Page 23 - WJOLS - Laparoscopic Journal

WJOLS

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

anomaly. Maintenance of continuity between the CHD and noninflammatory groups were comparatively evaluated. The

cystic common biliary duct by preserving part of the GB incidences of major postoperative complications were 0%

permits easy repair on a T-tube. in RLC cases and 17% in CLC cases in the severe
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About 250 biliary injuries in a study, many biliary inflammatory group. 5
8
misidentification injuries occur due to error traps method In another study, the complication rate was lower in
that work well in most circumstances but which are apt to RLC group patients (3% vs 22.6% ). Complications included
certain conditions. The most common cause of CBD injuries, urinary tract infection and wound infection in
misidentification results from the ‘infundibular technique’ CLC group patients, but only wound infection in RLC group
error trap. This problem is usually associated with severe patients.
inflammation which hides the cystic duct and obliterates In conclusion of a study done by Tuveri M et al, RLC
Calot’s triangle making the CHD appear to be part of GB remains a safe option when dealing with patients with difficult
wall. Another error trap—RLC has been associated with anatomy at the Calot’s triangle but its adoption needs a good
injuries in which the vascular component has been even surgical judgment.
more serious than the biliary one. These injuries result in Refering to another study, RLC technique provides
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hepatic infarction requiring liver resection, possibly including an alternative to CLC technique in patients at high risk for
transplantation. As opposed to CLC error trap, the fundus- conversion or CBD injury. It reports the complication of a
down error trap usually occurs at OC after conversion. retained CBD stone after utilizing this technique. IOC was
Knowledge of these error traps and their avoidance can not performed due to the concern for causing CBD injury
help to reduce the incidence of biliary injuries (Fig. 2). in a patient with significant periductal inflammation and
The cystic duct may be hidden in some patients having no risk factors for CBD stones. Following discharge, the
LC, especially in the presence of inflammation. This may patient developed jaundice 3 days later and returned for
lead to the deceptive appearance of a false infundibulum evaluation. He required ERCP for removal of a CBD stone.
that misleads the surgeon into identifying the CBD as the It should now be recognized that there is a risk of displacing
cystic duct. Biliary injury is more likely when cystic duct a gallstone into the CBD in utilizing RLC technique. This
identification is made by relying solely on the appearance of report highlights the importance of IOC when using this
the junction of the cystic duct with the infundibulum, and technique, even in patients considered to be at low risk
this technique should be abandoned. 12
for having CBD stones. If IOC is considered hazardous,
then intraoperative ultrasound should be the modality of
COMPLICATIONS
choice.
A study in which LC was carried out in 173 patients, RLC
was performed in 81; the result of the study reported that RATE OF CONVERSION
RLCs were performed without severe complications, either
immediate or late. 2 Nerima General Hospital, Tokyo, Japan, study has a very
5
Around 129 consecutive LCs were carried out and cases clear answer in this field. The rates of conversion to
of RLC and CLC in a severe inflammatory and laparotomy were 0% in RLC cases and 33% in CLC cases
in the severe inflammatory group.
Contracted GB is known to result from long-standing
chronic cholecystitis, in which rigid fibrosis of areolar tissue
makes cystic duct and cystic artery structures relatively
more fragile and vulnerable to injury during Calot’s triangle
dissections. It might be the fibrotic rigidity nature of
pericholecystic areolar tissue in patients with contracted
GB that contributes to the high incidence of obscure
anatomy in triangle of Calot, intraoperative hemorrhage and
CBD injury encountered during CLC. From reports in a
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study, contracted GB is the leading cause of conversion
from LC to OC due to obscure anatomy or increased risk
for intraoperative hemorrhage from GB bed. The conversion
rate was markedly lower in the RLC group patients. The
reasons for conversions, included CBD injuries,
intraoperative hemorrhage and obscured anatomy. So, this
is the cause for decreasing the rate of conversion in RLC
Fig. 2: Most common error traps which occur during performance of
CLC and RLC. (Ref. catalog.nucleusinc.com/imagescooked/1783W.jpg) group from 18.75 to 2.08%. 14

World Journal of Laparoscopic Surgery, January-April 2011;4(1):25-29 27