Page 24 - WJOLS - Laparoscopic Journal

Moatassim Barham
HOSPITAL STAY AND COST EFFECTIVENESS affords better visualization of the cystic duct and CBD with
less chance of CBD injury. Many studies were reported
Mean of 2.2 days was the postoperative stay with no delayed 17
4
sequela in a prospective study. Regarding another study, without immediate or late complications. The facility to
RLC had shorter postoperative hospital stays by an average retract the liver and carry out RLC extends techniques
of 2 days when compared with CLC. 8 developed for OC into the laparoscopic arena. It offers the
surgeon the safety and versatility during LC that it confers
LEARNING CURVE during OC. 18

RLC can reduce the time of surgery and is an easier technique CONCLUSIONS AND RECOMMENDATIONS
to perform. Therefore, it can be proposed as the standard
procedure and not only be used for difficult LCs. 15 RLC appears to be a safe procedure and does not
compromise the CLC method. After reviewing all data,
DISCUSSION however, I would like to recommend the following algorithm
regarding laparoscopic management of GB diseases. Firstly,
A great deal continues to be written about CBD injuries in
LC, which serves to underscore the seriousness of the the surgeon should try CLC, as the technique is most familiar
complication and the perception that it can and should be and comfortable to most surgeons. Secondly, if obscure
avoided. The current rate of major CBD injury in LC has anatomy should occur without proceeding to irreparable
stabilized at 0.1 to 0.6%, and series with no major CBD hemorrhage or CBD injury, the surgeon should resort to
injuries have been reported; while many believe that the rate RLC on site. Usually, this will solve the problem. Thirdly, if
of major CBD injury in OC is lower than in LC, controversy hemorrhage or CBD injury do occur, conversion to OC is
remains. A host of factors has been associated with CBD always a viable choice and should not be deemed a failure.
injury, including surgeon experience, patient age, male sex However, RLC as CLC, remains to have its error trap that
and acute cholecystitis, though the effect that acute is mostly leading to vasculobiliary injuries as well as the
cholecystitis has on injury rates remains controversial. CBD drawback of retained GB stones tendency which mandates
injuries, which occur with LC, frequently involve complete routine IOC.
disruption and excision of ducts and may be associated
with hepatic vascular injuries. Since, major CBD injuries REFERENCES
with LC are most frequently due to duct misidentification, 1. Nuzzo G, et al. The risk of biliary ductal injury during LC.
techniques for prevention and/or recognition focus primarily J Chir (Paris) Nov 2004;141(6):343-53.
on careful anatomic definition to ensure the ‘critical view’ 2. Sváb J, et al. Prevention, diagnosis and treatment of iatrogenic
prior to dividing any structures. The Society of American lesions of biliary tract during LC. Rozhl Chir Apr 2005;84(4):176-
81.
Gastrointestinal and Endoscopic Surgeons (SAGES) first 3. Richard M Vazquez. Common sense and CBD injury: CBD
offered guidelines for the clinical application of LC as a injury revisited Surg Endosc 2008;22:1743-45.
safe and effective treatment for most patients with 4. Kelly MD. Laparoscopic retrograde (fundus first) chole-
symptomatic gallstones in May 1990. These guidelines have cystectomy. PMID: 20003333 (PubMed-indexed for
MEDLINE) PMCID: PMC 2801662 Free PMC Article.
periodically been updated, and the last guidelines, in 5. Uyama I, et al. Laparoscopic retrograde cholecystectomy (from
November 2002, expanded to include all laparoscopic biliary fundus downward) facilitated by lifting the liver bed up to the
tract surgeries, keeping in mind the safty and effectiveness diaphragm for inflammatory GB. Surg Laparosc Endosc Dec
of the procedures. The CLC technique for dissection of GB 1995;5(6):431-36.
from the liver bed as described in the guidelines is to start 6. Kato K, et al. A new technique for LC-RLC: An analysis of 81
cases. Endoscopy May 1996;28(4):356-59.
from the GB infundibulum and work superiorly using 7. Ichihara T, et al. Tape ligature of cystic duct and fundus-down
electrocautery to remove GB from the bed. The technique approach for safety LC: Outcome of 500 patients. Hepato-
of RLC has also been advocated, particularly in cases with gastroenterology Mar-Apr 2004;51(56):362-64.
significant inflammation. The standard technique works well 8. Shing-Moo Huang, et al. Overcoming the difficulties in
and, with no compelling data to use the alternative technique, laparoscopic management of contracted GB with gallstones:
Possible role of fundus-down approach, Surg Endosc.
the choice is left to the surgeon. 16 9. Tuveri M, et al. Limits and advantages of fundus-first LC:
LC from fundus downward is desirable when exposure Lessons learned. J Laparoendosc Adv Surg Tech A Feb
of the cystic duct is difficult and hazardous. First, the cystic 2008;18(1):69-75.
duct and artery are exposed and clipped, and the artery is 10. Moshe Hashmonai, et al. An anomaly of the extrahepatic biliary
System. Arch Surg 1995;130(6):673-75.
divided. Then removal of the GB is started from fundus 11. Steven M Strasberg. Error traps and vasculo-biliary injury in
downward. After GB is dissected from the liver bed, the laparoscopic and OC, Hepatobiliary Pancreat Surg 2008;15:284-
cystic duct is double clipped and divided. This approach 92.

28
JAYPEE