Ports In Laparoscopic Cholecystectomy Research Articles

Comparative Study of the Incidence of Port Site Infection in Disposable Ports and Reprocessed Disposable Ports in Laparoscopic Cholecystectomy.

Port site infection (PSI) is a rare complication of laparoscopic surgery that can reduce the benefits of this minimally invasive surgery and increase postoperative complications. As a variety of disposable ports (single-use ports) and reprocessed ports are used in laparoscopic surgeries, this study was conducted to compare the incidence of PSI in disposable ports and reprocessed disposable ports in laparoscopic cholecystectomy (LC). In this prospective cohort study, 473 patients were studied. Two hundred fifteen and two hundred fifty eight were in the disposable port group and reprocessed disposable port group, respectively. The demographic characteristics and incidence of superficial and deep infection were evaluated using the researcher-made checklist of infection assessment standards at intervals of 3 to 5 and 5 to 14 days following LC using call and physical examination on day 14. Data analysis was performed using descriptive statistics and statistical tests in SPSS software. The incidence of PSI, 3 to 5 and 5 to 14 days after surgery in the reprocessed disposable port group was significantly higher than that in the disposable ports group. In both groups, all PSI accrued in the epigastric port area (where the gallbladder was removed) ( P < 0.05). On the basis of the results, our study suggests using disposable ports instead, and in the case of using reprocessed disposable ports in LC, upgrading of disinfection and sterilization techniques is necessary.

Left or right is right? Ectopic gallbladder

Ectopic gallbladder (GB) is a rare entity with an incidence of <1%. True left-sided GB (LSG), i.e., GB seen under the left lobe of the liver and to the left of the falciform ligament, presents as a surgical problem on table, due to its unusual presentation and lack of findings on imaging. What we may perceive as an LSG on the table, may in fact be a normally located GB under the right lobe but with the ligamentum teres being attached to the right lobe, giving the appearance of a left-sided gallbladder. Here, we are presenting a case of a true LSG which was discovered on table. By minimizing the use of electrocautery and placing an additional port along with the traditional ports in laparoscopic cholecystectomy, we were able to perform a successful cholecystectomy.

Three Ports Versus Four Ports Laporoscopic Cholecystectomy

Background: A four trocar laparoscopic cholecystectomy become the standard procedure since the first laparoscopic procedure was reported. But laparoscopic cholecystectomy has gained many steps such as reduction in port number and size. Objective: To compare Clinical results from three ports versus the traditional four ports in laparoscopic cholecystectomy. Patients and Methods: A prospective randomized clinical trial of 100 patients was done on those who were admitted for elective laparoscopic cholecystectomy in Baquba teaching hospital, between April 2014 and March 2015, patients were classified into two groups (A) for three ports and (B) for 4 ports. Variables such as, complications, operative time, postoperative pain, nausea, and vomiting were assessed. Results: One-hundred patients were included in this study, age of them ranged from 18-70 year and a male to female ratio was 1:9. There were no significant differences in demographic data between the two groups. Postoperative pain, analgesic requirements, nausea and vomiting, and hospital stay were slightly more in group B but statistically not significant. Postoperative return to activity was shorter in group A 6.10 versus 7.00 days for group B with (p= 0.021) which is statistically significant. There is no difference in the rate of complications. Conclusion: Three ports laparoscopic cholecystectomy is feasible as an alternative for four ports without any significant complication. Keywords: Laparoscopy; Cholecystectomy; Postoperative complications

Postoperative Pain after Gallbladder Retrieval from Umbilical and Epigastric Ports in Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Objective: To compare the postoperative pain after gallbladder removal from umbilical port site versus epigastric port site, after four ports laparoscopic cholecystectomy. Methods: Randomized controlled trial was performed from January 2017 till January 2018, at a private hospital setup, with patients of either gender, age 18 years and above, planned laparoscopic cholecystectomy for symptomatic cholelithiasis were considered. Patients having polyps in gallbladder, empyema, mucocele or perforated gallbladder requiring emergency surgery were excluded. They were randomly assigned, 65 patients in which gallbladder removed through umbilical port (group A) and 65 in which epigastric port was used for gallbladder removal (group B). Postoperative pain was determined after one day, at the time of discharge from hospital and after one month of surgery, with the help of Numerical Analogue Scale (NAS). Results: From a total of 130 patients, 65 patients in group A had median (IQR) pain scores of 5 (1.5), 4 (1) and 2 (1) as compared to group B pain scores of 4 (1), 2 (1) and 1 (0.5) at one day post-surgery (p-value=0.000), at discharge from hospital (p-value<0.001) and after a month of surgery (p-value<0.001), respectively. A definitive decline in the postoperative pain scores was evaluated in group B from the day of operation till a month after surgery during follow up visits (p-value<0.001). Conclusion: Epigastric port site removal of gallbladder produced less postoperative pain after removal of gallbladder as compared to the umbilical port site. We therefore are in favor of removal of gallbladder from epigastric port site.

A comparative study of postoperative port-site pain after gallbladder retrieval from umbilical versus epigastric ports in laparoscopic cholecystectomy.

Introduction:Gall bladder (GB) retrieval is an important cause for postoperative pain after laparoscopic cholecystectomy (LC). GB is usually extracted either from the epigastric or the umbilical port and there are limited data to decide the superiority of one over other in terms of postoperative pain. This study was designed to determine whether GB retrieval from the umbilical port was associated with less pain as compared to epigastric port in adult patients undergoing four ports elective LC.Material and Methods:A total of 100 patients took part in the study and were randomly allocated into 2 groups. Postoperatively, port-site pain score was assessed at 1, 6, 12, and 24 h by visual analog scale (VAS) score both for the epigastric and umbilical ports in all the patients and the collected data were analyzed by using SPSS version 22.Result:VAS score for postoperative pain at epigastric port at 1, 6, 12, and 24 h found to be higher as compared to umbilical port (6.640 ± 1.494 vs. 5.500 ± 1.176, 6.620 ± 1.549 vs. 5.320 ± 1.188, 6.100 ± 1.549 vs. 4.660 ± 1.232, 5.250 ± 1.459 vs. 3.970 ± 1.274, respectively) which was statistically significant (P value 0.001). But the time taken for retrieval of GB was significantly longer in the umbilical group (4.94 ± 1.56 vs. 3.24 ± 1.29).Conclusion:Umbilical port is better as compared to epigastric port for GB retrieval in patient undergoing elective four port LC in terms of postoperative port-site pain but it takes relatively longer time for the extraction.

Simultaneous laparoscopic cholecystectomy with abdominoplasty

Background: The use of laparoscope in surgical removal of gall bladder became one of the most popular surgical procedures and abdominoplasty which was used from long time even during 1900, mostly done as a separate surgical procedure in our research we combined both procedures in the patients subjected to the study.Methods: Thirty-two patients presented to our hospital with abdominal wall laxity and symptomatic cholelithiasis. All of them wanted to undergo a cosmetic procedure (abdominoplasty) to reduce the abdominal wall laxity. They were also diagnosed to have cholelithiasis and had intermittent episodes of pain in the right upper quadrant of the abdomen. The ports for laparoscopic cholecystectomy were made in such a way that all the ports sites were under the elevated skin flap that was excised during abdominoplasty, and there was no scar in the upper abdomen.Results: The procedure was completed without leaving any tell-tale signs of laparoscopic cholecystectomy, and this led to a better cosmetic result from the patients’ point of view.Conclusions:On conclusion, we recommend asking for abdominal ultrasound examination for all patients coming for abdominoplasty especially following weight loss after surgery for morbid obesity even if the patient is asymptomatic. We recommend the use of the technique which we used for port placement as it is convenient, easy, and has no side effects on patients in comparison with other techniques.

Fewer-than-four ports versus four ports for laparoscopic cholecystectomy.

Traditionally, laparoscopic cholecystectomy is performed using two 10-mm ports and two 5-mm ports. Recently, a reduction in the number of ports has been suggested as a modification of the standard technique with a view to decreasing pain and improving cosmesis. The safety and effectiveness of using fewer-than-four ports has not yet been established. To assess the benefits (such as improvement in cosmesis and earlier return to activity) and harms (such as increased complications) of using fewer-than-four ports (fewer-than-four-ports laparoscopic cholecystectomy) versus four ports in people undergoing laparoscopic cholecystectomy for any reason (symptomatic gallstones, acalculous cholecystitis, gallbladder polyp, or any other condition). We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2013), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization International Clinical Trials Registry Platform portal to September 2013. We included all randomised clinical trials comparing fewer-than-four ports versus four ports, that is, with standard laparoscopic cholecystectomy that is performed with two ports of at least 10-mm incision and two ports of at least 5-mm incision. Two review authors independently identified the trials and extracted the data. We analysed the data using both the fixed-effect and the random-effects models. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis, whenever possible. We found nine trials with 855 participants that randomised participants to fewer-than-four-ports laparoscopic cholecystectomy (n = 427) versus four-port laparoscopic cholecystectomy (n = 428). Most trials included low anaesthetic risk participants undergoing elective laparoscopic cholecystectomy. Seven of the nine trials used a single port laparoscopic cholecystectomy and the remaining two trials used three-port laparoscopic cholecystectomy as the experimental intervention. Only one trial including 70 participants had low risk of bias. Fewer-than-four-ports laparoscopic cholecystectomy could be completed successfully in more than 90% of participants in most trials. The remaining participants were mostly converted to four-port laparoscopic cholecystectomy but some participants had to undergo open cholecystectomy.There was no mortality in either group in the seven trials that reported mortality (318 participants in fewer-than-four-ports laparoscopic cholecystectomy group and 316 participants in four-port laparoscopic cholecystectomy group). The proportion of participants with serious adverse events was low in both treatment groups and the estimated RR was compatible with a reduction and substantial increased risk with the fewer-than-four-ports group (6/318 (1.9%)) and four-port laparoscopic cholecystectomy group (0/316 (0%)) (RR 3.93; 95% CI 0.86 to 18.04; 7 trials; 634 participants; very low quality evidence). The estimated difference in the quality of life (measured between 10 and 30 days) was imprecise (standardised mean difference (SMD) 0.18; 95% CI -0.05 to 0.42; 4 trials; 510 participants; very low quality evidence), as was the proportion of participants in whom the laparoscopic cholecystectomy had to be converted to open cholecystectomy between the groups (fewer-than-four ports 3/289 (adjusted proportion 1.2%) versus four port: 5/292 (1.7%); RR 0.68; 95% CI 0.19 to 2.35; 5 trials; 581 participants; very low quality evidence). The fewer-than-four-ports laparoscopic cholecystectomy took 14 minutes longer to complete (MD 14.44 minutes; 95% CI 5.95 to 22.93; 9 trials; 855 participants; very low quality evidence). There was no clear difference in hospital stay between the groups (MD -0.01 days; 95% CI -0.28 to 0.26; 6 trials; 731 participants) or in the proportion of participants discharged as day surgery (RR 0.92; 95% CI 0.70 to 1.22; 1 trial; 50 participants; very low quality evidence) between the two groups. The times taken to return to normal activity and work were shorter by two days in the fewer-than-four-ports group compared with four-port laparoscopic cholecystectomy (return to normal activity: MD -1.20 days; 95% CI -1.58 to -0.81; 2 trials; 325 participants; very low quality evidence; return to work: MD -2.00 days; 95% CI -3.31 to -0.69; 1 trial; 150 participants; very low quality evidence). There was no significant difference in cosmesis scores at 6 to 12 months between the two groups (SMD 0.37; 95% CI -0.10 to 0.84; 2 trials; 317 participants; very low quality evidence). There is very low quality evidence that is insufficient to determine whether there is any significant clinical benefit in using fewer-than-four-ports laparoscopic cholecystectomy compared with four-port laparoscopic cholecystectomy. The safety profile of using fewer-than-four ports is yet to be established and fewer-than-four-ports laparoscopic cholecystectomy should be reserved for well-designed randomised clinical trials.

A prospective, randomized, single-blind trial of 5-mm versus 3-mm ports for laparoscopic cholecystectomy: is smaller better?

Single-incision laparoscopic cholecystectomy (SILC) is said to provide improved cosmesis with a reduction in postoperative pain, but SILC involves a change in operative technique. A single-blind, randomized controlled trial compared cosmetic outcomes and postoperative pain between 3- and 5-mm ports used for laparoscopic cholecystectomy (LC). For this study, 80 patients with symptomatic gallstones were recruited from a single center and randomized to a LC using either a 5-mm port and three 3-mm ports (group A) or a 10-mm port and three 5-mm ports (group B). Operative details; pain scores at 1h, 6h, and 1week; and analgesia required during the first week were collected. Cosmetic outcome was assessed at 6months using a validated questionnaire. For each group, 40 patients were recruited. The two groups were well matched except for sex. Group A had 11 males, and Group B had 4 males. The mean operative time was 49±12min (range, 24-120min) in the 3-mm group versus 46±19min (range, 21-124min) in the control group (p=0.40). The two groups did not differ statistically in the day case rate. The pain scores in Group A were 2.5±2.1 at 1h, 3.2±2.2 at 6h, and 0.8±2.2 at 1week versus 4.2±2.9 at 1h, 3.3±2.4 at 6h, and 2.1±2.4 at 1week in Group B (p=0.003, 0.63, and 0.002, respectively). No difference in the analgesia consumption was observed during the first postoperative week. The patients in Group A had significantly better cosmetic outcome scores at 6months. The use of 3-mm ports is technically feasible in patients undergoing LC for gallstones. The operating times are comparable with those for conventional LC, whereas the pain scores are reduced, and the cosmetic outcome is better.

SILS cholecystectomy, early experience of a single institution: pilot study of 21 cases

Many surgeons have attempted to reduce the number and the size of ports in laparoscopic cholecystectomy to decrease parietal trauma and pain, and to improve cosmetic results. We report a series of laparoscopic cholecystectomies using a single-port technique (SILS) through an umbilical incision in a pilot group of 21 cases. Our goal was to validate and develop the single-port access as a viable option. All the operations were performed using an umbilical SILS port (Ethicon). Most reported techniques utilize special purpose-made instruments. This article provides a stepwise description of the procedure using all straight instruments. No special reticulating instruments or flexible telescopes were used. We report our early difficulties and concerns about the procedure and propose solutions to the problems. Patients' request for improved cosmesis impels surgeons toward the application of SILS, but the true advantage of the technique should be assessed by more evidences. For this reason, we are planning a single-institution, prospective randomized controlled trial to compare postoperative pain, operating time and cosmetic result between one port and standard laparoscopic surgery.

Scarless Cholecystectomy: Laparoscopic Cholecystectomy with Abdominoplasty

Three patients presented to our hospital with abdominal wall laxity and symptomatic cholelithiasis. All of them wanted to undergo a cosmetic procedure (abdominoplasty) to reduce the abdominal wall laxity. They were also diagnosed to have cholelithiasis and had intermittent episodes of pain in the right upper quadrant of the abdomen. The ports for laparoscopic cholecystectomy were made in such a way that all the ports sites were removed in the skin flap that was excised during abdominoplasty, and there was no scar in the upper abdomen. The procedure was completed without leaving any telltale signs of laparoscopic cholecystectomy, and this led to a better cosmetic result from the patients' point of view.

Comparing of the Results between Single Port and Three Ports in Laparoscopic Cholecystectomy

The aim of this prospective trial was to observe the results of the two types of techniques. Single port laparoscopic cholecystectomy (SPLC) (56 cases) indication was polyp disease and mild cholecystitis with gall bladder stone (no right upper quadrant tenderness in physical examination, no gall bladder wall thickening in image study). Three ports laparoscopic cholecystectomy (TPLC) (46 cases) was applied to previous laparoscopic surgery indication. There were slight differences in indication as there are still limitations in applying single port laparoscopic cholecystectomy in all patients. The two groups were similar with respect to demographic characteristics. There were no significant differences in operation time, bile leakage during operation, postoperative hospital stay, pain score. Additional port(s) use in single port laparoscopic cholecystectomy were 13 cases, the reasons were difficult dissection of Calot's triangle (7 cases), incomplete ligation by Hem-o-lok clip (3 cases), cystic artery bleeding (3 cases), difficult visual due to obesity (1 case). Single port laparoscopic cholecystectomy is still in its initial stages. Although many controversies remain regarding stability and possibility, it is believed that development and exchange of new instruments and techniques will form an important part of future minimal invasive surgery.

Laparoscopic common bile duct exploration using a rigid nephroscope

Patients with cholelithiasis and choledocholithiasis are increasingly managed with laparoscopic bile duct exploration and cholecystectomy. Large impacted bile duct stones continue to defy laparoscopic extraction. This study explored the feasibility of laparoscopic bile duct clearance using a rigid nephroscope, which is suited to extracting large stones. This prospective study recruited patients with large bile duct stones and a bile duct wider than 8 mm on ultrasonography. In addition to standard ports for laparoscopic cholecystectomy, a custom-made 9-mm port was introduced in the epigastrium for the rigid nephroscope, which was negotiated into the bile duct through a choledochotomy. Rigid graspers and lithotripters were introduced through the nephroscope to fragment and remove the calculi. Between December 2005 and September 2008, 18 patients had nephroscope-guided bile duct exploration (mean(s.d.) age 49(13.9) years, bile duct diameter 11.3(2.3) mm). Three patients had solitary stones and 15 had multiple calculi. Most of the stones were removed with graspers, but the lithotripter was required in five patients. The mean(s.d.) hospital stay was 6(2.3) days. Two patients required postoperative endoscopic retrograde cholangiopancreaticography for residual stones. The rigid nephroscope was useful for laparoscopic bile duct exploration, particularly for large impacted stones.