Page 52 - World Journal of Laparoscopic Surgeons
P. 52

Malwinder Singh et al
























                         Fig. 1: Rouviere’s sulcus                         Fig. 2: Critical view of safety

          with a brief description and picture without a thorough  a telescope was put in. After the abdominal survey, rest
          explanation of the rationale for this approach.     of the ports were put under direct vision, i.e., the 10-mm
             The primary purpose of study was to combine both  port in the epigastric region, 5-mm port in the right
          RS and CVS and to understand why this method is pro-  hypochondrium, and another 5-mm port in the anterior
          tective in reducing the incidence of biliary tract injury  axillary line (subcostal). The patient was placed in reverse
          through its use.                                    Trendelenburg’s (Fowler’s) position with the patient’s
                                                              head up and tilted to the left and the surgeon standing
          MATeRIALS AND MeTHODS                               on left side of the patient. Gallbladder was grasped from

          The study was done with 100 patients undergoing lapa-  the fundus through a 5-mm port and retracted.
          roscopic cholecystectomy in a tertiary care hospital in   Rouviere’s sulcus was identified  and dissection
          northern India.                                     of triangle of Calot’s was done above the level of this
             The patients presented to the surgical outpatient   sulcus and CVS was created. Cystic artery and duct
          department with diagnosis of gallbladder stones. Patients   were defined. Cystic duct and cystic artery were clipped
          who gave informed consent after full explanation were   separately using Liga clips. Gallbladder removal was
          electively admitted for an ambulatory laparoscopic cho-  done from a 10-mm port (epigastric). Abdominal cavity
          lecystectomy after preanesthetic check-up and routine   was washed with normal saline to remove all the clots
          investigations. Close monitoring was done in terms of  and spilled biliary content, if any.
          vitals, postoperative complications, and morbidity.    Complete hemostasis was achieved. All port sites
                                                              were closed with non-absorable suture. All patients were
          Inclusion Criteria                                  followed up after 1 week with history and clinical exami-
          •  Uncomplicated symptomatic cholelithiasis         nation for any postoperative complications.
          •  Medically fit and stable patients
                                                              ReSULTS
          exclusion Criteria
                                                              A total of hundred (n = 100) patients were taken up for
          •  Multiple comorbid diseases, coagulation disorders  laparoscopic cholecystectomy according to the preset
          •  Suspected/proven malignancy                      selection criteria:
          •  Absence of RS                                    •  Uncomplicated symptomatic cholelithiasis
          •  Conversion to open cholecystectomy               •  Medically fit and stable patients
             Operative technique: Four-port technique for laparo-  The patients presented to the outpatient department
          scopic cholecystectomy was used. Two 10-mm ports and  with symptomatic cholelithiasis. All the patients had
          two 5-mm ports were used, 10-mm ports in the umbilical  routine investigations and a preanesthetic check-up for
          and epigastric region and 5-mm ports in the right hypo-  fitness for surgery. The average duration of surgery after
          chondrium and anterior axillary line (subcostal).   identifying RS and achievement of CVS was 65.30 minutes
             Pneumoperitoneum was created by inserting Veress  (20–120 min) (Table 1).
          needle in the infraumbilical region. After creating    The average hospital stay was 1.33 days (1–5 days)
          pneumoperitoneum, a 10-mm port was introduced and  (Table 2). There was no bile duct injury after identification
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