Laparoscopic Gallbladder Removal Research Articles

The access and invasiveness-based classification of medical procedures to clarify non-invasive from different forms of minimally invasive and open surgery.

The rapid development of less invasive and traumatic medical procedures has resulted in a mixture of terms used to describe them, without any agreed definition for each. This is confusing to both medical professionals and patients and can lead to unrealistic patient expectations. The aim of this article is to show the current confused nomenclature and to suggest a new, simple classification based on access and invasiveness (AI) that can be applied to any medical procedure. We performed an online search for definitions for 'non-invasive', 'non-surgical', 'minimally invasive', 'minimal access', 'pinhole' and 'keyhole'. We then searched peer-reviewed medical papers (PRMPs) and patient facing websites (PFWs) for the following index procedures, to see which of the original 6 terms were used to describe them: transvaginal ultrasound, sclerotherapy for leg veins, botulinum toxin injections, dermal fillers, endovenous thermal ablation and laparoscopic gall bladder removal. We found a wide variety of definitions for each of the initial terms. In both PRMPs and PFWs, there were a variety of terms used for each index procedure (i.e.: transvaginal ultrasound, injections of sclerotherapy, botulinum toxin or dermal fillers being both 'non-invasive' and 'minimally invasive') showing confusion in the classification of procedures. We suggested the 'AI classification' based on access (A - none, B - natural orifice or C - penetrating an epithelial surface) and invasiveness (1 - none, 2 - surface damage, 3 - needle = <21G, 4 - cannula >21G but not a surgical trocar, 5 - surgical trocars or small incisions and 6 - incisions). The current confusion of terms used for procedures that are less invasive than the open surgical alternatives leads to confusion and possible false patient expectations. We have proposed an AI classification that can be applied easily to any procedure, giving a uniform classification for medical professionals and patients to understand.

Role of Critical View of Safety in Laparoscopic Cholecystectomy

Background: Biliary injury is frequently seen as a complication after laparoscopic removal of gall bladder. In order to minimize the occurrence of this dreadful complication, “critical view of safety” involving dissection in the triangle of Calot’s and subsequent recognition of cystic structures before surgery has been proposed. Objective: To determine the role of critical view of safety in laparoscopic cholecystectomy. Study Design: Descriptive cross-sectional study. Place and Duration of Study: Department of Surgery, Benazir Bhutto Shaheed Teaching Hospital Abbottabad from 1st January 2018 to 30th September 2019. Methods: Three hundred patients requiring laparoscopic cholecystectomy were enrolled. Before clipping, the cystic artery and duct were isolated by critical view of safety. Demographic data of patients in addition to occurrence of intra-operative or post-operative complications was recorded. Results: Majority of study participants were females, 264 (88%) females and 36 (12 %) males. Females were older than males (p&gt;0.05). Operative findings included non inflamed gall bladders in 83% patients of which 90% were females and rest were males. Difficult cholecystectomy like acutely inflamed gall bladder was seen in 17% patients and out of those 13% were females. Most of the patients were discharged from hospital by the third post-operative day. Only one patient developed bile leak but that was due to cystic duct slipped ligature. Conclusions: The incidence of injury to biliary ducts during laparoscopic cholecystectomy can be minimized by application of “critical view of safety”. Key words: Critical view of safety (CVS), Laparoscopic cholecystectomy (LC), Common bile duct (CBD)

Bikini laparoscopic cholecystectomy: a replica of notes cholecystectomy

Background: Conventional four port laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis. Single incision lap. chole, Needloscopic cholecystectomy, NOTES Lap. chole. and Robotic cholecystectomy has been described primarily to further minimize the trauma and to improve cosmetic outcome. However, the cosmetic benefit is offset by expenses, non ergonomic approach and a steep learning curve. A new economic and an aesthetic approach of laparoscopic removal of gall bladder through bikini incisions is described. The purpose of this study is to find out the feasibility and safety of this technique. Methods: Non obese Patients (BMI <25) with normal gall bladder wall thickness were included. Informed consent for conversion was obtained. Intra operative bladder decompression was done by urinary catheterization. Surgery was performed by standard operative steps in split leg position. Both legs were placed at 200 below the level of torso. The surgeon stood in middle of legs. Long bariatric instruments were used. The first assistant on left side and the scrub nurse was positioned on the right side of patient. A 10 mm camera port was inserted in mid line 2 cms above pubic symphysis and two 5 mm working ports in both mid clavicular lines in lower iliac fosse. Fourth 3 mm port to retract fundus was made in right hypochondrium if required. Results: Eighteen patients were operated with this technique as day care surgery from Nov. 2017–Sept. 2018. Patients of acute cholecystitis, abdomino pelvic surgery, Pancreatitis and endoscopic retrieval of CBD stones were excluded. Sixteen were female and two were male patients. Majority of them, 88.9% were young (24–40 years). Operative steps were similar to conventional laparoscopic cholecystectomy. Surgery was completed by three ports in ten patients. Eight patients (44.44%) required fourth 3 mm port in right hypochondrium to retract gall bladder fundus. Mean duration of surgery 50.6 minutes (35–75). Specimen was retrieved through supra pubic port under vision by putting a camera from one of the 5 mm port. No conversion or complications was observed. Patients were discharged on the same day. Mean Post op followed up was 6.8 months. All patients are doing well and none developed port site infection or hernia. Conclusion: Bikini laparoscopic cholecystectomy is feasible, safe, and can be successfully performed with conventional long laparoscopic instruments. Learning curve is minimal. Like NOTES hybrid cholecystectomy, this technique leaves an invisible scar hidden under garments and there is no escalation of the cost from conventional four ports Laparoscopic Cholecystectomy.

Laparoscopic management of double gallbladder diagnosed intraoperatively: A case report and review of literature

Double gallbladder is a rare congenital anomaly, which can present a challenge for the surgeon who performs laparoscopic cholecystectomies. The common first-line modality for screening in symptomatic gallbladder pathology is still ultrasonography, even though the accuracy is low. Preoperative diagnosis of this anomaly is not common as it is available in only 50 % of cases. Preoperative diagnosis and being acquainted with this anomaly decrease the possibility of injury to the biliary tract, the number of postoperative complications and the possible need for further surgical procedures.We present a case of double gallbladder which was diagnosed during the operative procedure. Based on ultrasonography screening, which showed a gall-stone in an unchanged gallbladder, a laparoscopic gallbladder removal was indicated. Despite the finding of a double gallbladder, the performance of laparoscopic gallblade removal was uneventful.

Enlargement of umbilical incision in standard laparoscopic cholecystectomy is frequently necessary: An argument for the single incision approach?

Objective: Cosmetic result after cholecystectomy is up for debate. The aim of this study was to investigate the incidence and extent of enlargement of initial skin and fascia incision in standard laparoscopic cholecystectomy and to detect predictive factors for such an enlargement. Material and methods: The size of the umbilical incision was measured before and after standard laparoscopic gallbladder removal in 391 patients from August 2009 to October 2012. Predisposing factors for the need of enlargement of the umbilical incision were analysed. Results: Additional enlargement of the umbilical incision for gallbladder removal was required in 35.8% of the patients at skin level, and in 40.4% at fascia level. The median enlargement of the umbilical skin incision was 11 mm, from 25 mm to 36 mm. Gallbladder weight, total stone weight, maximum diameter of largest stone and shorter initial length of incision were independent predisposing factors for enlargement of the incision. Conclusions: In standard laparoscopic cholecystectomy the umbilical incision frequently requires secondary enlargement, especially if a large stone mass is involved. Therefore, the cosmetic result after laparoscopic cholecystectomy depends on more than only the technique used for access and the surgical technique for cholecystectomy should be chosen individually for each patient according to the stone mass.

Drain After Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis. A Pilot Randomized Study.

Drainage after laparoscopic cholecystectomy (LC) for acute calculous cholecystitis (ACC) is used without evidence of its efficacy. The present pilot study was designed to address this issue. After laparoscopic gallbladder removal, 15 patients were randomized to have a drain positioned in the subhepatic space (group A) and 15 patients to have a sham drain (group B). The primary outcome measure was the presence of subhepatic fluid collection at abdominal ultrasonography, performed 24h after surgery. Secondary outcome measures included postoperative abdominal and shoulder tip pain, use of analgesics, and morbidity. Abdominal ultrasonography did not show any subhepatic fluid collection in eight patients (53.3%) in group A and in five patients (33.3%) in group B (P = 0.462). If present, median (range) subhepatic collection was 50mL (20-100mL) in group A and 80mL (30-120mL) in group B (P = 0.573). No significant differences in the severity of abdominal and shoulder pain and use of parenteral ketorolac were found in either group. Two biliary leaks and one subhepatic fluid collection occurred postoperatively. The present study was unable to prove that the drain was useful in LC for ACC, performed in a selected group of patients.

Drain after elective laparoscopic cholecystectomy. A randomized multicentre controlled trial

Routine drainage after laparoscopic cholecystectomy is still debatable. The present study was designed to assess the role of drains in laparoscopic cholecystectomy performed for nonacutely inflamed gallbladder. After laparoscopic gallbladder removal, 53 patients were randomized to have a suction drain positioned in the subhepatic space and 53 patients to have a sham drain. The primary outcome measure was the presence of subhepatic fluid collection at abdominal ultrasonography, performed 24 h after surgery. Secondary outcome measures were postoperative abdominal and shoulder tip pain, use of analgesics, nausea, vomiting, and morbidity. Subhepatic fluid collection was not found in 45 patients (84.9 %) in group A and in 46 patients (86.8 %) in group B (difference 1.9 (95 % confidence interval -11.37 to 15.17; P = 0.998). No significant difference in visual analogue scale scores with respect to abdominal and shoulder pain, use of parenteral ketorolac, nausea, and vomiting were found in either group. Two (1.9 %) significant hemorrhagic events occurred postoperatively. Wound infection was observed in three patients (5.7 %) in group A and two patients (3.8 %) in group B (difference 1.9 (95 % CI -6.19 to 9.99; P = 0.997). The present study was unable to prove that the drain was useful in elective, uncomplicated LC.

Intraoperative Suspicion of Gallbladder Carcinoma in Laparoscopic Surgery: What to Do?

The frequency of gallbladder cancer in Europe is less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, patients with gallstones have gallbladder removal much earlier in their gallstone history. So the percentage of gallbladder carcinomas will decrease in the future. We report on our surgical procedures in patients with suspicious gallbladders having laparoscopic gallbladder removal, and how to proceed after the diagnosis of gallbladder carcinoma. From June 1990 to December 2001, we have performed 7,130 cholecystectomies in a single department. 47 of these patients (0.66%) were identified as having carcinoma. There were 40 females and 7 males, with a mean age of 70.6 years. In 17 cases (36%) there was a preoperative suspicion of malignancy. Most commonly, in 30 cases (64%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathological examination of the resected gallbladder. We recommend removal with a bag for all gallbladders with a suspected wall or scleroatrophic calcified gallbladder area. In stage Tis or T1 laparoscopy + cholecystectomy is sufficient. For T2 and T3 we perform reoperation with liver bed resection and lymphadenectomy.

Laparoscopic and Laparotomic Cholecystectomy: A Randomized Trial Comparing Postoperative Respiratory Function

Background: The fact that pulmonary complications occur in 20–60% of the patients subjected to abdominal operations clearly indicates that the lungs are the most endangered organ during the postoperative period. Objective: The aim of this study was to demonstrate the impact of cholecystectomy on postoperative respiratory disturbances by comparing the laparotomic cholecystectomy with laparoscopic gallbladder removal. Patients and Methods: A hundred cholecystectomized patients were included in the prospective randomized clinical trial. Half of the patients were operated on by the laparotomic procedure, whereas the other half underwent laparoscopic cholecystectomy. Spirometric parameters, arterial blood gases, and acid-base balance were determined before the operation, and at 6, 24, 72 and 144 h postoperatively. Abdominal distension was assessed by auscultating intestinal peristaltics, abdominal circumference measurement, and time interval to restitution of defecation. Results: Six hours postoperatively, the values of ventilation parameters decreased on average by 40–50% from the baseline preoperative values in both groups of patients. The group of patients submitted to laparotomic cholecystectomy had significantly lower spirometric values and slower recovery of the ventilation parameters than the laparoscopic cholecystectomy group. Abdominal circumference was significantly greater and the time needed for restitution of peristaltics and defecation was significantly longer in the laparotomic cholecystectomy group compared to the group of laparoscopic cholecystectomy. Conclusions: Statistically significant impairments including hypoxia, hypocapnia and hyperventilation were observed in the patients submitted to laparotomic cholecystectomy, indicating the presence of objective respiratory risk, especially in elderly patients and patients with obstructive pulmonary diseases or cardiac insufficiency.

Surgical internet at a glance: Volume III

Surgical internet at a glance: Volume III

Laparoscopic Techniques: What is the Role in Inflammatory Bowel Disease?

Laparoscopic cholecystectomy has quickly become the preferred technique for removing the gallbladder. Real advantages in the area of laparoscopic gallbladder removal have spurred interest towards other areas of laparoscopic surgery. There has been interest in laparoscopic bowel surgery but this approach has not gained popularity as quickly as gallbladder surgery. Reasons surround the fact that the bowel is a continuous organ (versus an end organ like the gallbladder) laden with bacteria and it has a rich blood supply. These differences make laparoscopic bowel surgery more difficult and challenging. If inflammatory bowel disease (IBD) is considered, the indications to approach surgery laparoscopically fall into two categories: current and future indications. The current indications are diagnostic laparoscopy, fecal diversion, limited bowel resections with extracorporeal anastomosis and stoma closures. Future indications include laparoscopic subtotal colectomy and laparoscopic assisted pelvic pouch procedures. As experience is gained and laparoscopic instruments are modified and refined for bowel surgery, intracorporeal anastomosis and more extensive bowel resections will be feasible. Currently laparoscopic bowel surgery can be done in select circumstances for problems associated with IBD. It has yet to be proven if doing the surgery laparoscopically provides advantages for bowel surgery as has been demonstrated with gallbladder surgery. Prospective studies are underway to answer these questions.

Bile leak after laparoscopic cholecystectomy. Diagnostic and therapeutic application of endoscopic retrograde cholangiopancreatography.

Laparoscopic cholecystectomy, introduced less than 2 years ago, is widely accepted by patients and physicians despite the lack of controlled trials comparing this technology with conventional cholecystectomy. Recent series have described a variable incidence of biliary tract injury with laparoscopic gallbladder removal. The primary interaction of endoscopic retrograde cholangiopancreatography with this technology is usually in the preoperative or postoperative diagnosis and treatment of common bile duct stones. During a 12-month period, 597 patients underwent laparoscopic cholecystectomy by 20 general surgeons at six Puget Sound (Wash) hospitals. All patients with symptomatic postoperative biloma diagnosed by abdominal ultrasound or computed tomography with or without endoscopic retrograde cholangiopancreatography, as well as those who had acute bile duct injury diagnosed and repaired at the time of cholecystectomy, were retrospectively reviewed. Three bile duct transections were acutely recognized and treated with hepaticojejunostomy. Fourteen additional patients presented within 7 days with biloma, three of whom were treated with percutaneous drainage alone. Of the remaining 11 patients who underwent endoscopic retrograde cholangiopancreatography, six were noted to have common bile duct injuries; two, bile duct transections; and 3, cystic duct leaks that required a variety of endoscopic or surgical therapies. In all, 17 (2.9%) of 597 patients sustained a bile duct injury and, to date, seven (1.2%) of 597 patients required surgery for such injury. In a regional setting, laparoscopic cholecystectomy appears to be associated with a higher incidence of bile duct injury than previous reports of open cholecystectomy. Possible explanations include variant anatomy plus failure to obtain an operative cholangiogram, inadequate dissection, injudicious use of cautery or clip placement, inherent limitations of the procedure, or the learning curve associated with a new technology.

Bile Leak After Laparoscopic Cholecystectomy

Background.— Laparoscopic cholecystectomy, introduced less than 2 years ago, is widely accepted by patients and physicians despite the lack of controlled trials comparing this technology with conventional cholecystectomy. Recent series have described a variable incidence of biliary tract injury with laparoscopic gallbladder removal. The primary interaction of endoscopic retrograde cholangiopancreatography with this technology is usually in the preoperative or postoperative diagnosis and treatment of common bile duct stones. Methods. — During a 12-month period, 597 patients under-went laparoscopic cholecystectomy by 20 general surgeons at six Puget Sound (Wash) hospitals. All patients with symptomatic postoperative biloma diagnosed by abdominal ultrasound or computed tomography with or without endoscopic retrograde cholangiopancreatography, as well as those who had acute bile duct injury diagnosed and repaired at the time of cholecystectomy, were retrospectively reviewed. Results.— Three bile duct transections were acutely recognized and treated with hepaticojejunostomy. Fourteen additional patients presented within 7 days with biloma, three of whom were treated with percutaneous drainage alone. Of the remaining 11 patients who underwent endoscopic retrograde cholangiopancreatography, six were noted to have common bile duct injuries; two, bile duct transections; and 3, cystic duct leaks that required a variety of endoscopic or surgical therapies. In all, 17 (2.9%) of 597 patients sustained a bile duct injury and, to date, seven (1.2%) of 597 patients required surgery for such injury. Conclusions.— In a regional setting, laparoscopic cholescystectomy appears to be associated with a higher incidence of bile duct injury than previous reports of open cholecystectomy. Possible explanations include variant anatomy plus failure to obtain an operative cholangiogram, inadequate dissection, injudicious use of cautery or clip placement, inherent limitations of the procedure, or the learning curve associated with a new technology. (Arch Intern Med.1992;152:1040-1043)