Surgical strategies in difficult laparoscopic cholecystectomy

Background: Difficult laparoscopic cholecystectomy can be anticipated based on the pre-operative and intra-operative factors such as old age, male sex, history of multiple attacks of recent origin or repeated admissions, diabetes mellitus, previous upper abdominal surgery, cirrhotic pancreatitis and patients presenting with cholangitis. Laparoscopic cholecystectomy has become the gold standard for all the gall bladder diseases. Rate of conversion from laparoscopic to open technique can be minimized by adhering to the basic principles of surgery and keeping in mind the critical anatomy while doing the safe and meticulous dissection.
Material & methods: We had defined the nine critical landmarks in the anatomy of gall bladder for assisting the surgeon in doing step by step dissection in difficult cases from retrospective analysis of our series of 6840 cases operated over a period of 14 years. We analysed our results with respect to the rate of conversion to open surgery as well as the bile duct injuries in total and in difficult cases respectively.
Results: A total of 6840 cases were operated in a period of 14years and out of which 1410 cases fulfilled the criteria for the difficult cholecystectomies. We had converted 29 cases to open technique with a conversion rate of 0.42% and encountered 4 major bile duct injuries with an incidence of 0.05% of the total cases and 0.28% of the difficult cases. All the injuries occurred in the difficult group and none in the other group.
Conclusion: We may conclude from our experience that emphasis should always be laid on the clear view and accurate hemostasis to prevent untoward incidents like bile duct injury which is the major cause of morbidity after laparoscopic cholecystectomy. Use of gauze piece and suction canula for the blunt dissection in acute and friable cases are always handy tools for the safe dissection.

Session: Poster

Program Number: P310

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