Page 22 - WJOLS - Laparoscopic Journal

Moatassim Barham

Laparoscopy Hospital (WLH). Selected papers were
screened for further references. Criteria for selection of
literature were methods of analysis (statistical or
nonstatistical) and the institution where the study was done
(specialized one for laparoscopic surgery). Priority
was taken to select the newest comparative studies from
well-known scientific highly specialized journals. Number
of cases were not considered as a criteria since the procedure
itself is not universally undertaken as CLC.
A prospective record of all LCs carried out by an
experienced laparoscopic surgeon following his appointment
in Bristol in 2004, was examined. RLC was resorted to
when difficulties were encountered with exposure and/or
dissection of Calot’s triangle. A conclusion recommended
that this technique does have a place and should be in the
armamentarium of the laparoscopic surgeon. 4
Fig. 1: RLC technique commencing from the fundus downwards
(Ref. www.themgcarshop.com/.../cholecystectomy.jpg)
PATIENT SELECTION METHODS
In the background of the comparative results of the study 23 minutes shorter in RLC than in the usual LC because
which was carried out at Nerima General Hospital, Tokyo, IOC was used much less often. 6
5
Japan, RLC showed satisfactory results in terms of both Regarding the study contributed by Shing-Moo Huang
8
safety and reliability in patients with severe inflammatory and Kuang-Ming Hsiao, the operation time was similar in
disease. the RLC and CLC groups.
9
A prospective record of all LCs carried out in Bristol, In the study of Tuveri M et al the median operating
4
in 2004, was examined. RLC was resorted to when time for the RLC was 65 minutes (range 40-170).
difficulties were encountered with exposure and/or
dissection of Calot’s triangle. RLC was attempted INCIDENCE OF BILIARY INJURY
successfully in 11 out of 1,041 patients. The age ranged RLC approach provides better visualization of the GB, cystic
from 28 to 80 years (mean 61) and there were seven males. duct and CBD with less chance of CBD injury, due to clear
Indications were: fibrous, contracted GB (7), Mirizzi identification of the ductal system, without the need for
syndrome (2) and severe kyphosis (2). Histopathology IOC. 6
showed chronic cholecystitis (7), xanthogranulomatous The easy and safe contrivance for LC with taping of
cholecystitis (3) and acute necrotizing cholecystitis (1). the cystic duct followed by resection of the GB with the
fundus-down approach, performed for 500 patients in which
OPERATIVE TECHNIQUES
the cystic duct was cut-off only after the confirmation of
RLC procedure is as follows: First, the cystic duct and no CBD injury was reported. In the conclusion, the authors
7
artery are exposed at the junction of the ampulla. The cystic memorial comment was: “Thanks to this tape procedure,
duct is clipped, and the artery is divided. Removal of the there was no CBD injury in our 500 cases. We recommend
GB is then started from the fundus to cystic duct this tape ligature of the cystic duct with the RLC approach
downwards. After the GB has been dissected from the liver to decrease the incidence of CBD injury”.
bed, the cystic duct is double-clipped and divided (Fig. 1). 6 Some surgeons use RLC techniques routinely when
In conventional OC, the fundus-down approach is a performing LC and claim to have lower incidence of CBD
more common procedure than the approach in the reverse injury than that of conventional techniques. The reason was
direction. The easy and safe contrivance for LC with taping that it adopted an operative strategy similar to OC proceeding
of the cystic duct temporarily with Teflon tape followed by from the fundus towards the cystic duct and cystic artery.
resection of the GB with the fundus-down approach was RLC seemed to lower the CBD injury rate from 6.5 to 0%. 8
performed. The tape was used for pulling down the cystic A case study was reported whereas an anomaly of the
duct, and Calot’s triangle was easily visible. The cystic duct extrahepatic biliary system is found in which the CHD was

was cut off only after the confirmation of no CBD injury. 7

found to enter the GB whereas the cystic duct drained the
10

whole biliary system into the duodenum. Rarity of this
OPERATIVE TIME

configuration led to transection of the CHD during LC in

A study in which LC was carried out in 173 patients, RLC most cases. In this case study, dissection of the GB starting

was performed in 81; the mean operating time was from the fundus will allow timely discovery of such an
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JAYPEE