Technique Of Laparoscopic Cholecystectomy Research Articles

Acquiring laparoscopic skill for colorectal surgery: based on the experience of a colorectal surgeon

Laparoscopic colorectal surgery is a skill-dependent procedure. The present study aims to analyze the learning curve of a properly trained surgeon, with basic laparoscopic techniques, to become skillful in performing laparoscopic colorectal operations. A series of non-selective, consecutive 189 cases of laparoscopic colorectal surgery were accomplished, from December 2009 to February 2012, by one surgeon with years of skilled technique in laparoscopic cholecystectomy, rich experience in assisting laparoscopic colorectal surgery, and experience of approximately 180 procedures of gastric and colorectal surgery annually. 170 out of 189 procedures were radical operations for colorectal neoplasma, including right colectomies in 28 cases, left colectomies in 5 cases, sigmoidectomies in 28 cases, high Dixon procedures in 45 cases, low Dixon (total mesorectal excision, TME) procedures in 41 cases and Miles procedure in 23 cases. 19 other patients underwent combined procedures for multi-primary tumors or inflammatory enteritis. All these procedures were analyzed according to time span (the earlier half and later half) in respect to length of surgery, intraoperative blood loss, number of lymph nodes retrieved, intraoperative events and postoperative complications. For radical right colectomy, the D2 dissection conducted in the earlier phase (n = 8) had the similar length of surgery, more blood loss and less LN retrieval, compared with the D3 dissection conducted in recent phase (n = 20). The earlier performed high Dixon procedures (n = 22) consumed longer time than the later procedures (n = 23) consumed, but with similar blood loss and LN retrieval. Low Dixon (TME) procedures showed significant differences in length of surgery and blood loss relative to time span. Recently performed simoidectomy and Miles procedures showed a trend of shorter time consumed compared with earlier performed procedures. Conversion ratio to open surgery was 1.05%. Adverse effects occurred in 8 cases of surgeries, including intestinal injury (3/189), insufficient distal margin (2/189), intraoperative bleeding (2/189) and vaginal injury (1/76). There was no operative death. Chief complications included urinary retention 5.82%, ileus 4.76%, anastomotic leak 4.24%, perineal infection 23.08% (6/26), wound dehiscence 2.65%, gastrointestinal bleeding 1.59%, peritoneal infection 1.06%. Surgery for distal rectum tended to have more complications, such as urinary retention, anastomotic leak and perineal infection. The later performed low Dixon procedures produced insignificantly fewer anastomotic leaks than those in the earlier phase. For a trained surgeon with basic laparoscopic techniques, there are at least 15 - 25 cases of different procedures needed for him/her to become skilled to perform laparoscopic surgery. The learning curve should also depend on the annual number of colorectal surgeries.

Initial experience of glove port technique in single incision laparoscopic cholecystectomy using conventional laparoscopic instruments

Introduction: Single-incision laparoscopic surgery is an attractive approach for cholecystectomy. However, its widespread application has many limitations. A significant obstacle of application in developing countries is the expensive and non-affordable specialized single port systems and roticulating instruments.

Single-Port Laparoscopic Cholecystectomy Using the Innovative E. K. Glove Port: Our Experience

The technique of laparoscopic cholecystectomy continues to evolve with a trend towards decreasing use of working ports. One of the emerging concepts of 21st century is single-port surgery. It has further minimized the minimally invasive surgery. However, the main drawbacks of this technique are the lack of “triangulation” to which the laparoscopic surgeons have grown accustomed to, the clustering of instruments, and the costly multichannel ports, which are very costly and, in fact, are not affordable by the majority of the population in a developing country like India. From September 2009 to December 2011, 210 patients identified as having biliary colic, chronic cholecystitis, and previous biliary pancreatitis or obstructive jaundice due to stones (managed by ERCP) underwent single-port laparoscopic cholecystectomy using the E. K. glove port. The operating time was reasonable and can be lessened with experience. Excellent exposure of the critical view was obtained in all cases. This technique is safe, feasible, reproducible, cheap, and easy to learn. It may be an alternative to the currently available single-port access system, especially in a developing country like India. If required, placement of the remaining two to three ports for a more conventional laparoscopic cholecystectomy can be done.

Laparoscopic cholecystectomy techniques with special care treatment in acute cholecystitis patients regardless of operation timing.

The optimal timing for laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) remains controversial. In this study, we aggressively performed three types of LC techniques in AC patients at different time with our care procedure. Forty-three patients with AC were retrospectively divided into two groups: Group one (n=16, within 72 hrs at the onset of symptoms) and Group two (n=27, beyond 72 hrs after the onset of symptoms). Standard, subtotal or prograde cholecystectomy were performed for all cases, depending on the fragility of gallbladder wall, difficulty of gallbladder dissection, assurance of Calot's triangle and quality of retraction over Hartman pouch. There were no statistical differences between both groups with regards to age, operation time, length of hospital stay and complications. Gangrenous cholecystitis was found in 6.3% of cases in Group one and 26.9% in Group two, although not statistically different. Four cases (two in each of groups) underwent prograde cholecystectomy and four cases in the group 2 received subtotal cholecystectomy; all with longer operation time and length of stay, as compared to standard cholecystectomy. None of the 43 patients was converted to open procedure. Complications in this study were minor. LC can be safely performed in patients with AC with special care, regardless of the duration between the onset of symptoms and operation. In addition to standard procedures, subtotal and prograde cholecystectomy could help to manage inflammatory gallbladder and obscured Calot's triangle.

Magnetically anchored camera and percutaneous instruments maintain triangulation and improve cosmesis compared with single-site and conventional laparoscopic cholecystectomy

This study evaluated operative outcomes and ergonomics for a magnetic camera (MAGS) used in conjunction with percutaneous instruments [percutaneous surgical set (PSS)] compared with single-site laparoscopic (SSL) and conventional laparoscopic (LAP) cholecystectomy techniques. Four surgical trainees each performed three porcine cholecystectomies using three randomized techniques including MAGS/PSS, SSL, and LAP. The operative outcomes, procedure-specific ratings (1-5 scale; 1=superior), workload (1-10 scale; 1=superior), and global impressions (1-10 scale; 10=superior) were recorded. Comparisons used analysis of variance (ANOVA) on ranks (Kruskal-Wallis), and p values lower than 0.05 were considered significant. The operative outcomes were similar except for significantly higher blood loss with SSL (16.3±10.3) versus LAP (2.8±1.5; p<0.05) but not with MAGS/PSS (4.8±3.8). Several inadvertent tissue-damaging events occurred with SSL but not with MAGS/PSS or LAP. The incision was significantly shorter with MAGS/PSS (29.3±2.8mm) and SSL (29.3±2.5mm) than with LAP (48.0±3.6mm; p<0.05). Compared with SSL (3.6±0.5), the procedure-specific ratings significantly favored MAGS/PSS (2.8±0.4) and LAP (1.7±0.2; p<0.05). Ergonomics and technical challenges both were rated significantly inferior with SSL (4.3±1.0 and 3.8±0.5, respectively) versus LAP (1.5±0.6 and 2.0±0.8, respectively; p<0.05) but not with MAGS/PSS (2.5±1.0 and 3.0±0.8, respectively). Both MAGS/PSS (4.5±0.5) and SSL (4.8±1.0) were associated with a significantly greater workload than LAP (2.5±0.6; p<0.05). Global impression ratings were significantly higher for LAP (8.7±1.3) versus SSL (5.8±2.0; p<0.05) but not for MAGS/PSS (7.1±1.8). Cosmesis was significantly better with MAGS/PSS (9.5±0.6) versus LAP (6.5±2.4; p<0.05) but not with SSL (8.8±1.3). The MAGS/PSS technique allows better triangulation and fewer technical difficulties than SSL and better cosmesis than LAP. Further development of these devices is warranted.

New Technique of Clipless Laparoscopic Cholecystectomy

Background: In laparoscopic cholecystectomy (LC), application of clips is the standard method for controlling the cystic duct and artery. However, this is not without problems. We propose a modified technique for management of cystic duct and artery in LC. Methods: Since 2007, 328 patients presented with symptomatic gallstones were included. In those patients, the cystic artery was divided by monopolar cautery and the cystic duct was ligated intracorporeally using nonabsorbable suture. Results: Three patients (0.9%) have bleeding from cauterized cystic artery; bleeding was controlled by diathermy in two of them and application of metal clip was necessary in the remaining patient. Cystic duct leak was detected in only one patient (0.3%), and it was managed by percutaneous drainage. At follow up we did not encounter abnormalities suggestive of bile duct stricture. Conclusion: The proposed modification of LC is feasible, practical, safe and economic as well. It is associated with reduced risk of postoperative morbidity.

A Novel Retraction Instrument Improves the Safety of Single-Incision Laparoscopic Cholecystectomy in an Animal Model

Single-incision laparoscopic cholecystectomy (SILC) promises improved cosmesis and may further minimize the invasiveness of intraabdominal interventions but cannot come at the expense of patient safety. This study describes the evaluation of a novel 5-mm instrument designed for SILC that maintains an equivalent critical view to that obtained with standard multiport laparoscopic cholecystectomy (MLC). Sixteen animals were randomly assigned to one of four study arms. Four techniques for laparoscopic cholecystectomy were used: standard four-port MLC, three-instrument SILC (SILC-A), three-instrument SILC using a suture for lateral retraction (SILC-B), and three-instrument SILC using the novel instrument for retraction (SILC-C). Each case was timed and video-recorded. The video was cropped to obscure the method of retraction and evaluated by five experienced laparoscopic surgeons blinded to the technique used. Each case was rated subjectively on a safety and visualization scale of 1-4. SILC-A and SILC-B cases were significantly longer in duration than both SILC-C and MLC cases. The safety and visualization scale results were lower for the SILC-A technique but were equivalent for the MLC, SILC-B, and SILC-C techniques. This study introduces a novel instrument for gallbladder retraction. In this initial evaluation, the new instrument showed encouraging results in its ability to generate good visualization, support the safe critical view technique, and reduce the length of the procedure.

Single-port versus needlescopic versus conventional laparoscopic cholecystectomy: a comparative study

Single-port laparoscopic cholecystectomy (LC) has been recently introduced to achieve clinical benefits over standard LC. However, surgical outcomes of this operation have been poorly described compared with current techniques. The purpose of this study is to evaluate the surgical outcomes of single-port LC compared with needlescopic and conventional LC. We reviewed the surgical outcomes of consecutive patients with symptomatic gallbladder stone disease who underwent single-port LC (31 cases), needlescopic LC (26 cases) and conventional LC (32 cases) from March 2009 to January 2010. Operation time, hospital stay, conversion, complications, and postoperative pain using visual analog scale were analyzed. In addition, patients were interviewed for overall satisfaction and cosmetic results. BMI in the single-port group was significantly lower than in the conventional group (26.0 ± 4.0 vs 30.8 ± 7.3 kg/m(2) , P=0.0017). Operation time in the single-port group was significantly longer than in the conventional group (65.1 ± 20.1 minutes vs 52.2 ± 19.6 minutes, P=0.012). There was one conversion in the single-port group. In nine cases in the single-port group (29%), a Kirschner wire or a suture retractor helped visualization. There was one complication in the single-port group (wound infection) and one in the needlescopic group (bile leak, requiring laparoscopy). Hospital stay, visual analog scale scores, and overall satisfaction did not vary among these groups. Greater cosmetic satisfaction was shown in the single-port group compared with the conventional group (P=0.039). Single-port LC is feasible and secure, with better cosmetic results than conventional LC. Further prospective randomized studies are still required to show its superiority over current LC techniques.

Laparoscopic Cholecystectomy: Fundus First or Fundus Last-Which and Why?

Biliary tract injury represents the most serious and potentially life-threatening cholecystectomy complication. It is important to identify thestructure of Calot�s triangle during isolation of cystic duct to decrease this injury. Cystic duct isolation is the first dangerous techniquein laparoscopic cholecystectomy. Retrograde (fundus first) dissection is frequently used in open cholecystectomy and although feasiblein laparoscopic cholecystectomy, it has not been widely practiced as the antegrade conventional one. This article is presented to showthat retrograde method appears to be a safe procedure and does not compromise the conventional one. It should be tried if obscureanatomy should occur without proceeding to irreparable hemorrhage or biliary injury. If these do occur, conversion is always a viablechoice and should not be deemed a failure. However, retrograde dissection remains to have its error trap that is mostly leading tovasculobiliary injuries as well as the drawback of retained GB stones tendency.Abbreviations: OC: Open cholecystectomy, LC: Laparoscopic cholecystectomy, RLC: Retrograde laparoscopic cholecystectomy,CLC: Conventional laparoscopic cholecystectomy, GB: Gallbladder, CBD: Common bile duct, CHD: Common hepatic duct, IOC:Intraoperative cholangiography, ERCP: Endoscopic retrograde cholangiopancreaticography.

Single-Working-Instrument, Double-Trocar, Clipless Cholecystectomy Using Harmonic Scalpel: A Feasible, Safe, and Less Invasive Technique

The aim of this study was to evaluate the safety and efficacy of the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH) in the closure/division of the cystic duct and artery, and bladder dissection in laparoscopic cholecystectomy as a single working instrument, with the use of a two-working-trocar technique, compared with the regular laparoscopic clip/cautery, three-trocar technique. This prospective study included 160 patients with symptomatic gallstone disease who were randomly assigned for laparoscopic cholecystectomy by either Harmonic shear as a single working instrument, with the two-trocar technique (group 1 = 80 patients) or group 2 (regular clip/cautery, three-trocar technique) comprising 80 patients. No significant complications were encountered in either group; however, 1 case in the regular laparoscopy group suffered mild leakage that was treated conservatively. Intraoperative bile spillage was insignificantly comparable in both groups (10 versus 13%; P = 0.46). The median operative time was statistically significantly shorter in the Harmonic group (20 versus 45 minutes; P = 0.0001). Also, hospital stay was significantly shorter in the Harmonic group (1 versus 1.5 days, respectively; P = 0.001), but no statistically significant difference was found in the incidence of postoperative complications. The overall cosmetic results and patient satisfaction was better in the Harmonic group. The Harmonic shear is as safe and effective as the clip/cautery technique in laparoscopic cholecystectomy in achieving hemobiliary stasis, with shorter operative time, especially if used solely as a working instrument. The two-trocar technique is safe, feasible, and provides better cosmetic results and patient satisfaction.

“Single-Port” Laparoscopic Cholecystectomy—The Aberdeen Technique

Laparoscopic cholecystectomy remains the most frequently performed minimally invasive operation for general surgeons. The next step toward "scar-less" surgery uses a modified single multichannel port inserted through the umbilicus. The use of a single port requires modification of the currently established technique for laparoscopic cholecystectomy with a single-port protocol. This new method presents a few technical difficulties and challenges compared with the conventional 3-port or 4-port laparoscopic cholecystectomy. We discuss maneuvers to help overcome these difficulties based on our initial experiences. All the data for the procedures that were performed were prospectively collected and analyzed. Single port cholecystectomy was attempted in 30 patients (all females) with no intraoperative/postoperative complications from September 2008 to March 2008. In all, 20 of 30 patients had their operation completed with the use of a single port. An extra 5-mm epigastric port was required in 8 of the 20 patients. Another 2 of 20 patients required conversion of the operation into a standard laparoscopic technique (1x3-port and 1x4-port procedure). All the patients were discharged within 24 hours. There were no intraoperative or postoperative complications or mortalities. The single-port technique is feasible for performing routine laparoscopic procedures. With further advances in surgical technique, technology, and instrumentation, this technique can be reproduced to perform more complex biliary and other procedures in future.

Combined Operation of Laparoscopic Cholecystectomy during Laparoscopic Appendectomy in Patient with Chronic Gallbladder Disease

Purpose: Laparoscopic cholecystectomy (LC) for asymptomatic gallbladder disease has been increasing since 1990 due to the development of LC technique. Moreover, it might be considered when someone with asymptomatic gallbladder disease needs emergency operation due to acute abdomen such as acute appendicitis. The aim of this study is to identify the efficacy of concurrent laparoscopic appendectomy with cholecystectomy. Methods: From January 1997 to June 2009, 40 patients underwent laparoscopic appendectomy with cholecystectomy at Ewha Womans University Mokdong Hospital. 40 patients were enrolled in this study. We analyzed, retrospectively, clinical and diagnostic information, time and open conversion rate in operation, length of postoperation hospital stay, and complication rate. Results: The mean age was 44.53±15.34 and male to female ratio was 1 to 1.86. 5% of all patients underwent abdominal surgery and 20% of all patients had associated diseases. Most common associated symptoms and final diagnosis were right lower abdominal pain (72.5%) and simple gallbladder stone (62.5%). Mean operation time was 98.75±33.14 min. and there was no open conversion. Mean length of postoperation hospital stay was 5±2 days. There was one (2.5%) postoperative complication. Conclusion: Combined operation of laparoscopic cholecystectomy during laparoscopic appendectomy can be a good modality for patients with chronic gallbladder disease.

COMPARATIVE ANALYSIS OF SPINAL VS GENERAL ANAESTHESIA FOR LAPAROSCOPIC CHOLECYSTECTOMY: A PROSPECTIVE RANDOMIZED STUDY

INTRODUCTION: Spinal anaesthesia has not been routinely employed as a sole technique for laparoscopic cholecystectomy. This study was conducted to compare the advantages and disadvantages of these two methods of anaesthesia employed in laparoscopic cholecystectomy. METHODS: We compared hundred successive patients of laparoscpic cholecystectomy , between January 2008 and June 2009, who were randomly divided into two equal groups; one group was subjected to GA whereas the other underwent spinal anesthesia. The inclusion criteria of this study were ASA I& II grade patients, BMI< 30 with normal coagulation profile. Hyperbaric 3 ml plain bupivacaine 0.5% was administered for spinal anaesthesia. Intraoperative parameters, postoperative pain and recovery in general, as well as patient satisfaction at follow-up were prospectively recorded to assess the feasibility and safety of the procedure.OBSERVATION: None of the patients had significant haemodynamic perturbation other than transient hypotension and bradycardia during surgery. The mean operative time was 40.25 minutes. There was no statistical significance in post operative pain and vomiting in both groups. Recovery was uneventful and without any morbidity or mortality. CONCLUSION: All of the patients and surgeons were satisfied with laparoscopic cholecystectomy under spinal anaesthesia, therefore this form of anaesthesia may be an appropriate choice and can increase the number of patients eligible for surgery. However this approach requires a cooperative patient, a skilled laparoscopic surgeon, a gentle surgical technique and an enthusiastic anaesthesiologist.

Safety and efficacy of laparoscopic cholecystectomy during pregnancy: A comparative study between low-pressure and gasless laparoscopy

Pregnancy and high parity increase the risk of cholelithiasis and its complications during pregnancy. Laparoscopic cholecystectomy for failed conservative treatment of symptomatic cases during pregnancy is no longer been a contraindication. The potential risk of pneumoperitoneal pressure and CO2 insufflation triggered the use of modified techniques as gasless and low pressure cholecystectomy for materno-fetal safety. Patients and methods: Thirteen pregnant patients with indicated cholecystectomy were randomly assigned for either low-pressure laparoscopy (LPL) (6 patients) or gasless laparoscopy (GL) (7 patients). Patients were compared for respiratory and blood gases changes, hemodynamic changes, anesthetic requirements, surgical and early postoperative outcomes and materno-fetal well-being during hospitalization and they were followed up till delivery. Results: After CO2 insufflation there were significant differences between the 2 groups with increase in the cardiopulmonary parameters namely; PaCO2, PetCO2 , peak airway pressure, heart rate and the mean arterial blood pressure and a decrease in pH in the LPL group. The operating time and anesthetic drugs used were significantly more for the GL group. No recorded differences in the postoperative abdominal pain, postoperative nausea and vomiting (PONV) and fetal heart rate changes. Conclusion: Both low pressure and gasless laparoscopy provide a safe technique for laparoscopic cholecystectomy during pregnancy. However, gasless technique is associated with lower cardiopulmonary effects, despite its longer operating time. In patients with compromised cardiopulmonary function during pregnancy, the gasless technique provides a safer method to avoid the potential adverse effects of pneumoperitoneal pressure and CO2 insufflation.

Body-First Laparoscopic Cholecystectomy: A Three-Trocar Technique for Difficult Gallbladders

In this paper, we report on a modified technique of laparoscopic cholecystectomy (LC), using three-trocars in cases of difficult anatomy at the Calot's triangle without the insertion of more additional trocars, in order to validate its feasibility, efficacy, and safety. We retrospectively analyzed 67 consecutive cases of body-first LCs performed for gallbladder disease from January to December 2007. The surgical technique was compared with respect to operative times, conversion to open cholecystectomy, postoperative complications, and length of postoperative stay. The body-first LC was successful in 64 patients (95.6%). The median operating time was 32 minutes (range, 27-90) for chronic cholecystitis, 53 minutes (range, 41-145) for acute cholecystitis, and 62 minutes (range, 35-170) for interval cholecystectomy. The difference in duration of the surgical procedure between the chronic cholecystitis group and the other two groups was significant (P < 0.05). We did not find any significant difference in the average operating time between the acute cholecystitis group and the interval cholecystectomy. The average postoperative hospital stay was 1 day (range, 1-3). No common bile duct injuries and no complications occurred in the series reported in this paper. The body-first three-trocar LC is a safe option when dealing with patients with difficult anatomy at the Calot's triangle. It yields a low conversion rate and avoids the insertion of any additional trocars. Further studies are required on the long-term efficiency and reliability of this technique in order to fully evaluate its value.

Systematic review: open, small‐incision or laparoscopic cholecystectomy for symptomatic cholecystolithiasis

Laparoscopic cholecystectomy has become the method of choice for gallbladder removal, although evidence of superiority over open and small-incision cholecystectomy is lacking. To compare the effects of open, small-incision and laparoscopic cholecystectomy techniques for patients with symptomatic cholecystolithiasis. We conducted updated searches until January 2007 in multiple databases. We assessed bias risk. Fifty-nine trials randomized 5556 patients. No significant differences in primary outcomes (mortality and complications) were found among all three techniques. Both minimal invasive techniques show advantages over open cholecystectomy in terms of convalescence. Small-incision cholecystectomy showed shorter operative time compared with laparoscopic cholecystectomy (random effects, weighted mean difference, 16.4 min; 95% confidence interval, 8.9-23.8), but the two techniques did not differ regarding hospital stay and conversions. No significant differences in mortality and complications were found among all three techniques. Laparoscopic cholecystectomy and small-incision cholecystectomy are preferred over open cholecystectomy for quicker convalescence. Laparoscopic cholecystectomy and small-incision cholecystectomy show no clear differences on patient outcomes.

Single-step treatment of gall bladder and bile duct stones: A combined endoscopic–laparoscopic technique

Introduction The advent of endoscopic techniques changed surgery in many regards. In the management of cholelithiasis; laparoscopic cholecystectomy (LC) is today the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic common bile duct exploration (LCBDE) by the transcystic approach or laparoscopic choledocotomy, open CBD exploration and postoperative ERCP. A major concern regarding both pre- and postoperative extraction of CBD stones (CBDS) by the ERCP is the risk of development of pancreatitis, also more than 10% of the preoperative ERCP is normal. More recently the alternative technique of combined LC with intraoperative ERCP and ES is emerging in an attempt to manage cholecysto-choledocholithiasis in a single-step procedure. Objectives The aim of this work was to assess the treatment of common bile duct stones (CBDS) in a one-stage operation by laparoscopic cholecystectomy (LC) and intraoperative endoscopic retrograde cholangiopancreatography (LC + IO-ERCP) and endoscopic sphincterotomy (ES). Patients and methods This study was carried out on 45 patients with gall bladder stones and with suspected or confirmed CBDS at the Gastrointestinal Surgery Unit in the Main Alexandria University Hospital. They were treated by a single-step procedure combining LC and IO-ERCP. Laparoscopic intraoperative cholangiography (IOC) was carried out to confirm the presence of CBDS. A soft-tipped guide-wire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guide-wire. Endoscopic sphincterotomy was performed and the stones were extracted with a retrieval balloon or with a Dormia basket. The surgical operating time, surgical success rate, postoperative complications, retained CBDS, and postoperative length of hospital stay were assessed. Results There were 30 females and 15 males. Their mean age was 45.07 + 11.3 years (ranging from 27 to 65years). Twenty-seven patients had confirmed CBDS by preoperative ultrasound (US) and/or MRCP. Eighteen patients were suspected for CBDS on clinical, laboratory and/or US basis. Conversion to open cholecystectomy occurred in one case due to severe adhesions at the Calot's triangle. IOC revealed the presence of CBDS in 36 patients. IO-ERCP with ES was performed successfully in 33 patients and stones were extracted endoscopically. Passage of the guide-wire through the papilla failed in three patients. Cholecystectomy was completed laparoscopically in 44 patients. The mean operative time was 119 + 14.4 min (ranging from 100 to 150 min). Minor postoperative complications occurred in 15 patients. No postoperative complications related to the procedure, i.e., pancreatitis, bleeding, perforation, were encountered. Patients regained their bowel motion on the next day and were discharged after a mean hospital stay of 2.55 + 0.89 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evidence of retained CBDS. The mean duration of the postoperative follow-up was 9 + 4.07 months (ranging from 3 to14 months). Conclusion The current study suggests that LC + IO-ERCP for the management of cholecysto-choledocholithiasis is a safe and aneffective technique with a low rate of post-ERCP pancreatitis. It offers another alternative for surgeons especially those who do not practice LCBDE to treat patients in a single setting. However, additional studies with larger patient populations are needed keeping in mind that the limiting characteristic is the proximity and availability of the endoscopic settings.

Laparoscopic Transumbilical Cholecystectomy: Surgical Technique

Laparoscopic cholecystectomy is generally performed using 4 ports by transperitoneal access. Recent developments regarding laparoscopic surgery have been directed toward reducing the size or number of ports to achieve the goal of minimally invasive surgery, by minilaparoscopy, natural orifice access, and the transumbilical approach. The aim of this article is to describe our laparoscopic transumbilical cholecystectomy technique using conventional laparoscopic instruments and ports. The Veress needle was placed through the umbilicus, which allowed carbon dioxide inflow. A 5-mm trocar was placed in the periumbilical site for the laparoscope followed by the placement of 2 additional 5-mm periumbilical trocars. The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed, and all 3 periumbilical skin incisions were united for specimen retrieval. Five transumbilical cholecystectomies were performed following this technique. The mean BMI was 26.6 kg/m(2). The mean operative time and blood loss were 46.2 minutes and 55 mL, respectively. No intraoperative complications occurred. Analgesia was performed using dipyrone (1g IV q6h) and ketoprofen (100 mg IV q12 h). Time to first oral intake was 8 hours. Mean hospital stay was 19.2 hours. Laparoscopic transumbilical cholecystectomy seems to be feasible even using conventional laparoscopic instruments and can be considered a potential alternative for traditional laparoscopic cholecystectomy.

Technical Notes and Tips: Clipless Technique of Laparoscopic Cholecystectomy Using the Harmonic Scalpel

Technical Notes and Tips: Clipless Technique of Laparoscopic Cholecystectomy Using the Harmonic Scalpel

Randomized Trial of Low-pressure Carbon Dioxide-elicited Pneumoperitoneum Versus Abdominal Wall Lifting for Laparoscopic Cholecystectomy

Two alternative surgical techniques for elective laparoscopic cholecystectomy (LC), low-pressure insufflation of the peritoneal cavity and abdominal wall lifting (AWL), have been developed over time to minimize the disadvantages associated with CO2-elicited pneumoperitoneum. To the best of our knowledge, the 2 methods have seldom been compared as regards their relative advantages and disadvantages. Eighty patients scheduled for elective LC were randomized into either a low-pressure (8 mmHg) CO2 insufflation method (LPLC) group, or a gasless technique using a subcutaneous abdominal wall lifting device (GLC group). The duration of the surgical procedure, the surgical results including level of postoperative pain, and perioperative cardiopulmonary function changes experienced by the members of both groups were compared. Laparoscopic surgery was completed for all but 1 patient from each group due to an inadequate surgical-site exposure. There was no mortality for study participants, and no major complications were noted for members of either group. The LPLC group evidenced a shorter surgical duration as compared to the GLC group (77 +/- 28 minutes vs. 98 +/- 27 minutes, respectively; p < 0.01) and a lower incidence of postoperative shoulder pain (2/38 vs. 8/39, respectively; p < 0.05), although significant differences in intraoperative pulmonary function were noted (an increased PaCO2, Pet CO2 and peak-airway pressure and decreased arterial blood pH; p < 0.01) for the LPLC group compared to the GLC group. Both alternative methods for this type of surgery appeared feasible and safe for LC. Low-pressure CO2 pneumoperitoneum had a shorter surgical duration and less postoperative shoulder pain compared to the GLC technique, but did not feature any other advantage over the AWL technique with regard to impact on cardiopulmonary function.