Evaluation of Avascular ‘holy Plane’ Based Cold Dissection Technique in Consecutive Unselected Laparoscopic Cholecystectomies: Results of 7 Year Experience

Brij B Agarwal, MD, Sneh Agarwal, MD, Manish K Gupta, Dr, Nayan Agarwal, Mr, Dhruv Agarwal, Dr, Karan Goyal, Dr, Satish Saluja, MD, Krishan C Mahajan, MD, Krishna A Agarwal, Dr, Himanshu Pandey, MD

Sir Ganga Ram Hospital, Dr. Agarwal’s Surgery, New Delhi, India

INTRODUCTION-This study was undertaken to evaluate the existence, accessibility, surgical definition of avascular holy planes and their applicability in performing a safe laparoscopic cholecystectomy (LC), by exploring them by cold dissection alone keeping the energized dissection (ED) as a rescue hemostatic aid.

METHODS AND PROCEDURES -A prospective (June 2005- June 2012) case series of consecutive unselected consenting candidates for LC performed on index hospitalization without any exclusion (except unfitness for general anesthesia) at the apex tertiary level Institute that pioneered laparoscopic surgery in North India. Standard 4 port LC with a standard perioperative protocol was followed. Cystic duct/artery were endoclipped. Dissection was done in accessible avascular planes (without ED) between the gallbladder (GB) and adjoining structures / adhesions.
Study Points-

PerioperativeTechnical difficulty, Hemodynamic instability, ED-usage, GB-bed Hemoclipping / gauze compression, Conversion, Blood transfusion (BT), Iatrogenic GB perforation , Injury to Duct/s (Biliary) or Intraperitoneal Operative Trauma to viscera (IDIOT)
PostoperativeFailed oral feed for >6 hrs; peritonism for >24 hr (paralytic ileus); shoulder tip pain for >24 hrs; biliary leak; re-hospitalization for any complication
Other dataLength of hospital stay (LOS), Self care ability within 1 day, Resumption of normal activity within 5 days, any adverse event in 3 months, mortality


Age(5-83 yrs), Mean(SD)46.38(13.4); Males 48.8(14.2) ; Females 45.23 (12.9)

Age (yrs) / n (%)<=20 21-4041-60 61-83 Total
Female-69%5(1.3) 136(36.2) 192(51.1) 43(11.4) 376(100)
Male-31%6(3.6) 42(25) 82(48.8) 38(22.6) 168(100)
Total-100%11(2) 178(32.7) 274(50.4)81(14.9) 544(100)
p value0.0862 0.01 0.627 0.00070.0002

Cold dissection enabling avascular holy planes could be found in all patients without any technical difficulty, irrespective of the severity/ nature of inflammation and/or adhesions.There was no hemodynamic instability / BT / IDIOT/ failed oral feeding / peritonism / paralytic ileus / shoulder tip pain beyond defined period. There was one conversion (cholecysto-colic fistula) and 43 (7.9%) iatrogenic GB perforations. Hemoclips (total 31) applied on GB bed in 27 (4.96%) patients (1.14 clips/patient). Gauze compression for hemostasis at GB bed required in 2(0.4%). All patients having only cholecystolithiasis were discharged as day care cases.

All type of biliopancreatic inflammation and adhesions encountered.

LOS (Days), <8 hrs =00-9 , Mean 0.89, SD 1.26, Median 1 (89.9% patients <1 day)
Cause of LOS >1 [ n(%)]Concomitant pancreatitis / cholangitis 52 (9.6), Peritonitis with perforated GB 2 (0.4), Retained CBD stone 1 (0.2)

All patients could take care of themselves the day after surgery and resume normal activity within 5 days of surgery . There was no biliary leak / re-hospitalization / mortality. No adverse event was seen during the 3 month follow up.

Cystic artery is the only blood supply to the GB, once clipped there is always a avascular holy plane for surgical dissection for safe laparoscopic cholecystectomy without the need for ED. The outcomes seem to be encouraging (in absence of ED), which need to studied further in better designed studies like RCT if ethically acceptable and permissible.

Session: Poster Presentation

Program Number: P325

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