DOI: http://dx.doi.org/10.18203/2349-2902.isj20211290

Intraoperative strategies to overcome difficulties in laparoscopic cholecystectomy for chronic calculous cholecystitis

Mohinder Singh, Dipesh Goel

Abstract


Background: Surgery in chronic cholecystitis is very challenging because of inability to hold the gall bladder, dense adhesions, frozen Calot’s triangle and difficulty in applying clips. Precise and meticulous dissection is required to establish critical view of safety. There is no consensus among surgeons about appropriate intraoperative steps in difficult gall bladder (GB) surgery. The authors aim to present various intraoperative difficulties and strategies to overcome them.  

Methods: A prospective study of 81 patients of chronic cholecystitis was done in our institution. They were divided in two groups. Group A in which surgery could be done easily. Group B in which surgery was difficult and different intraoperative strategies were applied to overcome them.

Results: Total 42 patients were included in group A and 39 patients in group B. Various difficulties encountered while performing laparoscopic cholecystectomy in group B were adhesions (53.8 %), inability to grasp the fundus of GB (15.3%), frozen Calot’s triangle (15.3%), inability to grasp the Hartmann’s pouch (12.8%) and cystic duct edema (2.5%).  

Conclusions: Intraoperative technique of identification of Rouviere′s sulcus first, followed by high peritoneal incision on the GB body. Subsequently blunt dissection of Calot’s triangle using gauze piece and hydro dissection by suction irrigation canula ventral to the sulcus. It created a retro gall bladder tunnel safely. It established the critical view of safety in all our cases. 


Keywords


Laparoscopic cholecystectomy, Cholecystitis, Bile duct injury, Critical view of safety

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References


Zhang WJ, Li JM, Wu GZ, Luo KL, Dong ZT. Risk factors affecting conversion in patients undergoing laparoscopic cholecystectomy. ANZ J Surg. 2008;78(11):973-6.

Georgiades CP, Mavromatis TN, Kourlaba GC, Kapiris SA, Bairamides EG, Spyrou AM, et al. Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy?. Surgic Endosc. 2008;22(9):1959-64.

Shinde J, Pandit S. Innovative Approach to a Frozen Calot’s Triangle During Laparoscopic Cholecystectomy. Ind J Surg. 2015;77(6):554–7.

Sewefy AM, Hassanen AM, Atyia AM. Retro infundibular laparoscopic cholecystectomy versus standard Laparoscopic Cholecystectomy in difficult cases. Int J Surg. 2017;43:75-80.

Neri V, Ambrosi A, Di Lauro G, Fersini A, Valentino TP. Difficult cholecystectomies: validity of the laparoscopic approach. J Soc Laparoendosc Surg. 2003;7(4):329.

Gupta N, Ranjan G, Arora MP. Validation of scoring system to predict difficult laparoscopic cholecystectomy, Int J. Surg. 2013;11(9):1002-6.

Akcakaya A, Okan I, Bas G, Sahin G, Sahin M. Does the difficulty of laparoscopic cholecystectomy differ between genders?. Ind J Surg. 2015;77(2):452-6.

Agarwal D, Arora D, Avasthi A, Kothari A, Dangayach KK. Study of 292 patients for prediction of difficult laparoscopic cholecystectomy using detailed history, clinical and radiological parameters. Int Surg J 2016;3:349-53.

Jones MW, Gnanapandithan K, Panneerselvam D, et al. Chronic Cholecystitis. In: StatPearls. Treasure Island (FL): Available at: https://www.ncbi.nlm.nih.gov/books/NBK470236/. Accessed on 08 February 2021.

Lo CM, Liu CL, Fan ST, Lai EC, Wong J. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Anna Surg. 1998;227(4):461.

Arora BK, Arora R, Arora A. Laparoscopic cholecystectomy in wall echo complex gall stone disease: a study. Int Surg J. 2017;4(4):1309-12.

Nidoni R, Udachan TV, Sasnur P, Baloorkar R, Sindgikar V, Narasangi B. Predicting Difficult Laparoscopic Cholecystectomy Based on Clinic radiological Assessment Clin Diagn Res. 2015;9(12):PC09–12.

Singh M, Prasad N. The anatomy of Rouviere's sulcus as seen during laparoscopic cholecystectomy: A proposed classification. J Minim Access Surg. 2017;13(2):89.

Bat O. The analysis of 146 patients with difficult laparoscopic cholecystectomy. Int J Clinic Experiment Medic. 2015;8(9):16127.

Targarona EM, Marco C, Balague C, Rodriguez J, Cugat E, Hoyuela C, et al. How, when, and why bile duct injury occurs. Surgic Endosc. 1998;12(4):322-6.

Atta HM, Mohamed AA, Sewefy AM, Abdel-Fatah AF, Mohammed MM, Atiya AM. Difficult laparoscopic cholecystectomy and trainees: predictors and results in an academic teaching hospital. Gastroenterol Res Pract. 2017;5;2017.

Jae Woo Park, Munjin Kim, Sang Kuon Lee, Appropriate Hospital Discharge Timing after Laparoscopic Cholecystectomy: Comparison of Postoperative Day 1 vs. Day 2 Discharge Protocol. J Minim Invasive Surg 2019;22(2):69-74

Henneman D, Da Costa DW, Vrouenraets BC, van Wagensveld BA, Lagarde SM. Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review. Surgic Endosc. 2013;27(2):351-8.