vs. 69.96 ± 38.69 mg,P = 0.00). There were no significant differences with respect to return of bowel function, nausea, and vomiting. No adverse reaction was observed in either group. Conclusion Intraperitoneal administration of hydrocortisone can significantly decrease pain and analgesic requirements after LC with no adverse effects.

A comparative study of the incidence of pain and infection in gall bladder extraction via umbilical and epigastric port

Background: In laparoscopic cholecystectomy, gall bladder extraction via different ports has always been a matter of concern for the surgeons. This study is designed so as to determine the difference in the rate of pain and infection in gall bladder extraction via umbilical and epigastric port.Methods: A prospective randomized study was done from January 2015 to December 2015 at S. N. Medical College, Agra in which 200 patients of cholelithiasis were considered. The patients were randomly selected in the operation theatre for gall bladder extraction via epigastric port (designated as Group-A with n = 100 patients) and gall bladder extraction via umbilical port (designated as Group-B with n = 100 patients).Results: Post-operative pain at 24 hours, in terms of VAS was 3.67±1.42 in Group-A while 2.47±1.17 in Group-B with 10 being the worst pain. The p-value was calculated as .000048. The result is significant at p&lt; .05. A total of eight patients out of two hundred patients suffered port site infections amongst which five were from Group-A (5%) and three were from Group-B (3%).Conclusions: This study thus indicates that in laparoscopic cholecystectomy, gall bladder retrieval through the umbilical port is a better alternative to gall bladder extraction via epigastric port in terms of post-operative pain and port site infection. Our study recommends gall bladder extraction via umbilical port rather than epigastric port.

COMPARISON OF INFECTION

Objectives: To describe the incidence of wound infection when gall bladderremoved through umbilical port using the bag formed by surgical glove with a group where bagis not used. Study Design: Descriptive study. Setting: Surgical units of Nishtar Hospital Multan.Period: Two years from November 2013 to November 2015. Material and Method: There were100 patients in study. All patients were divided in two groups, in one group a bag formedby surgical glove is used in other group gall bladder removed without bag. Results: In firstgroup where bag is used minor wound infection occurred in only one patient at the umbilicalport site. In second group where bag is not used for the extraction of gall bladder, the minorwound infection occurred in three patients. Conclusion: The use of endoglove is beneficial inminimizing the port site infection &amp; it is also economical.

English

Objectives: To describe the incidence of wound infection when gall bladderremoved through umbilical port using the bag formed by surgical glove with a group where bagis not used. Study Design: Descriptive study. Setting: Surgical units of Nishtar Hospital Multan.Period: Two years from November 2013 to November 2015. Material and Method: There were100 patients in study. All patients were divided in two groups, in one group a bag formedby surgical glove is used in other group gall bladder removed without bag. Results: In firstgroup where bag is used minor wound infection occurred in only one patient at the umbilicalport site. In second group where bag is not used for the extraction of gall bladder, the minorwound infection occurred in three patients. Conclusion: The use of endoglove is beneficial inminimizing the port site infection &amp; it is also economical.

Effect of bag extraction to prevent wound infection on umbilical port site wound on elective laparoscopic cholecystectomy: a prospective randomised clinical trial.

Laparoscopic cholecystectomy is the gold standard treatment for gallbladder stones. Complications due to laparoscopic procedure are rare, but rate of wound infection in some studies is about 8%. From January 2007 to December 2008, 320 laparoscopic cholecystectomies were performed at our hospital, and in 4.7% of them, wound infection of the umbilical trocar was identified. We believe that this infection rate could be lower and that it is necessary to implement a new technique to reduce the wound infection. The aim of the study was to evaluate the benefits of bag extraction of gallbladder to prevent the wound infection. Two-arm, parallel, 1:1, randomised controlled trial (ISRCTN38095251). All patients suffering from symptomatic gallbladder stones of low risk were enrolled for this study and were divided into two groups in basics gallbladder extraction: with (80 patients) or, as usually, without bag (76 patients). All patients with cholecystitis or accidental gallbladder perforation were excluded. We compared all the results to establish whether meaningful differences were found. The final sample analysed (156 patients) consisted of 121 women and 35 men; there were 80 in the control group and 76 in the study group. There were 15 (9.6%) diagnosed wound infections, eight cases in the study group and seven in the control group. There were no statistically significant differences. The determinant of wound infection in elective laparoscopic cholecystectomy is not the direct contact of the gallbladder with the wound; therefore, bag extraction is not necessary.

Transjejunal Extraction of Gallbladder After Mini-Laparoscopic Cholecystectomy in Patients with Previous Roux-en-Y Gastric Bypass: A Small Case Series.

The length of incisions on the abdominal wall directly correlates with wound-related morbidities and patient comfort. Both mini-laparoscopy (only ≤5-mm trocars) and natural orifice specimen extraction avoid larger abdominal incisions. This study described a new natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) cholecystectomy technique by combination of these two advanced laparoscopic techniques for cholelithiasis in patients who had prior laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity. Three patients (two males, one female; 39, 62, and 34 years old, respectively) were admitted with symptomatic cholelithiasis (multiple millimeter-sized gallstones), and all had previously had LRYGB. They were treated by mini-laparoscopic cholecystectomy using three 5-mm trocars. The gallbladder was removed through the dilated efferent limb of the jejunum, 5 cm distal from the gastrojejunostomy. Transjejunal extraction was performed under endoscopic guidance. The gallbladder in the jejenum was passed through the anastomosis and extracted with an endoscopic snare by the transoral way. The enterotomy was closed intracorporeally. There was no conversion or additional trocar requirement. All the procedures were completed successfully without problems. Respective operating times were 95, 75, and 120 minutes. Only 1 patient required postoperative analgesic; the others did not. The patients started to get a liquid diet on the night of surgery and were discharged on Days 1, 1, and 2, respectively, with normal diet recommendations. There were no morbidities. Mini-laparoscopic cholecystectomy is technically feasible in patients with previous LRYGB. Prior LRYGB was not an obstacle for transoral specimen extraction. The dilated efferent jejunal limb is a good alternative route for natural orifice specimen extraction. This report described the first natural orifice surgery through the small bowel.

Access to a Simulator is Not Enough: The Benefits of Virtual Reality Training Based on Peer‐Group‐Derived Benchmarks—A Randomized Controlled Trial

Virtual reality (VR) simulators are widely used to familiarize surgical novices with laparoscopy, but VR training methods differ in efficacy. In the present trial, self-controlled basic VR training (SC-training) was tested against training based on peer-group-derived benchmarks (PGD-training). First, novice laparoscopic residents were randomized into a SC group (n = 34), and a group using PGD-benchmarks (n = 34) for basic laparoscopic training. After completing basic training, both groups performed 60 VR laparoscopic cholecystectomies for performance analysis. Primary endpoints were simulator metrics; secondary endpoints were program adherence, trainee motivation, and training efficacy. Altogether, 66 residents completed basic training, and 3,837 of 3,960 (96.8 %) cholecystectomies were available for analysis. Course adherence was good, with only two dropouts, both in the SC-group. The PGD-group spent more time and repetitions in basic training until the benchmarks were reached and subsequently showed better performance in the readout cholecystectomies: Median time (gallbladder extraction) showed significant differences of 520 s (IQR 354-738 s) in SC-training versus 390 s (IQR 278-536 s) in the PGD-group (p < 0.001) and 215 s (IQR 175-276 s) in experts, respectively. Path length of the right instrument also showed significant differences, again with the PGD-training group being more efficient. Basic VR laparoscopic training based on PGD benchmarks with external assessment is superior to SC training, resulting in higher trainee motivation and better performance in simulated laparoscopic cholecystectomies. We recommend such a basic course based on PGD benchmarks before advancing to more elaborate VR training.

Design, Development, and Evaluation of a Novel Retraction Device for Gallbladder Extraction During Laparoscopic Cholecystectomy

BackgroundA source of frustration during laparoscopic cholecystectomy involves extraction of the gallbladder through port sites smaller than the gallbladder itself. We describe the development and testing of a novel device for the safe, minimal enlargement of laparoscopic port sites to extract large, stone-filled gallbladders from the abdomen. MethodsThe study device consists of a handle with a retraction tongue to shield the specimen and a guide for a scalpel to incise the fascia within the incision. Patients enrolled underwent laparoscopic cholecystectomy. Gallbladder extraction was attempted. If standard measures failed, the device was implemented. Extraction time and device utility scores were recorded for each patient. Patients returned 3–4 weeks postoperatively for assessment of pain level, cosmetic effect, and presence of infectious complications. ResultsTwenty (51 %) of 39 patients required the device. Average extraction time for the first eight patients was 120 s. After interim analysis, an improved device was used in 12 patients and average extraction time was 24 s. There were no adverse events. Postoperative pain ratings and incision cosmesis were comparable between patients with and without use of the device. ConclusionThe study device enables safe and rapid extraction of impacted gallbladders through the abdominal wall.

Preoperative ultrasound measurements predict the feasibility of gallbladder extraction during transgastric natural orifice translumenal endoscopic surgery cholecystectomy

Extraction of a gallbladder through an endoscopic overtube during natural orifice translumenal endoscopic surgery (NOTES) transgastric cholecystectomy avoids potential injury to the esophagus. This study examined the rate of successful gallbladder specimen extraction through an overtube and hypothesized that preoperative ultrasound findings could predict successful specimen passage. Gallbladder specimens from patients undergoing laparoscopic cholecystectomy were measured, and an attempt was made to pull the specimens through a commercially available overtube with an inner diameter of 16.7-mm. A radiologist blinded to the outcomes reviewed the available preoperative ultrasound measurements from these patients. Ultrasound dimensions including gallbladder length, width, and depth; wall thickness; common bile duct diameter; and size of the largest gallstone (LGS) were recorded. Multiple logistic regression analysis was performed to determine whether ultrasound findings and patient characteristics (age, body mass index [BMI], and sex) could predict the ability of a specimen to pass through the overtube. Of 57 patients, 44 (77%) who had preoperative ultrasounds available for electronic review were included in the final analysis. Gallstones were present in 35 (79%) of these 44 patients. Intraoperative gallbladder perforation occurred in 18 (41%) of the 44 patients, and 16 (36%) of the 44 gallbladders could be extracted through the overtube. Measurement of LGS was possible for 23 patients, and indeterminate gallstone size (IGS) was determined for 12 patients. The rate for passage of perforated versus intact gallbladders was similar (40% vs. 23%; p = 0.054). The LGS (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.02-1.33; p = 0.021) and IGS (OR, 22.97; 95% CI, 1.99-265.63; p = 0.025) predicted failed passage on multivariate logistic regression analysis. The passage rate was 80% for LGS smaller than 10 mm or no stones present, 18% for LGS 10 mm or larger, and 8% for IGS (p < 0.001). A majority of cholecystectomy specimens cannot pass through an endoscopic overtube. Preoperative ultrasound findings can predict successful specimen extraction. An IGS or a gallstone 10 mm or larger should be considered a relative contraindication to transgastric NOTES cholecystectomy.

Port-Site Hernia Following Laparoscopic Cholecystectomy

Port-site hernia is a rare but potentially serious complication of laparoscopic cholecystectomy. This study aimed to review the current literature, assess the incidence and causes of port-site hernias, and identify methods to reduce the risk. A systematic search of the literature published in English from 1995 to 2010 was conducted using PubMed to identify all reports of port-site, trocar-site, or incisional hernia following laparoscopic cholecystectomy. Studies in over 100 patients were identified before the application of defined exclusion criteria. The incidence of port-site hernia was calculated and compared with historical data. Predisposing factors were reviewed. Seven studies met the search criteria, with 99 port-site hernias in 5984 patients. The overall incidence of port-site hernia was 1.7% (range, 0.3% to 5.4). The most important factors were older age, higher body mass index, preexisting hernia, trocar design, trocar diameter, increased duration of surgery, and extension of the port site for gallbladder extraction. The incidence of port-site hernia is low but likely to be underestimated and has not declined over time. Awareness of the predisposing factors and modification of techniques may help to reduce the risk.

An alternative gallbladder extraction technique in laparoscopic cholecystectomy

In this era of minimally invasive surgery, the challenge remains in finding techniques to reduce access trauma in terms of fewer and smaller size trocar ports. Our new described technique will allow a smaller subxiphoid port to be used to achieve extraction of the gallbladder without the need to change to a 5 mm laparoscope. We believe this method is easy to learn, safe and with no observable complications from our experience.

Factores intraoperatorios predictivos del fracaso del régimen ambulatorio tras colecistectomía laparoscópica

To determine which intraoperative factors during ambulatory laparoscopic cholecystectomy predict postoperative admission. Between January 1999 and August 2003, we attempted 410 consecutive laparoscopic cholecystectomies. Intraoperative variables were analyzed using univariate and multivariate methods. An intraoperative score was applied to determine the probability of successful ambulatory surgery in each patient. A total of 88.5% of the patients were strictly ambulatory. Forty-two patients required overnight admission, mostly due to social factors, and five patients required admission after 24-48 hours. Intraoperative variables predictive of postoperative admission were an operating time of more than 60 minutes (p = 0.011), gallbladder dissection with anatomic difficulty (p = 0.001), and cystic artery hemorrhage (p = 0.041). Surgical access to the abdominal cavity, gallbladder perforation, trocar wound or hepatic bed bleeding, intensity or grade of hemorrhage, and gallbladder extraction were not predictive variables. Ambulatory laparoscopic cholecystectomy is a safe and effective procedure. Operating time, correct dissection of gallbladder structures and hemorrhage of the gallbladder hilus, especially of the cystic artery, play a major role in the success or failure of ambulatory laparoscopic cholecystectomy.

Use of non‐powder surgical glove for extraction of gallbladder in laparoscopic cholecystectomy

Background: The present study was conducted to evaluate the usefulness and safety of the non‐powder surgical glove for extraction of the gallbladder in laparoscopic cholecystectomy.Methods: A total of 830 patients who underwent laparoscopic cholecystectomy using the surgical glove for extraction of the gallbladder in our hospital were analyzed. The operative times, blood loss during the operation, intra‐ and postoperative complications, length of hospital stay and the rate of morbidity were evaluated.Results: The mean operative time, mean intraoperative blood loss and mean length of hospital stay were 98.9 min, 12.1 g, and 7.93 days, respectively. The most frequent complication in this study was postoperative bleeding from the liver bed or port sites. Postoperative wound infection was found in six (0.72%) of 830 cases. Umbilical port infection was found in five of six cases. Seven cases with gallbladder cancer were incidentally detected by intra‐ or postoperative pathology. Five cases underwent reoperation by open laparotomy to resect the regional lymph nodes. Two cases have been followed up, because the depth of cancer invasion was limited to the mucosa of the gallbladder. There was no intra‐abdominal abscess formation and no port site metastasis in this study.Conclusion: The use of the surgical glove for extraction of the gallbladder is safe, cheap, simple and potentially reduces significant morbidity. Its routine use at laparoscopic cholecystectomy is strongly advocated where bile leak occurs or tumor is suspected.

Preoperative ultrasonography and prediction of technical difficulties during laparoscopic cholecystectomy.

A prospective study was carried out to investigate the value of preoperative ultrasound findings for predicting difficulties encountered during laparoscopic cholecystectomy (LC). Altogether 160 consecutive patients with symptomatic gallbladder (GB) disease (130 females, 30 males) referred to the Jordan University Hospital were recruited for the purpose of this study. All patients underwent detailed ultrasound examination 24 hours prior to LC. The overall difficulty score (ODS), as a dependent variable, was based on the following operative parameters: duration of surgery, bleeding, dissection of Calot's triangle, dissection of gallbladder wall, adhesions, spillage of bile, spillage of stone, and difficulty of gallbladder extraction. Multiple regression analysis was used to assess the significance of the following preoperative ultrasound variables (independent) for predicting the variation in the ODS: size of the GB, number of GB stones, size of stones, location of GB stones, thickness of GB wall, common bile duct (CBD) diameter, and liver size. Only thickness of GB wall and CBD diameter were found to be significant predictors of the variation in the ODS (adjusted R2 = 0.25). We conclude that the preoperative ultrasound examination is of value for predicting difficulties encountered during LC, but it is not the sole predictor.

Intraabdominal contamination after gallbladder perforation during laparoscopic cholecystectomy and its complications.

Gallbladder perforation often occurs during laparoscopic cholecystectomy. The frequency and causes of gallbladder perforation as well as the relevant clinical background factors were investigated in 110 patients undergoing laparoscopic cholecystectomy. We also evaluated intraperitoneal contamination by bacteria and gallstones at the time of gallbladder perforation and investigated whether perforation caused early or late postoperative complications. Intraoperative gallbladder perforation occurred in 29 of the 110 patients (26.3%). It was caused by injury with an electric knife during dissection of the gallbladder bed, injury during gallbladder retraction with grasping forceps, injury during gallbladder extraction from the abdomen, and slippage of cystic duct clips (potentially causing bile and stone spillage). Perforation was more frequent in patients with positive bile cultures and in those with pigment stones (p < 0.02), but not in patients with cholecystitis or cystic duct obstruction. The peritoneal cavity was contaminated by bacteria in 11/29 patients (37.9%) and by spilled stones in 3/29 patients (10.3%). There was no difference in the incidence of postoperative complications between the patients with and without perforation either in the early postoperative period or during follow-up for 24-42 months. Only one patient developed abdominal pain and fever in the early postoperative period, and they were probably related to perforation. Although gallbladder perforation is sometimes unavoidable during laparoscopic cholecystectomy, the risk of severe complications appears to be minimized by early closure of perforation, retrieval of as many of the spilled stones as possible, and intraperitoneal lavage.

Laparoscopic Cholecystectomy: One Surgeon’s Experience in 100 Consecutive Cases

Initial 100 consecutive laparoscopic cholecystectomies performed by one surgeon were studied prospectively. The standard technique was modified in that the gallbladder removal was accomplished through the upper epigastric incision; there was no need to change the location of the camera. The conversion rate to open cholecystectomy was 2%. There were no major complications and no mortality. Minor complications occurred in 9% of the patients. Laparoscopic cholecystectomy can be performed safely in a community hospital setting. Simplified technique of gallbladder extraction is recommended.

Incision extension is the optimal method of difficult gallbladder extraction at laparoscopic cholecystectomy.

An unsolved problem of laparoscopic cholecystectomy is the optimal method of removing the gallbladder with thick walls and a large stone burden. Proposed solutions include fascial dilatation, stone crushing, and ultrasonic, high-speed rotary, or laser lithotripsy. Our observation was that extension of the fascial incision to remove the impacted gallbladder was time efficient and did not increase postoperative pain. We reviewed the narcotic requirements of 107 consecutive patients undergoing laparoscopic cholecystectomy. Fifty-two patients required extension of the umbilical incision, and 55 patients did not have their fascial incision enlarged. Parenteral meperidine use was 39.5 +/- 63.6 mg in the patients requiring fascial incision extension and 66.3 +/- 79.2 mg in those not requiring fascial incision extension (mean +/- standard deviation). Oral narcotic requirements were 1.1 +/- 1.5 doses vs 1.3 +/- 1.7 doses in patients with and without incision extension, respectively. The wide range of narcotic use in both groups makes these apparent differences not statistically significant. We conclude that protracted attempts at stone crushing or expensive stone fragmentation devices are unnecessary for the extraction of a difficult gallbladder during laparoscopic cholecystectomy.