Page 14 - Journal of Laparoscopic Surgery

Aswini Misro A
are divided. This step is completed by traction through
the port 3 instrument and clip application through port-
two. With continued traction applied to the Hartman’s
pouch in the upward and right direction (this open up
the interface between the gallbladder and the gallbladder
fossa of the liver), the gallbladder is separated from the
gallbladder fossa by electro-dissection with an appro-
priate instrument (either a monopolar hook, Maryland
or scissor). Before the final detachment of gallbladder
from the liver, the hemostasis of the gallbladder bed is
achieved, and the cystic pedicle (artery and duct) security
is confirmed. The 5 mm port is now withdrawn and the
specimen extracted through the epigastric port. A gener-
ous amount of peritoneal wash is given, and 100 mL of
normal saline mixed with bupivacaine is left in the sub- Fig. 6: Appearance of wounds immediately after closure
diaphragmatic space. Pneumoperitoneum is evacuated, on the 2nd postoperative day except for two patients. One
and the wounds closed in two layers. had severe abdominal pain and later developed surgical
Because of the presence of two ports in the same site infection, which subsided with wound drainage and
wound the range of their movement is likely to be the other patient developed fever in the postoperative
affected. Hence, careful attention should be paid to proper period. All the patients were happy and satisfied due to
alignment of the ports at the epigastric site. The chamber rapid and comfortable recovery and of course, about their
of the 5 mm port should be as close to the skin as possible small wound. Many patients were astonished small inci-
whereas that of 10 mm port should be as far away from the sion used to perform the surgery and hence were curious
skin as possible (Figs 2 and 5). The maneuverability and to know the procedure details (Fig. 6). Patients were
the freedom of a port depend on the rotational capacity or advised follow up on the 10th day, 3 months and 1 year
the swing of the ports (Please watch the video). With the following surgery. Out of 25 patients, 23 patients visited
measures mentioned above, we have observed that there the hospital for 10th day follow-up and were fine at that
is adequate overall maneuverability including a range of point in time. However, only seven have completed three
movement and reach of the instrument to complete the months follow up at the point of data collection, and none
procedure safely. The right and left-hand instruments of them had any complications including port site hernia.
work in close harmony as an assembly, with one grasp-
ing/retracting at a short distance from the other one(Figs 4 DISCUSSION
and 5). They move in tandem performing the dissection
bit by bit sequentially from Calot’s Triangle to the fundus Although laparoscopic cholecystectomy has been prac-
till the point of complete separation of the organ. ticed as a day care surgery, it is far from reality in our
set-up as most of the patients are from remote rural and
hilly areas with poor access to health care. That is the
RESULTS
reason for the patient being discharged routinely on
There was no incidence of the bile duct or vascular injury, the 2nd postoperative day. Secondly, the follow-up of
bile leak, iatrogenic injury, intra-operative perforation of the patients has remained far from ideal. Many of them,
the gallbladder, bile spillage, significant procedural blood once discharged, tend to avoid hospital follow up unless
loss, significant gas leak or subcutaneous emphysema at they are unwell. The geographic and telecommunication
either port site. The mean operating time was 50 minutes barriers are other factors which have prevented us from
(range 40–155 minutes). reaching out to them.
We have converted three cases from the two port tech- Two-port laparoscopic cholecystectomy has been prac-
nique to the standard four-port technique. One was due ticed by many surgeons successfully and has been reported
to the technical difficulty arising out of bleeding and the to be safe and superior to 4 port cholecystectomy in terms
2,3
other two due to difficult intra-operative findings. These of pain, cosmesis and patient acceptance. Various tech-
two cases had dense adhesions in the Calot’s triangle and niques and special instruments like innovative extracorpo-
gallbladder fossa respectively. However, none of them real knot by Mishra et al., “Twin-port” system (that allows
required conversion to open cholecystectomy. a 5 mm camera and a forceps through a single port) by
Patients were allowed orally as early as 6 hours fol- Kagaya et al., 2 mm or 3 mm endo graspers by Lee KW,
lowing surgery. All patients were routinely discharged have been used to accomplish the procedure without the
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