ORIGINAL ARTICLE
LAPAROSCOPIC CHOLECYSTECTOMY: OUR EXPERIENCE WITH
INITIAL70 CASES AFTER TRAINING IN LABORATORY SETTINGS.
Sarabjit Singh,Shubham Lavania.
1. Assistant Professor. Department of General Surgery, Guru Gobind Singh Medical College,Faridkot,Punjab.
2. Junior Resident. Department of General Surgery, Guru Gobind Singh Medical College,Faridkot,Punjab.
CORRESPONDING AUTHOR:
Dr. Sarabjit Singh,
223, Medical Campus,
Faridkot , Punjab.
E-mail: drsarab21@gmail.com.
ABSTRACT: Laparoscopic cholecystectomy is treatment of choice for gall stone disease.
Procedure is technically demanding and complication rate varies according to level of training
and experience of surgeon in laparoscopy. Training modules and exercises play a definitive role
in minimizing the complication rate and making the procedure safe. Here, we share our
experience of initial 70 cases of laparoscopic cholecystectomy after a short course of
laparoscopic training exercises.
KEY WORDS: Laparoscopic cholecystectomy, laparoscopic training exercises.
INTRODUCTION: Laparoscopic cholecystectomy is a combined endoscopic-operative technique
for removing the gallbladder. It is guided by an endoscope, camera and video monitor and is
performed through four cannulas. The gallbladder is dissected from liver under observation on
a monitor .The possible complications are bleeding, injury to common bile duct and technical
problems, such as gall bladder perforation [9].This is a safe procedure with low complication,
mortality and morbidity rate [10].The operating surgeon should be trained in laparoscopic skills
and supportive staff should be familiar with the equipment to minimize its complication rate.
Studies have shown that training in laparoscopic skills improves performance [3&4].
MATERIAL AND METHODS: 70 patients were operated for laparoscopic cholecystectomy at
our institute from august 2011 to January 2012.These were the initial and consecutive 70 cases
of author, after getting a short training in basic laparoscopic skills at a training centre
recognized by society of American gastro endoscopic and laparoscopic surgeons (SAGES) under
the supervision of expert trainers. During training, basic principles of laparoscopic surgery,
laparoscopic equipment , hand instruments and safe use of energy sources in laparoscopic
surgery were learned. In hands on training session laparoscopic port insertion, creation of
pneumoperitoneum and dissection techniques were practiced on porcine model. After the
intensive training period of two weeks, hand eye coordination exercises like cobra drill, circle
cutting were practiced on endotrainer box for 100 sessions, each of one hour duration. Rest of
the members of surgical team had no previous exposure or experience in laparoscopic surgery.
They were assigned duties and were instructed by author before and during the surgery.
All patients having symptomatic gall stones were included in study and procedure was
performed by four port technique in all the cases. Patients having acute cholecystitis, cardiorespiratory diseases, previous surgery and extensive scars, adhesions, suspected malignancy,
bleeding disorders and pregnancy were excluded from the study. Experience was recorded in
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ORIGINAL ARTICLE
terms of technical difficulties encountered by surgical team, duration of surgery, intra-operative
complications, post operative complications and hospital stay of patient.
RESULTS: Intra operative complications we encountered cystic artery bleed in 2 cases (2.85%).
Minor liver injury during trochar insertion occurred in 2 cases (2.85 %).There was no hollow
viscous injury. Minor bleed from cutaneous vessels occurred in 3 cases (4.28 %) during port
insertion. In 5 cases (7.14 %) there was gallstone spill in peritoneal cavity. This complication
occurred due to perforation of gall bladder at the time of gall bladder extraction. However these
stones were picked up and removed. Minor skin burn occurred in one patient (1.42%) due to
improper contact of patient plate. This healed with antiseptic dressings. We had to convert 3
cases (4.28 %) to open cholecystectomy due to cystic artery bleed and dense adhesion around
calot’s triangle. Average duration of procedures was 80 minutes.
Post operative complications: Post operatively one patient (1.42 %) had minor bile leak from
drain, which continued for about 10 days. Patient was managed conservatively and was
discharged in satisfactory condition. One patient (1.42%) developed postoperative fever which
lasted for 3 days and responded to antibiotics. Post operative pain in all the patients was
relieved by moderate dose of non steroidal anti-inflammatory drugs. Requirement of analgesics
was experienced only for first and second post-operative day. Average hospital stay was 2.5
days.
DISCUSSION: In all the cases primary port was inserted at umbilicus by open technique. In 3
cases (4.28 %) it was inadvertently inserted in subcutaneous space. It was immediately
recognized and corrected. We also had difficulty in manometric settings of insufflators and
electrical connection settings in initial 5 cases. In initial 6-7 cases our suction and irrigation
system was not ready. Either the machine was not plugged in or fluid container was not
connected to irrigation cannula. This led to undue struggle and stress when there was intraoperative bleed leading to blurring of vision. We think this was due to lack of experience on the
part of surgical team. Our nursing staff had no previous experience in laparoscopic procedures.
So every time we demonstrated the instruments before starting surgery and intra-operatively
there was lot of time lag in transferring desired instruments to surgeon. There was difficulty in
extraction of stone filled gallbladder through epigastric port in 25 cases (35.71%). We think
inappropriate traction and inadequate dilatation of tract led to perforation of gallbladder and
spill of gallstones in 5 cases. Cautery burn occurred due to incorrect contact between patient
and plate. We feel all these initial cases were performed safely except few minor complications.
Execution of task could be made efficient and easier by better organization of team and going
through a checklist of requirements.
In a study conducted by Khan MW, Aziz MM etal, some serious postoperative
complications occurred such as sub-hepatic abscess 0.02%, peritonitis due to gut perforation
0.04% and two deaths due to septicemia resulting from gut perforation [7]. Târcoveanu E etal
has reported conversion rate of 5.1% in their study [8].In two other studies by Yi F, Jin WS et al
and Hasbahceci M, Uludag M et al ,they have reported complications like liver bed injury (8%),
spilled gall stones (7.25%), port site infection( 2.75%), vascular injury (4.5%), biliary leak
(2.5%), bowel injury (0.75%), CBD stricture (1%),umbilical port hernia (0.5%) and common
bile duct injury( 0.27%), postoperative bleeding in (0.45%) and mortality rate 0.13%.[11&12].
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In our experience complication rate was comparatively less than the complication rate
in these studies. Studies have shown that laparoscopic training in laboratory settings improves
performance in operation theatre settings. Structuralized box-trainer laparoscopic training
significantly improves performance in complex virtual reality laparoscopic tasks [1]. Training
on a virtual or physical box-trainer significantly amends duration and economy as well as
movement precision in basic laparoscopic skills, and directly corresponds with the results
achieved in a real operating theatre [2, 5 & 6]. Because of prior training and skill exercises we
did not feel much difficulty in hand eye coordination and tissue handling during dissection. We
were able to perform our first 70 cases safely and with minimal complications. So our
experience suggests that laparoscopic cholecystectomy can be safely performed with minimal
complications and risk after basic training in laparoscopic skills.
Conflict of intrest : Authors do not have any conflict of interest.
REFERENCES:
1. Dariusz Łaski, Tomasz J. Stefaniak, Wojciech Makarewicz, Monika Proczko, Zbigniew
Gruca, and
Zbigniew Śledziński. Structuralized box-trainer laparoscopic training
significantly improves performance in complex virtual reality laparoscopic
tasks.Wideochir Inne Tech Malo Inwazyjne. 2012 March; 7(1): 27–32.
2. Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training
significantly reduces the error rate for residents during their first 10 laparoscopic
cholecystectomies. Am J Surg. 2007;193:797–804.
3. Gruca Z, Kobiela J, Stefaniak T. Usefulness of surgical simulators in minimal invasive
surgery education. Videosurgery and Other Miniinvasive Techniques. 2008;3:30–4.
4. Budzinski R, Michalik M, Frask A. Education in laparoscopic surgery. Videosurgery and
Other Miniinvasive Techniques. 2008;3:22–9.
5. Ganai S, Donroe JA, St Louis MR, et al. Virtual-reality training improves angled telescope
skills in novice laparoscopists. Am J Surg. 2007;193:260–5.
6. Wohaibi EM, Bush RW, Earle DB, et al. Surgical resident performance on a virtual reality
simulator correlates with operating room performance. J Surg Res. 2010;160:67–72.
7. Khan MW, Aziz MM. Experience in laparoscopic cholecystectomy. Mymensingh Med J.
2010 Jan;19(1):77-84.
8. Târcoveanu E, Niculescu D, Georgescu S, Epure O, Bradea C.Conversion in laparoscopic
cholecystectomy.
TheChirurgia (Bucur). 2005 Sep-Oct;100(5):437-44.[Article in
Romanian]
9. Gadacz TR, Talamini MA, Lillemoe KD, Yeo CJ.Laparoscopic cholecystectomy. Surg Clin
North Am. 1990 Dec;70(6):1249-62.
10. Halilovic H, Hasukic S, Matovic E, Imamovic G. Rate of complications and conversions
after laparoscopic and open cholecystectomy.Med Arh. 2011;65(6):336-8.
11. Yi F, Jin WS, Xiang DB, Sun GY, Huaguo D. Complications of laparoscopic cholecystectomy
and its prevention: a review and experience of 400 cases. Hepatogastroenterology. 2012
Jan-Feb;59(113):47-50.
12. Hasbahceci M, Uludag M, Erol C, Ozdemir A. Laparoscopic Cholecystectomy in a Single,
Non-teaching Hospital: An Analysis of 1557 Patients. J Laparoendosc Adv Surg Tech A.
2012 Mar 29.
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Exercises on endotrainer box
Dissection in laparoscopic cholecystectomy
Difficulty in extraction of gall bladder
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