Page 44 - World Journal of Laparoscopic Surgery

Difficult Laparoscopic Cholecystectomy
commonly associated factor in the USG findings that correlates Statistical Methods 8–10
with a difficult laparoscopic cholecystectomy. All the continuous variables will be represented by mean ±
standard deviation if they are normally distributed. All categorical
MAterIAls And Methods variables will be represented by percentages. Comparison of
The prospective observational study was conducted at the categorical variables will be done by either the Chi-squared
Department of General Surgery at Apollo Hospitals, Chennai, test or Fisher’s exact test. Comparison of normally distributed
Tamil Nadu, India, from November 2019 to April 2021. Male and continuous variables if any will be done by independent sample
female patients above 18 of age who are ready to participate were t-test. Comparison of non-normally distributed continuous
included after explaining potential advantages, and risks. Patients variables if any will be done by Mann–Whitney U test. A receiver
were also informed about the possibility of on-table conversion to operating characteristic (ROC) curve is drawn to see if there
open cholecystectomy. Written informed consent for laparoscopy is a cut-off that distinguishes between simple and difficult
and if required open cholecystectomy was taken for surgery from laparoscopic cholecystectomy instances. Data analysis will be
the patient. Permission was obtained from the ethics committee carried out by SPSS, v.25.0; p <0.05 will be considered statistically
and scientific advisory committee of the institution. significant.
Inclusion Criteria observAtIon And results
• Cholelithiasis
• Acute cholecystitis Among the 100 patients who were enrolled in the study, the mean
• Empyema GB age (standard deviation) is 48.04 (±14.23) and the median is 49. The
• Symptomatic polyps highest number of patients lies in the 51–60 years age-group. Out
• Non-functioning GB of the 100 cases studied, the number of male and female patients
• Gallstone pancreatitis with or without previous upper abdomen was 48 and 52, respectively.
surgery In these 100 patients, 26 patients had diabetes mellitus,
28 patients had hypertension, 10 patients had coronary artery
Exclusion Criteria disease, 6 patients had pulmonary disorder, 3 patients had renal
• Gallbladder cancer disorder, and 1 patient had liver problem.
• Cardiac failure Pain was presented as a complaint in 90 patients on admission.
• Portal hypertension A total of 73 patients had complaint of nausea and vomiting. Only
• Coagulopathies, uncorrectable coagulopathy two patients had complaints of a change of color of urine and
• Chronic obstructive pulmonary disease stools.
• Biliary enteric fistula Among the 100 patients 10 patients were asymptomatic and
• Pregnancy based on duration 38 patients were having acute disease and 52
• Hepatic and renal diseases patients were having chronic pathology. On examination, pallor,
cyanosis, clubbing, and edema were found to be absent. Only two
Methodology patients had icterus. Murphy’s sign was positive in 41 patients and
All patients who presented to the outpatient department with among these 100 patients, 18 of them had a previous history of
symptoms suggestive of GB disease were evaluated on the abdominal surgery.
following factors: The ultrasonography findings of the 100 patients are as listed
below. Among the 100 patients, 36 of them were found to have a
• Detailed history collection GB wall thickness of more than 4 mm, 90 of them were found to
• Systemic examinations have a distended GB and 15 of them had a CBD caliber size of more
• Investigations with particular reference to biliary pathology than or equal to 6 mm.
• Detailed ultrasound findings 6 A total of 35 patients out of 100 had their stone size more than
Preoperative USG findings such as thickness and size of the GB or equal to 1 cm and 20 of them had their stone impacted at the
wall, the diameter of the CBD, GB stone size and numbers, and the neck. Among these 100 patients, 39 patients had a pericholecystic
existence of fluid collection around the GB were given a grade of 1 fluid collection.
or 0 based on findings being affirmative or dissent. As depicted in Table 1, preoperative ultrasonography findings
After explaining the diagnosis to the patients and their atten- such as the thickness of the GB wall of more than 4 mm, stone at
dees, they consented to surgery. Preanesthetic assessment and the neck of the GB, with the company of pericholecystic fluid and
relevant investigation will be done. After relevant investigations GB stone size of more than or 1 cm were significant in predicting a
and preanesthetic evaluation, the patients will be subjected to difficult laparoscopic cholecystectomy.
laparoscopic cholecystectomy, under general anesthesia. All rele- As seen in Table 2, the existence of wall thickness of the GB greater
7
vant intraoperative findings will be noted. Intraoperative findings, than 4 mm was the most precise vaticinator for a difficult laparoscopic
namely, injury and damages made to the bile duct, CBD or artery, the cholecystectomy followed by gallstone impacted at the neck of the
existence of thick adhesions on the GB sides, region of the Calot’s GB, the existence of pericholecystic fluid and GB stone size of more
being frozen, ripped up GB and spillage of bile and stones, unusual than or equal to 1 cm.
and atypical anatomy, bleeding that hamper and obstruct the visual The preoperative ultrasonography score showed statistical
field and time taken of 60–120 minutes were considered as difficult significance in predicting a difficult laparoscopy cholecystectomy.
laparoscopic cholecystectomy. As in Tables 3 and 4, it has been validated that when we observe

230 World Journal of Laparoscopic Surgery, Volume 15 Issue 3 (September–December 2022)