Management Of Symptomatic Gallstone Disease Research Articles

Symptomatic Response After Laparoscopic Cholecystectomy for Symptomatic Gallbladder Polyps: A Patient Questionnaire.

Aim To assess the effect of laparoscopic cholecystectomy (LC) in relieving the biliary type symptoms in patients with gallbladder polyps (GBPs) and to determine the positive and negative predictive values (PPV, NPV) of abdominal ultrasound (US) for the pre-operative detection. Methods The data were retrieved from our tertiary hepatobiliopancreatic (HPB) center database for all patients who had an LC as a treatment for symptomatic GBPs between 2013 and 2022. The pre-operative US and postoperative histology reports were reviewed.Patients were contacted and asked to fill in a questionnaire using the Accurx® software (Accurx UK) asking them about the degree of symptom relief following their surgery. Subsequently, the responses were correlated with polyp size, and the data collected was used to determine the PPV and NPV of the US examination for the identification of GBPs. Results Seventy patients had GBPs reported on pre-operative US and/or postoperative histology reports. Thirty-six patients (51.4 %) replied to our questionnaire. Twenty-four patients (66.6 %) reported complete relief of pain post-operatively, eight (22.2%) had a significant improvement of symptoms but still had ongoing mild discomfort, two (5.5%) are still experiencing discomfort which has not reduced following their cholecystectomy and two patients (5.5%) were unsure of the degree of improvement. Overall, 89 % of the patients reported a complete or major improvement in their symptoms after LC. Nine patients with putative GBPs on their pre-operative US had negative final histology while 26 patients whose initial US report showed only gallstones (GSs), had GBPs confirmed by their histology report. The prevalence of GBPs in our snapshot cohort is 21.6%, with a PPV of US of 83.02%, an NPV of 90.37%, and an accuracy for detecting GBPs of 89.16%. Conclusion Although LC continues to be the gold standard for the management of symptomatic gallstone disease, assessing the benefit of symptomatic GBPs is presently lacking. This study has demonstrated that the majority of patients with symptomatic GBPs experience a complete resolution or major improvement of their symptoms following surgery. Furthermore, a significant number of patients undergoing surgery for putative GSs will have GBPs demonstrated following histological examination, suggesting that these two conditions either coexist or the pre-operative assessment by US is not sufficiently reliable. Randomized controlled trials are needed to define the cohorts who require surgery or are most likely to benefit.

A prospective observational study of predictive factors for conversion of laparoscopic to open cholecystectomy

Background: Cholelithiasis affects about 10 to 15% of general population. LC became the procedure of choice for management of symptomatic gallstone disease for its minimally invasive nature, minimal pain and earlier recovery. Methods: This study was carried out on 300 consecutive patients who underwent LC for gall stone disease (patients falling under inclusion criteria) in the Department of General Surgery, The Calcutta Medical Research Institute, Kolkata. Results: In this study 9% patient were converted to open cholecystectomy while 91% of the patient underwent successfully LC. Increased wall thickness of gall bladder (p=0.01), pericholecystic fluid collection (p=0.04), stone impaction at gall bladder neck (p=0.001), pain abdomen (acute cholecystitis, recurrent acute cholecystitis) (p=0.03), previous abdominal surgery (p=0.001), pre-operative jaundice (p=0.005) were found significant in this study for conversion to open surgery. Increased TLC, total bilirubin, alkaline phosphatase, alanine transaminase and aspartate transaminase (p<0.05) were also risk factors for conversion to open surgery. Conclusions: We conclude that LC is the gold standard treatment for gall stone disease. Identification and safeguarding the bile ducts and arteries is of utmost importance while performing LC.

Cystic Duct Remnant–Duodenal Fistula following Laparoscopic Cholecystectomy: A Case Report and Literature Review

Laparoscopic cholecystectomy is the most common procedure performed for the management of symptomatic gallstone disease. This, however, can be complicated by the formation of fistulous communications between the biliary tree and the gastrointestinal tract. This abnormal communication allows for the flow of bile and bowel contents between two systems (biliary system and intestine), which can cause abdominal pain, nausea, vomiting, and biliary sepsis. We would like to present a rare case of fistulous communication between the cystic duct stump and duodenum and outline possible contributing factors. The literature review describes the most common interventions for the management of fistulas with emphasis on ERCP and stent preferences to eliminate transpapillary pressure gradient, which directly contributes to fistula closure.

Ursodeoxycholic acid in the management of symptomatic gallstone disease: systematic review and clinician survey

Symptomatic gallstones are common. Ursodeoxycholic acid (UDCA) is a bile acid that dissolves gallstones. There is increasing interest in UDCA for symptomatic gallstones, particularly in those unfit for surgery. A UK clinician survey of use and opinions about UDCA in symptomatic gallstones was performed, assessing clinicians' beliefs and perceptions of UDCA effectiveness. A systematic review was performed in accordance with the PRISMA guidelines. PubMed, MEDLINE, and Embase databases were searched for studies of UDCA for symptomatic gallstones (key terms included 'ursodeoxycholic acid'; 'UDCA'; 'biliary pain'; and 'biliary colic'). Information was assessed by two authors, including bias assessment, with independent review of conflicts. Overall, 102 clinicians completed the survey, and 42 per cent had previous experience of using UDCA. Survey responses demonstrated clinical equipoise surrounding the benefit of UDCA for the management of symptomatic gallstones, with no clear consensus for benefit or non-benefit; however, 95 per cent would start using UDCA if there was a randomized clinical trial (RCT) demonstrating a benefit. Eight studies were included in the review: four RCTs, three prospective studies, and one retrospective study. Seven of eight studies were favourable of UDCA for biliary pain. Outcomes and follow-up times were heterogenous, as well as comparator type, with only four of eight studies comparing with placebo. Evidence for UDCA in symptomatic gallstones is scarce and heterogenous. Clinicians currently managing symptomatic gallstone disease are largely unaware of the benefit of UDCA, and there is clinical equipoise surrounding the benefit of UDCA. Level 1 evidence is required by clinicians to support UDCA use in the future.

HPB P33 Management of Gallstone Disease with Deranged Liver Function Tests – Single Centre Experience

Abstract Background Laparoscopic cholecystectomy (LC) has emerged as the gold standard for the treatment of symptomatic cholelithiasis, however, things are not quite so clear when it comes to managing cholelithiasis with suspected common bile duct (CBD) stones and debate continues among surgeons about the optimal pathway of management. The current recommendation is that patients with symptomatic cholelithiasis should be investigated for CBD stones. There is controversy because investigating for suspected choledocholithiasis by means of Magnetic resonance cholangiopancreatography (MRCP)/ pre-operative or post-operative Endoscopic retrograde cholangiopancreatography (ERCP)/ laparoscopic cholecystectomy with on-table cholangiography (OTC) may lead to subsequent over or under treatment with significant morbidity, readmissions, decline in Health Related Quality of Life (HRQoL) and costs to the health service. We conducted a retrospective clinical audit to compare our care provision for symptomatic gall stone disease with suspected choledocholithiasis against the guidelines laid down by Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) in 2016, NICE (2014) and European Society of Gastrointestinal Endoscopy (ESGE). This also highlights the importance of a single stage approach (LC with OTC) for management of gall stones with suspected CBD stones. Methods A retrospective audit was conducted for 18 months at a referral centre for hepato-pancreato-biliary (HPB) diseases, with available expertise for management of CBD stones, endoscopically and surgically. All patients admitted to general surgery facility with a diagnosis of gallstone disease with deranged liver function tests (LFTs), and suspicious of having or diagnosed to have common bile duct stones were included in the study. Patients aged 18 years and above with symptomatic gall stones suspected to have or diagnosed with choledocholithiasis were included, while patients with cholelithiasis but no evidence of stones in CBD on initial investigations were excluded. A total of 95 patients who met the inclusion and exclusion criteria were included in the study. We used the guidelines put forth by AUGIS (2016), NICE guidelines (2014), British Society of Gastroenterology (BSG) in 2017 and European Society of Gastrointestinal Endoscopy (ESGE) 2019 to compare management of symptomatic gallstone disease. Data with regards to length of hospital stay, comorbidities, investigations done, diagnosis, management, readmissions before undergoing further investigations or having a surgery (laparoscopic cholecystectomy) with or without on-table cholangiogram (OTC) were analysed. Data analysis for this set of data was done using numbers, percentages and descriptive statistics, using SPSS 25.0. Results Out of 95 patients, 90 had deranged LFTs at presentation (3 presented with cholangitis) and 5 had suspicious findings on initial imaging. The diagnosis included Mirizzi syndrome, pancreatitis, Choledocholithiasis, Biliary colic, Acute cholecystitis and benign CBD stricture. Out of 95 patients, 76 of them had Ultrasound abdomen as their initial investigation, mostly on the day of admission. 41 patients had MRCP, 73% of them during their index admission. Amongst the 95, 59% underwent ERCP, 76.8% of them during the index admission. The median time from admission to MRCP and ERCP was 5 and 8 days, respectively. Out of 56 patients who underwent ERCP, 9 of them had it done within 72 hours of admission. Overall, 22 patients underwent LC with OTC. Out of 95 patients, 51 patients underwent LC. Out of 79 patients who were fit for surgery, 28 of them were still awaiting surgery. Amongst 18 patients who had Pancreatitis at presentation, 14 of them underwent ERCP. Out of which 3 of them had LC during index admission. The maximum length of stay observed amongst 95 patients was 36. Amongst the 95 patients, the study also records that 13 patients had readmissions before they underwent ERCP or LC. Conclusions We found 16% compliance with the guidelines in regards to the timing of biliary decompression with ERCP. Our results show 66.66% compliance with guidelines, with regards to timing of biliary decompression in Cholangitis. The study reflects a significant non-adherence to the guidelines as 68.40% of patients could not have definitive management within the recommended time frame. Looking into the finer details, we found that 35.40% of the patients did not have their surgery at the time of the audit. 22% of patients had LC performed in accordance with the recommendations, while the timing of surgery in 78% of patients showed no compliance with the guidelines. Guidelines for management of patients with gallstone disease associated with CBD stones was not met for majority of patients. A significant number of patients were readmitted to the hospital because of delay in receiving further investigations or definitive surgery. There may be a role for multidisciplinary team meetings to identify patients requiring expedited ERCP, which in turn may translate into early definitive surgical management. Laparoscopic cholecystectomy with OTC, with or without laparoscopic CBD exploration or post-operative ERCP can be incorporated as an alternative to pre-operative ERCP to reduce patient morbidity and length of hospital stay.

A randomised clinical trial to study postoperative abdominal and shoulder tip pain following low and standard pressure laparoscopic cholecystectomy

BackgroundLaparoscopic cholecystectomy (LC) has become the gold standard for the management of symptomatic gallstone disease. The complications related to different pressure ranges of pneumoperitoneum have been studied widely with no definite conclusion till date. The current study was planned to determine the effect of standard versus low pressure laparoscopic cholecystectomy (LPLC) on postoperative abdominal and shoulder tip pain (STP). MethodsThe present randomised clinical trial included 84 patients divided into two groups: standard pressure laparoscopic cholecystectomy (SPLC) (13 mmHg) and LPLC (9 mmHg). The variables tested were abdominal pain at 3, 6, 12 and 24 h (by verbal rating scale), the incidence and intensity of STP, post-operative nausea and vomiting (PONV) and surgeon's comfort for the two techniques. ResultsThe demographic characteristics of patients were similar in both groups. In LPP group, the postoperative abdominal pain at 6, 12 and 24 h was significantly less than SPLC; p = 0.02. Incidence of shoulder pain was significantly less in low pressure group (7.14%) compared with standard pressure (28.57%). ConclusionsLow-pressure pneumoperitoneum (LPP) is safe and feasible surgery with reduced abdominal and STP.

Difficult Laparoscopic Cholecystectomy Predictors and its Significance: Our Experience.

Laparoscopic cholecystectomy (LC) has become the procedure of choice for the management of symptomatic gallstone disease. In LC, the surgeons encountered difficulties with acutely inflamed or gangrenous gallbladder (GB), dense adhesions at Calot's triangle, fibrotic and contracted GB, and cholecystoenteric fistula. Depending on the difficulty faced during the surgery, the outcome of LC may vary from abandoning the procedure or partial cholecystectomy to conversion into open cholecystectomy. Complications related to biliary tract or adjoining structures or vessels may also occur. Our aim was to assess the different preoperative factors in patients of cholelithiasis and ascertain the validity of the scoring system devised by Randhawa and Pujahari in preoperatively predicting the difficult LC in our hospital scenario. This hospital-based observational study was conducted in the Department of General Surgery for a period of 2 years. All diagnosed cases of cholelithiasis admitted for elective LC during the study period in our hospital were included in the study. In total, 154 patients, aged≥50 years, history of hospitalization for acute cholecystitis (AC), body mass index of 25 kg/m2 and more, abdominal scar, palpable GB, GB wall thickness ≥4 mm, pericholecystic collection, impacted stone found to be significant factors to predict difficult LC preoperatively. Endoscopic retrograde cholangiopancreatography and pancreatitis were found as independent risk factor for difficult LC. We recommend that the scoring system should be regularly used as a protocol for predicting difficulty levels preoperatively in LC. It can help to decide the surgical approach, counsel the patients, and reduce the complication rate, rate of conversion, and overall medical cost. The scoring system proposed by Randhawa and Pujahari is effective but has some lacunae.

Novel advances in surgery for Gallstone Disease.

Examine recent advances in the treatment of patients with complex gallstone disease. Laparoscopic common bile duct exploration (LCBDE) has been shown to be an effective and safe treatment for choledocholithiasis, resulting in decreased hospital length of stay and costs when compared with ERCP plus laparoscopic cholecystectomy (LC). Novel simulator-based curricula have recently been developed to address the educational gap that has resulted in an underutilization of LCBDE. Patients with cholecystitis who are too ill to safely undergo LC have traditionally been treated with percutaneous cholecystostomy (PC). Endoscopic ultrasound (EUS) guided gallbladder drainage is a novel definitive treatment for such patients and has been shown to result in decreased complications and hospital readmissions compared to PC. The management of symptomatic gallstone disease during pregnancy has evolved over the last several decades. While it is now well established that laparoscopic procedures under general anesthesia are safe throughout a pregnancy, recent studies have suggested that laparoscopic cholecystectomy during the third trimester specifically may result in higher rates of preterm labor when compared with non-operative management. Finally, indocyanine green (ICG) fluorescence cholangiography is a novel imaging modality that has been used during laparoscopic cholecystectomy and may offer better visualization of biliary anatomy during dissection when compared with traditional intraoperative cholangiography. A number of recent technological, procedural, educational, and research innovations have enhanced and expanded treatment options for patients with complex gallstone disease.

Management of Symptomatic Gallstone Disease during COVID-19 Lockdown in a High-Resource Setting: Is There a Need for Treatment Alterations?

Introduction: Cholecystectomy (CCE) is the treatment of choice of symptomatic gallstones. Due to the SARS-CoV-2 pandemic, operating room (OR) capacities have been reduced. The goal of this study was to evaluate the duration of symptoms of patients presenting with gallstone disease during a lockdown, the surgical management, and the severity grade of their disease. Materials and Methods: A cohort study of 353 CCEs performed at a university hospital over two 10-week periods during 2 pandemic lockdowns in Germany compared to corresponding periods in 2018 and 2019. Results: During the lockdowns, 101 CCEs were performed compared to 252 in the prior years. The number of elective CCEs was reduced to save OR capacities (p < 0.001), and the most common indication for CCE was acute cholecystitis. The median time to CCE after symptom onset was 3 days in both groups for acute cholecystitis. The severity of cholecystitis was comparable (p = 0.760). The time to CCE after choledocholithiasis was shorter during the lockdowns (median of 4 days vs. 9 days; p = 0.006). Conclusions: The incidence and severity of acute cholecystitis during the lockdowns were comparable to the prior years. Acute care surgery was provided at the expense of elective procedures, and there was no need for treatment alterations.

Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost–utility studies

IntroductionCholecystectomy is a standard treatment in the management of symptomatic gallstone disease. Current literature has contradicting views on the cost-effectiveness of different cholecystectomy treatments. We have conducted a systematic reappraisal...

Pre-operative assessment of difficult laparoscopic cholecystectomy: a scoring method

Background: Laparoscopic cholecystectomy (LC) has become the gold standard procedure for management of symptomatic gallstone disease. At times, it is difficult and takes longer time or has to be converted to an open procedure. The study was undertaken to determine the factors which predict difficult LC. The aim of the study was to evaluate a pre-operative scoring method to predict difficult LC.Methods: This was a prospective study conducted in the department of general surgery, MVJ Medical College, Bangalore from December 2020 to August 2021. There were 100 cases operated by experienced surgeons. Scoring method which included parameters from history, clinical and sonological findings with maximum score up to 15. Score up to 5 predicted easy, 6-10 difficult and 11-15 is very difficult.Results: Pre-operative scoring system correlated with 85.7% for easy, 83.3% in difficult cases and 100% in very difficult cases. The factors like previous history of hospitalization (p=0.004), clinically palpable gallbladder (GB) (p=0.009), impacted GB stone (p=0.001), pericholecystic collection (p=0.04), and abdominal scar due to previous abdominal surgery (p=0.009) were found statistically significant in predicting difficult LC.Conclusions: Pre-operative prediction of risk factors to assess the operative difficulty is an important point for planning the surgery and the high-risk patients may be informed accordingly.

ACCURACY OF RANDHAWA AND PUJAHARI PREOPERATIVE SCORING SYSTEM IN PREDICTION OF DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY IN EGYPTIAN POPULATION

Background: Laparoscopic cholecystectomy is the procedure of choice for management of symptomatic gallstone disease and one of the most commonly performed operations by general surgeons. Sometimes, it is difficult and takes longer time or has to be converted to an open procedure due to various difficulties faced while performing the procedure.Aim of the Work: To evaluate the accuracy of Randhawa and Pujahari preoperative scoring system in prediction of difficult laparoscopic cholecystectomy in Egyptian population.Patients and Methods: This is a prospective observational study that has been conducted in department of general surgery, Ain Shams University hospitals, including (60) patients undergoing elective laparoscopic cholecystectomy for symptomatic gall stones disease. The scoring system used was of Randhawa and Pujahari, based on history, clinical examination and radiological finding.Results: Showed that the scoring system is reliable to be used in Egyptian patient with sensitivity 77.78 % and specificity 95.12 %.Conclusion: Ranhawa and Pujahari scoring system are reliable and could be used in Egyptian patients undergoing elective laparoscopic cholecystectomy. This scoring system can help each of patients, surgeons and trainers. With the help of accurate prediction, high risk patient may be informed before operation and hence they may have a chance to make arrangements accordingly. On the other hand, surgeons also may have to schedule the time and team for the operation appropriately.

Preoperative prediction and good planning for technically difficult laparoscopic cholecystectomy: a scoring method

BackgroundLaparoscopic cholecystectomy (LC) has become the standard procedure of choice for management of symptomatic gallstone disease recently. Sometimes, it is difficult and takes longer time or it may be converted to an open procedure.AimThis study was undertaken to determine the preoperative factors and their predictive value for the difficulty of LC. The study used some important factors preoperatively that have a significant effect in the literature that can predict difficult LC via a scoring method in Menoufia University hospitals.Patients and methodsThe present retrospective study was conducted by an experienced laparoscopic surgeon in the period of 1 year from October 2018 to October 2019 in the Department of General Surgery at Menoufia University hospitals. The study included 132 patients who underwent LC. A total score up to 15 score from history, clinical, and sonological findings was retrospectively analyzed to evaluate preoperative predictors included in our study. Score up to 5 predicted easy, 6–10 difficult, and more than 10 very difficult LC. All the data was recorded in a tabulated form and analyzed using SPSS software, version 2018.ResultsThe factors included in the score of this study were divided as history factors, such as age, sex, BMI, previous abdominal surgery, and previous hospitalization for biliary causes; clinical factors, such as acute calcular cholecystitis, hydrops (mucocele) or empyema of gallbladder (GB), and acute pancreatitis; and sonological factors such as GB wall thickness, stone impacted at the neck of GB, common bile duct diameter, and pericholecystic fluid collection, and all were grouped to form a scoring method in Menoufia University hospitals that can strongly help the surgeon expect the difficulty of the procedure to be prepared preoperatively with the suitable plan for safety of both the surgeon and the patient.ConclusionThe scoring system depending on preoperative factors included in this study was so reliable and useful that it could successfully predict difficult cases.

Assessment of a Scoring System to Predict Difficult Laparoscopic Cholecystectomy

Introduction Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. It would be useful to have some reliable predictive factors for conversion in LC. Our aim is to predict difficult laparoscopic cholecystectomy preoperatively by using a scoring system.&#x0D; MethodsA total of 136 patients were included. The parameters considered for this study were old age, male sex, history of hospitalization, obesity, abdominal surgery scar, palpable gall bladder, gall bladder wall thickness, pericholecystic collection and impacted stone.&#x0D; ResultsAmong 136 cases, 70.6% were easy, 24.3% were difficult and 5.1% were very difficult intraoperatively. The factors like age &gt;50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness &gt;4mm and impacted stone were found statistically significant in predicting difficult LC. The preoperative scoring is statistically and clinically a good test for predicting the difficult LC (area under the curve = 0.824) with sensitivity of the test being 82.3% and specificity 72.7%. Conversion rate was 3.67%.&#x0D; ConclusionThe factors like age &gt;50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness &gt;4 mm and impacted stone are the preoperative predictors of difficult LC.

Assessment of a Scoring System to Predict Difficult Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. It would be useful to have some reliable predictive factors for conversion in LC. Our aim is to predict difficult laparoscopic cholecystectomy preoperatively by using a scoring system. Methods: A total of 136 patients were included. The parameters considered for this study were old age, male sex, history of hospitalization, obesity, abdominal surgery scar, palpable gall bladder, gall bladder wall thickness, pericholecystic collection and impacted stone. Results: Among 136 cases, 70.6% were easy, 24.3% were difficult and 5.1% were very difficult intraoperatively. The factors like age &gt;50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness &gt;4mm and impacted stone were found statistically significant in predicting difficult LC. The preoperative scoring is statistically and clinically a good test for predicting the difficult LC (area under the curve = 0.824) with sensitivity of the test being 82.3% and specificity 72.7%. Conversion rate was 3.67%. Conclusion: The factors like age &gt;50 years, history of hospitalization for acute cholecystitis, previous abdominal surgery, palpable gall bladder, wall thickness &gt;4 mm and impacted stone are the preoperative predictors of difficult LC.

Postcholecystectomy syndrome: a case report

&lt;p class="abstract"&gt;The term postcholecystectomy syndrome (PCS) refers to varied signs and symptoms attributed to patients on cholecystectomy for the surgical management of symptomatic gallstone disease. This complication occurs as a result of a pathological condition of the gallbladder or attribution of several symptoms. PCS affects about 10-15% of the patients. The management and treatment of PCS associated symptoms are depending on the specific diagnosis and may include pharmacological or surgical management. In the present case, a 74-year-old man undergone for laparoscopic cholecystectomy admitted with complaints of loose stools for several times with other complications (anaemia, leucocytosis, neutrophilia, and also reported known case of trigeminal neuralgia). The present case report added insight information on PCS and its therapeutic management.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Predicting operative difficulties during laparoscopic cholecystectomy using clinical and imaging criteria.

Introduction: Laparoscopic cholecystectomy has become the procedure of choice for the management of symptomatic gallstone disease. Difficulty in laparoscopic cholecystectomy is often encountered by surgeons and is associated with complications and a higher conversion rate. This study aims at identifying difficult laparoscopic cholecystectomies by clinical and imaging assessment and determining the utility of a pre-operative difficulty scoring system based on intra-operative findings. &#x0D; PATIENTS and METHODS: A hospital based observational study was conducted including all patients above age 18 years undergoing laparoscopic cholecystectomy. Randhawa’s preoperative score was calculated for every patient based on history, clinical and imaging parameters and the degree of operative difficulty was predicted. Another scoring was done using Sugrue’s scoring system based on intra-operative findings. The outcome factors studied were degree of operative difficulty or need for conversion and intra-operative and post-operative complications. The statistical analysis was done by using EPI INFO software version 7.&#x0D; RESULTS: A total 84 patients with mean age 42.96 +14.34 years with 58 females and 26 males were enrolled. Of them 28 (33.33%) had difficult laparoscopic cholecystectomies. The conversion rate to open cholecystectomy was 9.52%. Age above 50 years, prior history of acute cholecystitis, thickened gall bladder wall and stone impaction of Hartmann’s pouch were statistically significant pre-operative risk factors. The sensitivity of the preoperative score in identifying difficult cases was 85.7% with the specificity of 96.43%; positive predictive value of 92.31% and the negative predictive value of 93.10% and the accuracy was 92.86%. &#x0D; CONCLUSION: Pre-operative score and intra-operative findings are helpful in identifying difficult laparoscopic cholecystectomy.

Laparoscopic Common Bile Duct Exploration for Choledocholithiasis During a Pregnancy: a Case Report

SummaryIn population studies, gallstones are found in 6.5% to 8.4% of nulliparous women, and in 18.4% to 19.3% of women with two to three or more pregnancies (7). Approximately 1 in 500 to 1 in 635 women will require non-obstetrical abdominal surgery during their pregnancies. Pregnancy induced physiological hormonal changes are associated with a decrease of gallbladder motility and increased cholesterol saturation of bile, leading to biliary stone formation (12,6,8). Surgical approach nowadays is the method of choice in the management of symptomatic gallstone disease during pregnancy, preferably if possible surgery should be postponed to second trimester (7,8).Preoperative radiologic imaging using magnetic resonance cholangiopancreatography is the golden standard for patients with suspected choledocholithiasis, however, its application during pregnancy is limited (9). Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) may be used before, during or after laparoscopic cholecystectomy when it is indicated, but unfortunately, its application during pregnancy is associated with considerable number of complications concerning mother and fetus. Alternative approach has been developed and recommended for patients with the common bile duct (CBD) stones providing laparoscopic common bile duct exploration (LCBDE). Intraoperative cholangiography or intraoperative ultrasound (IOUS) are the methods currently used for detection of the CBD stones during laparoscopic cholecystectomy, however, IOUS can be considered as the method of choice during pregnancy (3).IOUS is a dynamic imaging modality that provides interactive and timely information during surgical procedures. Because the transducer is in direct contact with the organ being examined, high-resolution images can be obtained that are not degraded by air, bone, or overlying soft tissue (1).

Clipless harmonic scalpel assisted cholecystectomy versus conventional laproscopic cholecystectomy

Introduction: Laproscopic cholecystectomy is gold standard in the management of symptomatic gallstone disease. Ultrasonically activated scalpel has come up as alternative to traditional electrocautery for haemostatic dissection of tissues. Little research has been done to compare effectiveness of conventional laproscopic cholecystectomy and harmonic cholecystectomy. Aim and objective: To compare conventional laproscopic cholecystectomy versus clipless harmonic scalpel assisted cholecystectomy among the patients undergoing laproscopic cholecystectomy for symptomatic cholelithiasis at IGMC Shimla. Materials and method: Prospective study involved 400 patients operated for symptomatic cholelithiasis. Patients were divided into two groups of 200 patients each.Group A was control group who underwent conventional laproscopic cholecystectomy and Group B who underwent laproscopic cholecystectomy with harmonic scalpel. Results: In group A mean duration of surgery was 43 min and 20 seconds while in group B it was 30 min and 40 sec. In terms of intraoperative complications in group A gallbladder perforation was seen in 48 patients while in group B in 8 patients, while spillage of gall stones was seen in 48 patients in Group A it was seen in 8 patients in group B. Mean blood loss in group A was 19.72 cc while in group B it was 13.18 cc. Mean time interval of rescue with analgesic for post operative pain in group A was 7.64 while in group B was 8.72. Conclusion: Present study clearly establishes that harmonic laproscopic cholecystectomy is a safe alternative to conventional laproscopic cholecystectomy with short hospital stay, less postoperative pain, early recovery and comparable complication rate.

Preoperative prediction of difficult laparoscopic cholecystectomy: A scoring method

Background:Laparoscopic cholecystectomy (LC) has become the procedure of choice for management of symptomatic gallstone disease. At times, it is difficult and takes longer time or has to be converted to an open procedure. This study is undertaken to determine the predictive factors for difficult LC.Aim:The aim was to evaluate a scoring method to predict difficult LC preoperatively.Materials and Methods:There were 30 cases operated by a single experienced surgeon. There are total 15 score from history, clinical and sonological findings. Score up to 5 predicted easy, 6–10 difficult and >10 are very difficult.Results:Prediction came true in 76.4% for easy and 100% difficult cases; there were no cases with a score above 10. The factors like previous history of hospitalization (P - 0.004), clinically palpable gallbladder (GB) (P - 0.009), impacted GB stone (P - 0.001), pericholecystic collection (P - 0.04), and abdominal scar due to previous abdominal surgery (P - 0.009) were found statistically significant in predicting difficult LC.Conclusion:The proposed scoring system is reliable with a sensitivity of 76.47% and specificity of 100%.