Page 15 - World Journal of Laparoscopic Surgery

WJOLS

Comparison of Three-port vs Four-port Laparoscopic Cholecystectomy in a Medical College in the Periphery
5
performed annually. The advantages of laparoscopy up and right side up. Then 10-mm working port in the
over conventional or classic surgery include decreased subxiphoid (epigastric) area was inserted.
pain, improved cosmetic results, and a decreased dura- In group II patients, two 5-mm ports in the right
tion of hospital stay. For this reason, LC is nowadays midclavicular line subcostally and in the anterior axillary
performed through fewer and smaller ports. In recent line at the level of the umbilicus were put. In patients of
years, multiple studies of single-incision laparoscopic group I, a 5-mm port was put in the right midclavicular
surgery (SILS) have been published. The only reported line. In patients of group II, the fundus of the gallbladder
advantage of SILS over standard LC is an improved was grasped through the lateral port and retracted above
6,7
cosmetic result. Four-port LC is most commonly the liver margin. In patients of group I, the gallbladder
used, as this method provides better anatomic views fundus was retracted toward the superolateral direction
8
and is easier to learn. This study has been undertaken with the help of atraumatic grasper.
to assess the feasibility of three-port LC and compare After port placement, posterior dissection of the
its advantages and disadvantages over the standard Calot’s triangle was started. Once posterior dissection
four-port technique. was complete, anterior dissection of Calot’s triangle was
done. A large window between the cystic duct and cystic
MATERIALS AND METHODS artery was made. The junction of the cystic duct and
common bile duct was identified. Then two proximal and
A total of 260 adult patients with cholelithiasis of either
sex and in the age group of 18 to 60 years, admitted to the one distal LIGACLIPs were applied on the cystic duct. The
surgical wards of the Maharishi Markandeshwar Institute cystic duct was then cut off in between the clips. Cystic
of Medical Sciences and Research, Mullana, from April artery was either coagulated with bipolar cautery or was
2014 to March 2015, were taken up for the study. From divided between the two clips. Then, the gallbladder was
this group, 60 patients were excluded as they did not removed from the liver bed using a hook dissector. The
meet the inclusion criteria. gallbladder was extracted through the subxiphoid port.
The patients were divided into group I: Three-port Subhepatic drain was used in selected cases if postop-
LC and group II: Four-port LC, as 100 in each group. erative bleeding or bile leakage was expected. Operative
All the cases of chronic calcular cholecystitis were time from start of procedure (supraumbilical incision) to
included in the study, and the cases diagnosed with acute the closure of the wound was noted down.
cholecystitis, empyema gallbladder, perforation gallblad- Postoperative assessment included temperature,
der, and contraindications for laparoscopic surgery were pulse, blood pressure , postoperative pain, and postopera-
excluded from this study. tive analgesia requirements. After surgery, postoperative
In all the cases, relevant history, general physical complications were recorded on day 1 and after day 7.
examination, and the routine blood and radiological inves- The findings noted down for the patients in the two
tigations were done as per proforma attached, to confirm subgroups were compared, and results were evaluated
the diagnosis and assess medical fitness of the patients. at the end of this study.
OBSERVATIONS
Procedure of Laparoscopic Cholecystectomy
In the present study, we have compared the two methods
All the patients were given an injection of ceftriaxone
1 gm intravenously before the procedure. Patients were of LC, i.e., three-port LC and the standard four-port LC.
asked to empty the urinary bladder before moving to Cases were divided into two groups of 100 each
the operation theater. All patients were operated under randomly and were designated as groups I and II. In
general anesthesia. A nasogastric tube was inserted group I, three-port LC was performed and in group II
and stomach aspirated, in cases where stomach was four-port LC was performed.
distended. Most of the patients in the present study were in the
The Veress needle was inserted through a stab inci- age group of 31 to 40 years (33%), ranging between 18
sion in the supraumbilical region. Once the needle tip and 60 years, with a mean age of 39.33 years.
entered the free peritoneal cavity, it was connected to the
pneumoinsufflator and insufflated until the pressure was Table of Age Distribution
raised to 10 mm Hg. The Veress needle was removed and Regarding symptoms, all the patients had pain as their
then at the site of Veress needle puncture a 10- mm safety chief complaint. So, pain was the single most driving force
trocar was inserted. When the trocar reached the abdomi- for the patient to seek treatment. Vomiting was present
nal cavity, it was removed and a telescope was introduced in only 22 to 24% of the patients, especially during acute
through the cannula. Operating table was tilted, head end attacks (Table 1).
World Journal of Laparoscopic Surgery, January-April 2017;10(1):12-16 13