**Part 1**

**General Surgery Procedures** 

**1** 

**The Laparoscopic Appendectomy** 

*Liaquat University of Medical and Health Sciences, Jamshoro (Sindh),* 

Acute appendicitis is one of the commonest surgical problems afflicting a major population all over the world. No age is immune to it but it is most prevalent during adolescent and child hood. The outcome can be very serious at both extremes of life and there is a life time risk of developing acute appendicitis in about 5-8% nothing. An early surgical removal after diagnosis is the most preferred and agreeable treatment. Appendectomy through grid iron incision has enjoyed a unique reputation of a standard operation globally. It is one of the most common abdominal operations performed all over the world. The open appendectomy through right grid iron incision was introduced by Mc Burney (Mc Burney 1894) and this technique enjoyed decades of un-opposed reputation and widespread use globally because of its proven safety and efficacy. The introduction of laparoscopy has brought a major change in the field of surgery. The laparoscopic appendectomy is gradually gaining popularity over the past 10-15 years by way of proving improved diagnostic outcome and decreased rate of wound problems. It was way back in 1983 when a first laparoscopic surgery for acute appendicitis was performed by a German Gynaecologist Semm (Semm K 1983). There are a number of reports published in favour of laparoscopic approach in terms of rapid recovery, a faster wound healing, lowered rate of complications, and an early resumption of oral intake (Martin LC et al 1995) while others (John Brenden Hansen 1996) claimed that though it takes a comparatively longer time but yet is safe and effective way of treating acute appendicitis as it reduces post-operative stay substantially and would help the patient return to work earlier. An almost similar recommendation came from many similar studies in a very short span of time comparing laparoscopic versus open appendectomy, claiming substantial advantage over open technique (Rober Globus et al 1998). A superiority in terms of cosmetic results and cost-effectiveness was another reason that majority favoured this recently introduced technique. A recent study claims it to be a safe option in children compared to the open operation (Lee SL 2011). There were however a lot of reservations as to the safety and applicability of this procedure as elaborated by many studies (Ingraham et al 2010) (Yano H et al 2004) (Kamal M 2003). There is a limitation to the use of this laparoscopic approach in third world countries where the economical constraints, lack of facility and a general fear keeps them from getting operated (Saunders S 2002). Despite all the limitations ,the scope of laparoscopic appendectomy is on the rise and although it has not yet achieved the status of a "Gold Standard " treatment as enjoyed by laparoscopic cholecystectomy, there is a gradual acceptance of this procedure all over the

**1. Introduction** 

**– A Recent Trend** 

Arshad M. Malik

*Pakistan* 

## **The Laparoscopic Appendectomy – A Recent Trend**

Arshad M. Malik

*Liaquat University of Medical and Health Sciences, Jamshoro (Sindh), Pakistan* 

#### **1. Introduction**

Acute appendicitis is one of the commonest surgical problems afflicting a major population all over the world. No age is immune to it but it is most prevalent during adolescent and child hood. The outcome can be very serious at both extremes of life and there is a life time risk of developing acute appendicitis in about 5-8% nothing. An early surgical removal after diagnosis is the most preferred and agreeable treatment. Appendectomy through grid iron incision has enjoyed a unique reputation of a standard operation globally. It is one of the most common abdominal operations performed all over the world. The open appendectomy through right grid iron incision was introduced by Mc Burney (Mc Burney 1894) and this technique enjoyed decades of un-opposed reputation and widespread use globally because of its proven safety and efficacy. The introduction of laparoscopy has brought a major change in the field of surgery. The laparoscopic appendectomy is gradually gaining popularity over the past 10-15 years by way of proving improved diagnostic outcome and decreased rate of wound problems. It was way back in 1983 when a first laparoscopic surgery for acute appendicitis was performed by a German Gynaecologist Semm (Semm K 1983). There are a number of reports published in favour of laparoscopic approach in terms of rapid recovery, a faster wound healing, lowered rate of complications, and an early resumption of oral intake (Martin LC et al 1995) while others (John Brenden Hansen 1996) claimed that though it takes a comparatively longer time but yet is safe and effective way of treating acute appendicitis as it reduces post-operative stay substantially and would help the patient return to work earlier. An almost similar recommendation came from many similar studies in a very short span of time comparing laparoscopic versus open appendectomy, claiming substantial advantage over open technique (Rober Globus et al 1998). A superiority in terms of cosmetic results and cost-effectiveness was another reason that majority favoured this recently introduced technique. A recent study claims it to be a safe option in children compared to the open operation (Lee SL 2011). There were however a lot of reservations as to the safety and applicability of this procedure as elaborated by many studies (Ingraham et al 2010) (Yano H et al 2004) (Kamal M 2003). There is a limitation to the use of this laparoscopic approach in third world countries where the economical constraints, lack of facility and a general fear keeps them from getting operated (Saunders S 2002). Despite all the limitations ,the scope of laparoscopic appendectomy is on the rise and although it has not yet achieved the status of a "Gold Standard " treatment as enjoyed by laparoscopic cholecystectomy, there is a gradual acceptance of this procedure all over the

The Laparoscopic Appendectomy – A Recent Trend 5

instruments, multiplying the actual cost manyfolds compared to the open appendectomy (Ignacio RC 2004). This is contrary to the belief of others (Neendham PJ et al 2009) who claim that laparoscopic appendectomy can be performed in a reasonable cost despite use of disposable items. Despite accumulation of substantial data favouring laparoscopic appendectomy, there continues an expanding controversy as to the safety if this procedure in patients with complicated appendicitis as well as post-operative recovery and operative

There are certain guidelines as laid down by the experts who are considered pioneers of various laparoscopic procedures. These guidelines would help the beginners to follow so as to avoid any undue stress and mistakes during the early phase of their training. These guidelines are based on the existing data coupled with individual experiences formed into consensus. These guidelines help the beginners to have a better understanding of the procedure as to the proper selection of the patients, the indications of laparoscopic appendectomy, various complications that might develop and thus to select the most appropriate operative procedure under a given situation. The best guidelines in this regard are provided by the society of American Gastro-intestinal and Endoscopic Surgeons (SAGES). A similar guideline focussing on diagnosis and treatment of acute appendicitis is

**2. Guidelines for laparoscopic appendectomy** 

provided by SSAT (Society for the surgery of alimentary tract).

reputation as a good alternative to the open appendectomy.

The laparoscopic appendectomy is divided into two basic approaches as under

The intra-corporeal variety involves the creation of pneumo-peritoneum by a 10mm supraumbilical port followed by the insertion two 5mm working ports well outside the midline. A thorough inspection of the abdominal cavity is followed by identification, skeletinization and removal of the appendix after ligation/clipping of the meso-appendix intra-corporeally. This approach is adopted and practiced at a number of centres and is gradually gaining

The extra-corporeal video assisted appendectomy is another type of laparoscopic appendectomy which involves the initial steps of intracorporeal appendectomy up till creation of pneumo-peritoneum, identification and skeletinization of appendix same as in the case of intra-corporeal appendectomy. The following steps differ in that the appendix is brought out on the surface through a 10 mm port in right iliac fossa and then further steps are just the same as in open appendectomy. This technique usually involves 2-3 ports (Konstadoulakis MM et al 2004) but a number of studies have recently published using the same technique with a single peri-umbilical port (Koontz CS et al 2006). The author compared video-assisted extra-corporeal appendectomy with conventional open appendectomy believing that this method has an advantage over open appendectomy of having less chances of diagnostic error as well as it has the advantages of open appendectomy of feeling the appendix, ligating the appendix manually outside on the surface . This has an additional advantage of having a secure ligation

**3. Verities of laparoscopic appendectomy** 

1. Intra-corporeal Laparoscopic appendectomy

2. Extra-Corporeal appendectomy.

time.

world based on various factors in favour of laparoscopic approach. The main advantages reported over open appendectomy include an accuracy of diagnosis especially in females when various other conditions can mimic acute appendicitis, an excellent cosmetic outcome, minimal tissue trauma, substantially reduced operative and post operative complications, and an early return to work. Ulrich Guller et al 2004 proposed that laparoscopic appendectomy decreases in-hospital admission, in hospital mortality, and post operative complications. Despite innumerable reports favouring laparoscopic appendectomy, the technique is really slow to gain popularity and not many centres are doing this procedure regularly. There seems to be no obvious reasons for this. The uptake of laparoscopic technique for appendicitis is slow to evolve all over the world. Loannis Kehagias et al 2008 reported recently very promising results of laparoscopic appendectomy emphasizing availability of the sophisticated instruments as well as adequate experience of the surgeon to play a key role for a successful laparoscopic appendectomy. The elderly patients are thought to be at a higher risk of developing complications following acute appendicitis and there are reports claiming that laparoscopic appendectomy is a presumably superior option for the elderly victims of acute appendicitis (Wu SC et al 2011). Despite of lots of benefits elaborated in many randomized trials and other similar studies talking high of laparoscopic approach, a number of critics have shown a marginal benefit of the laparoscopic approach over open conventional technique ( Jane Garbutt 1999, Kathouda N 2005, Oannis Kehagias 2008, Olmi S 2995, Lee SL 2011, Saunders S 2002, Martin LC, 1995,). The adequate data in favour of this technique has not really brought a significant change of mind as yet and there is a clear split of opinion as to the optimum method of treatment of acute appendicitis. There is a school of thought which considers this mode of treatment to be time consuming, but shorter hospital stay, better cosmetic results and cost effective. This is contrary to the belief of many surgeons who continue to practice open appendectomy by the same conventional method considering it to be the standard operation for acute appendicitis. The real challenge in laparoscopic approach is considered to be those patients where the appendix is severely inflamed, twisted, retro-caecal or is in pelvis or there are firm adhesions making its skeletinization difficult by laparoscopic means. It is claimed that the commonest problems faced are in the complicated appendicitis where even the experts feel difficulty. A number of conflicting results negating the advocates were published making its feasibility questionable in complicated cases of acute appendicitis (Ortega AE et al 1995) (Bresciani et al 2005) (Katkhuda N 2005). Yoshiwa et all claim lack of proper training and lack of knowledge about basic technique to be responsible for its limited use presently . An extended and undue prolonged operative time taken in laparoscopic approach has been reported to be one of the disadvantages of this technique (Reiertsen O etal 1997). This has been attributed to the learning curve of the surgeons and it was believed that with experience the difference in operative time of the two techniques becomes almost negligible (Kehagias I et al 2008). Similarly, the cost effectiveness can be achieved by decreasing the operative time and a high level of skill to make it more feasible for the developing countries (Ali R et al 2010).The laparoscopic procedure is still under evaluation and a number of changes are made in the original procedure. Vipul D et al introduced a two port technique instead of three port technique introduced, (Song Yi Kim et al 2010). This report was carried out by a trainee and there was a learning curve of thirty patients. (Ulritch Guller et al 2004) proposed laparoscopic appendectomy to be much superior than the open technique in terms of hospital stay, cosmetics, early return to work and post-operative mortality. There are reports questioning its cost as there is longer operative time and use of disposable

world based on various factors in favour of laparoscopic approach. The main advantages reported over open appendectomy include an accuracy of diagnosis especially in females when various other conditions can mimic acute appendicitis, an excellent cosmetic outcome, minimal tissue trauma, substantially reduced operative and post operative complications, and an early return to work. Ulrich Guller et al 2004 proposed that laparoscopic appendectomy decreases in-hospital admission, in hospital mortality, and post operative complications. Despite innumerable reports favouring laparoscopic appendectomy, the technique is really slow to gain popularity and not many centres are doing this procedure regularly. There seems to be no obvious reasons for this. The uptake of laparoscopic technique for appendicitis is slow to evolve all over the world. Loannis Kehagias et al 2008 reported recently very promising results of laparoscopic appendectomy emphasizing availability of the sophisticated instruments as well as adequate experience of the surgeon to play a key role for a successful laparoscopic appendectomy. The elderly patients are thought to be at a higher risk of developing complications following acute appendicitis and there are reports claiming that laparoscopic appendectomy is a presumably superior option for the elderly victims of acute appendicitis (Wu SC et al 2011). Despite of lots of benefits elaborated in many randomized trials and other similar studies talking high of laparoscopic approach, a number of critics have shown a marginal benefit of the laparoscopic approach over open conventional technique ( Jane Garbutt 1999, Kathouda N 2005, Oannis Kehagias 2008, Olmi S 2995, Lee SL 2011, Saunders S 2002, Martin LC, 1995,). The adequate data in favour of this technique has not really brought a significant change of mind as yet and there is a clear split of opinion as to the optimum method of treatment of acute appendicitis. There is a school of thought which considers this mode of treatment to be time consuming, but shorter hospital stay, better cosmetic results and cost effective. This is contrary to the belief of many surgeons who continue to practice open appendectomy by the same conventional method considering it to be the standard operation for acute appendicitis. The real challenge in laparoscopic approach is considered to be those patients where the appendix is severely inflamed, twisted, retro-caecal or is in pelvis or there are firm adhesions making its skeletinization difficult by laparoscopic means. It is claimed that the commonest problems faced are in the complicated appendicitis where even the experts feel difficulty. A number of conflicting results negating the advocates were published making its feasibility questionable in complicated cases of acute appendicitis (Ortega AE et al 1995) (Bresciani et al 2005) (Katkhuda N 2005). Yoshiwa et all claim lack of proper training and lack of knowledge about basic technique to be responsible for its limited use presently . An extended and undue prolonged operative time taken in laparoscopic approach has been reported to be one of the disadvantages of this technique (Reiertsen O etal 1997). This has been attributed to the learning curve of the surgeons and it was believed that with experience the difference in operative time of the two techniques becomes almost negligible (Kehagias I et al 2008). Similarly, the cost effectiveness can be achieved by decreasing the operative time and a high level of skill to make it more feasible for the developing countries (Ali R et al 2010).The laparoscopic procedure is still under evaluation and a number of changes are made in the original procedure. Vipul D et al introduced a two port technique instead of three port technique introduced, (Song Yi Kim et al 2010). This report was carried out by a trainee and there was a learning curve of thirty patients. (Ulritch Guller et al 2004) proposed laparoscopic appendectomy to be much superior than the open technique in terms of hospital stay, cosmetics, early return to work and post-operative mortality. There are reports questioning its cost as there is longer operative time and use of disposable instruments, multiplying the actual cost manyfolds compared to the open appendectomy (Ignacio RC 2004). This is contrary to the belief of others (Neendham PJ et al 2009) who claim that laparoscopic appendectomy can be performed in a reasonable cost despite use of disposable items. Despite accumulation of substantial data favouring laparoscopic appendectomy, there continues an expanding controversy as to the safety if this procedure in patients with complicated appendicitis as well as post-operative recovery and operative time.

#### **2. Guidelines for laparoscopic appendectomy**

There are certain guidelines as laid down by the experts who are considered pioneers of various laparoscopic procedures. These guidelines would help the beginners to follow so as to avoid any undue stress and mistakes during the early phase of their training. These guidelines are based on the existing data coupled with individual experiences formed into consensus. These guidelines help the beginners to have a better understanding of the procedure as to the proper selection of the patients, the indications of laparoscopic appendectomy, various complications that might develop and thus to select the most appropriate operative procedure under a given situation. The best guidelines in this regard are provided by the society of American Gastro-intestinal and Endoscopic Surgeons (SAGES). A similar guideline focussing on diagnosis and treatment of acute appendicitis is provided by SSAT (Society for the surgery of alimentary tract).

#### **3. Verities of laparoscopic appendectomy**

The laparoscopic appendectomy is divided into two basic approaches as under


The intra-corporeal variety involves the creation of pneumo-peritoneum by a 10mm supraumbilical port followed by the insertion two 5mm working ports well outside the midline. A thorough inspection of the abdominal cavity is followed by identification, skeletinization and removal of the appendix after ligation/clipping of the meso-appendix intra-corporeally. This approach is adopted and practiced at a number of centres and is gradually gaining reputation as a good alternative to the open appendectomy.

The extra-corporeal video assisted appendectomy is another type of laparoscopic appendectomy which involves the initial steps of intracorporeal appendectomy up till creation of pneumo-peritoneum, identification and skeletinization of appendix same as in the case of intra-corporeal appendectomy. The following steps differ in that the appendix is brought out on the surface through a 10 mm port in right iliac fossa and then further steps are just the same as in open appendectomy. This technique usually involves 2-3 ports (Konstadoulakis MM et al 2004) but a number of studies have recently published using the same technique with a single peri-umbilical port (Koontz CS et al 2006). The author compared video-assisted extra-corporeal appendectomy with conventional open appendectomy believing that this method has an advantage over open appendectomy of having less chances of diagnostic error as well as it has the advantages of open appendectomy of feeling the appendix, ligating the appendix manually outside on the surface . This has an additional advantage of having a secure ligation

The Laparoscopic Appendectomy – A Recent Trend 7

Fig. 2. Appendix drawn out on surface and meson-appendix legated.

Author conducted a study in 2009 comparing the open appendectomy (OA) versus Video assisted extra-corporeal appendectomy (VAECA) wherein a total number of 283 patients of acute appendicitis were split into two groups. We explained this newly emerging technique as well as the conventional appendectomy to all the patients as and when they were diagnosed. The intended operative techniques were fully explained to the patients in terms of merits and demerits of the operative technique. The grouping of the patients was based on their own choice and by coin toss when patients did not show any preference for any particular technique. Of the total number, 150(53%) were operated by open Technique while 133(47%) by video-assisted extracorporeal technique of appendectomy. Majority of patients (89%) in the VAECA group were operated by three port technique while few (11%) could be successfully completed by two ports only. All patients below 10 years and those with suspected appendicular mass were excluded from the study. This was an initial study on the video assisted technique and we had promising results to conclude that VAECA could be a better alternate to open appendectomy in a majority of patients with acute appendicitis without complications. Some of the results are shown below showing comparison of the two

The results in our study were very promising in terms of safety, reliability and feasibility. The major advantages that we could conclude was fewer wound infections, less severe post-

**3.2 Authors study** 

techniques.

of meso- appendix to avoid cystic arterial bleeding. Before displaying the results of the study, a brief introduction to the basic technique of video-assisted extra-corporeal appendectomy (VAECA) is given below.

#### **3.1 Technique of video-assisted laparoscopic appendectomy ( Malik et al 2009 )**

This is a modified form of laparoscopic appendectomy where we combine the steps of both open and inta-corporeal techniques of appendectomy. The surgeon stands on left side of the supine patient. A 10 mm sub-umbilical port is made for the camera while another 10 mm port is made in the right iliac fossa. Both of these ports can be interchanged for camera as and when needed. The identification and skeletinization of the appendix is much easier because of video-scopic vision where surgeon can actually visualize if there are any adhesions and a finger guided adhesiolysis can be done under vision. Once the appendix is identified and isolated, a grasper is introduced to get hold of the organ and the abdominal cavity is deflated and appendix is drawn on the surface. The remaining steps are just as the way we perform open appendectomy. Once the meso-appendix is ligated and appendix removed, the appendicular stump is returned back and ports are closed after a final look inside the abdominal cavity.Some of the steps of this procedure are highlighted below by the following operative pictures

Fig. 1. Appendix drawn into sheath of 10mm trocar

of meso- appendix to avoid cystic arterial bleeding. Before displaying the results of the study, a brief introduction to the basic technique of video-assisted extra-corporeal appendectomy

This is a modified form of laparoscopic appendectomy where we combine the steps of both open and inta-corporeal techniques of appendectomy. The surgeon stands on left side of the supine patient. A 10 mm sub-umbilical port is made for the camera while another 10 mm port is made in the right iliac fossa. Both of these ports can be interchanged for camera as and when needed. The identification and skeletinization of the appendix is much easier because of video-scopic vision where surgeon can actually visualize if there are any adhesions and a finger guided adhesiolysis can be done under vision. Once the appendix is identified and isolated, a grasper is introduced to get hold of the organ and the abdominal cavity is deflated and appendix is drawn on the surface. The remaining steps are just as the way we perform open appendectomy. Once the meso-appendix is ligated and appendix removed, the appendicular stump is returned back and ports are closed after a final look inside the abdominal cavity.Some of the steps of this procedure are highlighted below by

**3.1 Technique of video-assisted laparoscopic appendectomy ( Malik et al 2009 )** 

(VAECA) is given below.

the following operative pictures

Fig. 1. Appendix drawn into sheath of 10mm trocar

Fig. 2. Appendix drawn out on surface and meson-appendix legated.

#### **3.2 Authors study**

Author conducted a study in 2009 comparing the open appendectomy (OA) versus Video assisted extra-corporeal appendectomy (VAECA) wherein a total number of 283 patients of acute appendicitis were split into two groups. We explained this newly emerging technique as well as the conventional appendectomy to all the patients as and when they were diagnosed. The intended operative techniques were fully explained to the patients in terms of merits and demerits of the operative technique. The grouping of the patients was based on their own choice and by coin toss when patients did not show any preference for any particular technique. Of the total number, 150(53%) were operated by open Technique while 133(47%) by video-assisted extracorporeal technique of appendectomy. Majority of patients (89%) in the VAECA group were operated by three port technique while few (11%) could be successfully completed by two ports only. All patients below 10 years and those with suspected appendicular mass were excluded from the study. This was an initial study on the video assisted technique and we had promising results to conclude that VAECA could be a better alternate to open appendectomy in a majority of patients with acute appendicitis without complications. Some of the results are shown below showing comparison of the two techniques.

The results in our study were very promising in terms of safety, reliability and feasibility. The major advantages that we could conclude was fewer wound infections, less severe post-

The Laparoscopic Appendectomy – A Recent Trend 9

**Operative problems:** 

N= Number of patients

1-2 days 3-4 days 5-6 days

Lengthening of incision

Difficulty in mobilization

Minor wound /port infection Partial wound dehiscence Wound/port bleeding Respiratory tract infection

*\* P value* is statistically significant

Table 3. Postoperative complications

*\* P value* is statistically highly significant

Table 4. Hospital stays in both groups

Residual abscess

N= Number of patients

N= Number of patients

Bleeding from appendicular artery

Perforation of appendix during mobilization

Minor trauma to neighboring structures

*\* P value* is statistically highly significant for all groups

Table 2. Comparison of operative complications in both groups

**OA n (%)** 

66(44.0%) 42(28.0%) 42(28.0%)

Difficulty in localization of appendix

**n (%)**

**Type of operation (n = 283)** 

> 3(2.0%) 6(4.0%) 32(21.3%) 2(1.3%) 17(11.3%) 19(12.7%)

**Type of operation (n = 283)** 

> **VAECA n (%)**

7(5.3%) 0 5(3.8%) 7(5.3%) 2(1.5%)

**(n = 283) P value** 

**VAECA n (%)** 

128(96.2%) 1(0.8%) 4 (3.0%)

**OA n (%)** 

13(8.7%) 9(6.0%) 3(2.0%) 13(8.7%) 5(3.3%)

**Type of operation** 

**VAECA n (%)** 

**OA P-Value** 

7(5.3%) 9(6.8%) 4(3.0%) 5(3.8%) 23(17.3%) 7(5.3%)

\*< 0.001

**P value** 

< 0.01\*

< 0.001\*

operative pain, better cosmesis, shorter operative time and early recovery. It was also compared in terms of cost as we found out that there is reasonable reduction in the total cost of operation in VAECA group because we ligated the mesoappendix and appendicular stump by a suture in place of metal clips usually applied in intracorporeal technique of laparoscopic appendectomy. The magnificent telescopic vision of whole abdomen makes identification and dissection of inflamed appendix reasonably easier compared to open appendectomy. It is claimed that VAECA combines safety and efficiency of both intracorporeal laparoscopic appendectomy and conventional open appendectomy ( Valioulis I et al 2001 ). Any associated pathology can also be identified by using video assisted technique and this is of particular significance when diagnosis of acute appendicitis is doubtful (Mayer A et al 2004). The lowered rate of wound sepsis in our study are because of least contact of infected appendix with the surrounding walls of the port as it is fully drawn into the sheath of the trocar before its retrieval. This is contrary to the belief of Suttie SA and Seth S who claim an increased rate of wound infection in video-assisted extracorporeal appendectomy compared to conventional open appendectomy (Suttie SA and Seth S 2004). Author continued the same study and a total number of the study subjects has reached to 1700 of which only 625(36.76%) gave consent for open appendectomy while remaining (63.23%, n=1075) patients were willing for video-assisted laparoscopic appendectomy. This clearly shows that the results of video-assisted laparoscopic appendectomy are more acceptable to the patients. There was a gross difference in the total operative time compared to the open conventional appendectomy as well as intra-corporeal appendectomy. The diagnostic error as well as confirmation of the diagnosis is more reliable in the video-assisted extra-corporeal appendectomy. The total cost is reduced in VAECA due to use of suture in place of clips and reduced operative time also adds reducing the cost of operation. Post-operative complications are reasonably less in VAECA compared to other two techniques of appendectomy. Author is convinced that video-assisted approach of laparoscopic appendectomy is a better alternative procedure that can be effective when there is simple acute appendicitis without mass formation or many adhesions. Further RCT's on this technique of VAECA can help establishing this technique as a better alternate in un-complicated patients of acute appendicitis and more so in young adult females where the diagnosis of acute appendicitis cannot be established with certainty.


\*P value is <0.001 for all groups and is statistically highly significant N= Number of the patients

Table 1. Comparison of mean operative time in both groups.

operative pain, better cosmesis, shorter operative time and early recovery. It was also compared in terms of cost as we found out that there is reasonable reduction in the total cost of operation in VAECA group because we ligated the mesoappendix and appendicular stump by a suture in place of metal clips usually applied in intracorporeal technique of laparoscopic appendectomy. The magnificent telescopic vision of whole abdomen makes identification and dissection of inflamed appendix reasonably easier compared to open appendectomy. It is claimed that VAECA combines safety and efficiency of both intracorporeal laparoscopic appendectomy and conventional open appendectomy ( Valioulis I et al 2001 ). Any associated pathology can also be identified by using video assisted technique and this is of particular significance when diagnosis of acute appendicitis is doubtful (Mayer A et al 2004). The lowered rate of wound sepsis in our study are because of least contact of infected appendix with the surrounding walls of the port as it is fully drawn into the sheath of the trocar before its retrieval. This is contrary to the belief of Suttie SA and Seth S who claim an increased rate of wound infection in video-assisted extracorporeal appendectomy compared to conventional open appendectomy (Suttie SA and Seth S 2004). Author continued the same study and a total number of the study subjects has reached to 1700 of which only 625(36.76%) gave consent for open appendectomy while remaining (63.23%, n=1075) patients were willing for video-assisted laparoscopic appendectomy. This clearly shows that the results of video-assisted laparoscopic appendectomy are more acceptable to the patients. There was a gross difference in the total operative time compared to the open conventional appendectomy as well as intra-corporeal appendectomy. The diagnostic error as well as confirmation of the diagnosis is more reliable in the video-assisted extra-corporeal appendectomy. The total cost is reduced in VAECA due to use of suture in place of clips and reduced operative time also adds reducing the cost of operation. Post-operative complications are reasonably less in VAECA compared to other two techniques of appendectomy. Author is convinced that video-assisted approach of laparoscopic appendectomy is a better alternative procedure that can be effective when there is simple acute appendicitis without mass formation or many adhesions. Further RCT's on this technique of VAECA can help establishing this technique as a better alternate in un-complicated patients of acute appendicitis and more so in young adult females where

the diagnosis of acute appendicitis cannot be established with certainty.

\*P value is <0.001 for all groups and is statistically highly significant

Table 1. Comparison of mean operative time in both groups.

**Operative time:**  Up to 30 minutes 31-60 minutes 61-90 minutes Over 90 minutes

N= Number of the patients

**Type of operation** 

**OA n (%)** 

14(9.3%) 99(66.0%) 31(20.7%) 6(4.0%)

**(n = 283) P value** 

**VAECA n (%)** 

95(71.4%) 33(24.8%) 3(2.3%) 2(1.5%)


*\* P value* is statistically highly significant for all groups N= Number of patients

Table 2. Comparison of operative complications in both groups


*\* P value* is statistically significant N= Number of patients

Table 3. Postoperative complications


*\* P value* is statistically highly significant

N= Number of patients

Table 4. Hospital stays in both groups

The Laparoscopic Appendectomy – A Recent Trend 11

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appendectomy versus open appendectomy. J Laparoendosc Adv Surg Tech 2009;

one-trocar appendectomy—TULAA—as an alternative operation method in the

comparison of Laparoscopic appendectomy with open appendectomy.

Panagopoulos ,Fotis Kalfarentzos.Laparoscopic versus open appendectomy: which

acute appendicitis: a randomized prospective study. Surg Endosc. 2005; 19: 1193-95.

appendicectomy for suspected appendicitis. Cochrane database syst Rev 2011; 6; 7:

#### **4. Recent advances in laparoscopic appendectomy**

During the last few years there has been a dramatic improvement in the techniques of gaining access to the abdominal cavity minimizing the number of ports to a single incision in order to improve the cosmetic results. A number of techniques such as single incision laparoscopic surgery (SILS) and natural orifice transluminal surgery(NOTES) are introduced to improve the outcome of minimal access surgery and to make it still further less traumatic to the patients. The same advancements also apply to the laparoscopic appendectomy to make it more and less traumatic by way of reducing the number of ports. Initially both intrcorporeal and extra-corporeal techniques were performed by two to three ports. Recently a single incision, multi-luminal port appendectomy is introduced. The safety and efficacy of these newer techniques is yet to be established as there are no Randomized control studies to claim their benefits over multi port laparoscopic appendectomy (Rehman H 2011). Roberts KE(2009) described a true single port appendectomy (TSPA) by a new technique which he describes as "puppeteer technique" using single port and a pully of thread pulling the appendix. He claims this technique to be first of its kind which reduces the minimal access surgery to a further minimum level. Ates et al 2007 described a similar single port technique successfully and claim that this single port technique further makes minimally invasive surgery a better and safe option with minimal tissue trauma. Natural orifice transluminal endoscopic surgery (NOTES) is the most recent advancement in laparoscopic surgery. A cadaveric model appendectomy using NOTES technique by Santos BF et al 2011 via anterior transrectal route is found to be feasible ,time saving and easier to perform compared to posterior rectal approach. Eung Jin Shin et al 2010 reported transvaginal appendectomy using NOTES indicating many limitations to its use in human beings.Although there has been a tremendous improvement and advancement in minimally invasive surgical techniques to improve the outcome of different surgical procedures in terms of cosmetic results and cost effectiveness but the final word about there efficacy and effectiveness is yet to be established.

#### **5. References**


During the last few years there has been a dramatic improvement in the techniques of gaining access to the abdominal cavity minimizing the number of ports to a single incision in order to improve the cosmetic results. A number of techniques such as single incision laparoscopic surgery (SILS) and natural orifice transluminal surgery(NOTES) are introduced to improve the outcome of minimal access surgery and to make it still further less traumatic to the patients. The same advancements also apply to the laparoscopic appendectomy to make it more and less traumatic by way of reducing the number of ports. Initially both intrcorporeal and extra-corporeal techniques were performed by two to three ports. Recently a single incision, multi-luminal port appendectomy is introduced. The safety and efficacy of these newer techniques is yet to be established as there are no Randomized control studies to claim their benefits over multi port laparoscopic appendectomy (Rehman H 2011). Roberts KE(2009) described a true single port appendectomy (TSPA) by a new technique which he describes as "puppeteer technique" using single port and a pully of thread pulling the appendix. He claims this technique to be first of its kind which reduces the minimal access surgery to a further minimum level. Ates et al 2007 described a similar single port technique successfully and claim that this single port technique further makes minimally invasive surgery a better and safe option with minimal tissue trauma. Natural orifice transluminal endoscopic surgery (NOTES) is the most recent advancement in laparoscopic surgery. A cadaveric model appendectomy using NOTES technique by Santos BF et al 2011 via anterior transrectal route is found to be feasible ,time saving and easier to perform compared to posterior rectal approach. Eung Jin Shin et al 2010 reported transvaginal appendectomy using NOTES indicating many limitations to its use in human beings.Although there has been a tremendous improvement and advancement in minimally invasive surgical techniques to improve the outcome of different surgical procedures in terms of cosmetic results and cost effectiveness but the final word about there efficacy and

Ali R, Khan MR, Pishori T, Tayyab M. Laparoscopic appendectomy for acute appendicitis. Is

Ates O, Hakguder G, Olguner M, Akgur FM. Single-port laparoscopic appendectomy

Bresciani C, Perez RO, Habr-gama A, Jacob CE, Ozaki A, Batagello C et al. Laparoscopic

Chung RS, Rowland DY, Li P, Diaz J. A metaanalysis of randomized controlled trials of laparoscopic versus convention appendectomy. Am J Surg 1999; 177:250-53 Emple LK, Litwin DE, McLeods RS. A Meta analysis pf laparoscopic versus open

Heinzelmann M, Simmen HP, Cummins, Laeriader F. Is laparoscopic appendectomy the

this a feasible option for developing countries? Saudi J Gastroenterol 2010; 16(1):25-

conducted intra-corporeally with the aid of a transabdominal sling suture. J Pediatr

versus standard appendectomy outcomes and cost comparison in the private

appendectomy inpatients suspected of having acute appendicitis. Ca J Surg 1999;

**4. Recent advances in laparoscopic appendectomy** 

effectiveness is yet to be established.

Surg 2007;42(6):1071-4.

sector. J gastrointestinal Surg 2005; 9:1174-80.

new Gold standard? Arch surg 1995; 130(70); 782-85.

**5. References** 

29.

42: 377-83.


**2** 

*India* 

**Laparoscopic Management** 

**of Difficult Cholecystectomy** 

Mushtaq Chalkoo, Shahnawaz Ahangar, Ab Hamid Wani,

*Department of Surgery, Government Medical College Srinagar, Kashmir,* 

Asim Laharwal, Umar Younus, Faud Sadiq Baqal and Sikender Iqbal

Medicine is an ever changing art and needs to be shared with the progeny. Since the advent of laparoscopy, a new beginning started in the art of surgical craft. Many innovations and technical modifications are on the way for the satisfaction of the patient and the surgeon dealing with minimal access procedures. Laparoscopic cholecystectomy has revolutionized the whole globe and does not need any special mention. At the beginning surgeons would feel comfortable dealing with simple gallbladders but with the increase in expertise and introduction of newer armamentarium, difficult gallbladders are being subsequently dealt with. As of now, laparoscopic cholecystectomy can safely be declared as the gold standard for dealing with any kind of benign gallbladder disorder. However, before going to deal with the inflamed gallbladders; the skill of the surgeon, experience in laparoscopic techniques and thorough knowledge of risk factors are collectively important for a safe outcome. Even in the present era, the laparoscopic surgeon, amidst of such a substantial advance in laparoscopy, should have low threshold for conversion to open technique in case of difficulty. We strongly believe, from the experience we carry in dealing with these inflamed gallbladders, that every gallbladder is a book in itself which needs to be read time and again for a better and a safe outcome. Looking at the literature, the difficult thing to understand is to define the word 'difficult gallbladder.' However, we believe difficulty is a relative term and there are certain general principles that need to be followed before embarking on laparoscopic cholecystectomy. The aim of the operating surgeon should not only be giving the benefits of minimal access surgery but also avoiding the operative

The laparoscopic cholecystectomy is one of the common procedures performed globally so the errors are commonly reported. The beginners should start with the simple cases and the ideal patient would be one who is not obese, with no history of previous upper abdomen surgery, with a solitary stone in gallbladder and without features of cholecystitis. As the learning curve of the surgeon graphically increases, he can then deal with the difficult cases. We recommend the learning should be taken in a step ladder pattern. The patients having thick walled gallbladders, chronic cholecystitis, mucocele, inflamed Calot's triangle, previous upper abdomen surgeries, Mirrizi's, syndrome and obesity can be managed

**1. Introduction** 

complications and lessen the postoperative morbidity.


### **Laparoscopic Management of Difficult Cholecystectomy**

Mushtaq Chalkoo, Shahnawaz Ahangar, Ab Hamid Wani, Asim Laharwal, Umar Younus, Faud Sadiq Baqal and Sikender Iqbal *Department of Surgery, Government Medical College Srinagar, Kashmir, India* 

#### **1. Introduction**

12 Advances in Laparoscopic Surgery

Reiertsen O, Larsen S, Trondsen E,Edwin B, Faerden AE et al. Randomized controlled trial

Roberts KE. True single-port appendectomy:first experience with the "Puppeteer

Shin EJ, Jeong GA, Jung JC, Cho GS, Lim CW et al. Transvaginal appendectomy. J Korean

Santos BF, Hungness ES, Boller AM. Development of a feasible transrectal natural

Saunders S, Lefering R, Neuqubauer EA. Laparoscopic versus open surgery for suspected

Martin LC, Puente I, Sosa JL, Bassin A, Breslaw R, McKenney MG, E Ginzburg,Saleeman D.

Suttie SA, Seth S, Driver CP, Mahomed AA. Outcome after intra-and –extra-corporeal laparoscopic appendectomy techniques. Surg Endosc 2004; 18(7): 1123-5. Vipul D. Yagnik Jignesh B, rathod, Ajay G phatak. A retrospective study of two-port

Valioulis I, Hameury F, Dahmani L, Levard G. Laparoscope-assisted appendectomy in children: the two trocar technique. Eur J pediatr Surg 2001; 11(6):391-4. Wu SC, Wang YC, Fu CY, Chen RJ, Huang JC, Lu CW et al. Laparoscopic appendectomy

Yano H, Murakami M, Nakano Y, Tone T, Ohnishi T, Iwazawa T et al. Laparoscopic

Yoshikawa Seiichiro, Kidokoro Iba Tishiaki, Sugiysnma Kazuyushai, Fukunaga Tetsu et al.

anterior is better. Surg Endosc 2011;.{Epub ahead of print}.

appendectomy. Saudi J Gastroenterol 2010; 16(4):268-271.

appendicitis. Chochrane database sys rev 2002 ;( 1): CD 00 1546.

Surg 1997;84: 842-7.

technique". Surg endosc 2009;23(8):1825-30.

Semm K. Endoscopic appendectomy. Endoscopy 1983; 15:59-64.

Soc Coloproctology 2010; 26(6): 429-32.

Ann Surg 1995; 222(3):256-262.

2011; 77(4):466-70.

2004; 16:: 343-6.

with sequential design of laparoscopic versus conventional appendicectomy.Br J

endocscopic surgery(NOTES) approach in a cadaveric appendectomy model:

Open versus laparoscopic appendectomy. A prospective randomized comparison.

appendectomy and its comparison with open appendectomy and three port

provides better outcomes than open appendectomy in elderly patients. Am Surg

treatment for perforated appendicitis with pelvic abscess. Digestive endoscopy

Medicine is an ever changing art and needs to be shared with the progeny. Since the advent of laparoscopy, a new beginning started in the art of surgical craft. Many innovations and technical modifications are on the way for the satisfaction of the patient and the surgeon dealing with minimal access procedures. Laparoscopic cholecystectomy has revolutionized the whole globe and does not need any special mention. At the beginning surgeons would feel comfortable dealing with simple gallbladders but with the increase in expertise and introduction of newer armamentarium, difficult gallbladders are being subsequently dealt with. As of now, laparoscopic cholecystectomy can safely be declared as the gold standard for dealing with any kind of benign gallbladder disorder. However, before going to deal with the inflamed gallbladders; the skill of the surgeon, experience in laparoscopic techniques and thorough knowledge of risk factors are collectively important for a safe outcome. Even in the present era, the laparoscopic surgeon, amidst of such a substantial advance in laparoscopy, should have low threshold for conversion to open technique in case of difficulty. We strongly believe, from the experience we carry in dealing with these inflamed gallbladders, that every gallbladder is a book in itself which needs to be read time and again for a better and a safe outcome. Looking at the literature, the difficult thing to understand is to define the word 'difficult gallbladder.' However, we believe difficulty is a relative term and there are certain general principles that need to be followed before embarking on laparoscopic cholecystectomy. The aim of the operating surgeon should not only be giving the benefits of minimal access surgery but also avoiding the operative complications and lessen the postoperative morbidity.

The laparoscopic cholecystectomy is one of the common procedures performed globally so the errors are commonly reported. The beginners should start with the simple cases and the ideal patient would be one who is not obese, with no history of previous upper abdomen surgery, with a solitary stone in gallbladder and without features of cholecystitis. As the learning curve of the surgeon graphically increases, he can then deal with the difficult cases. We recommend the learning should be taken in a step ladder pattern. The patients having thick walled gallbladders, chronic cholecystitis, mucocele, inflamed Calot's triangle, previous upper abdomen surgeries, Mirrizi's, syndrome and obesity can be managed

Laparoscopic Management of Difficult Cholecystectomy 15

The difficulty encompasses a gamut of factors that arise from the patient, the surgical scene and the surgeon himself. The various safety measures in performing a safe laparoscopic cholecystectomy should not be undermined and left to the oblivion. The surgeon needs to give a due importance and weightage to all those techniques that will safeguard him for a smooth travel. One should resort to open laparoscopy in all those difficulties which make closed laparoscopy dangerous for the patient. The surgeon needs to be familiar with the angled scopes. Intraoperative cholangiography or laparoscopic ultrasound, if available, needs to be performed to identify the biliary anatomy and common duct stones. The adequate instrumentation is the key to a successful procedure. Toothed graspers are required to retract or grasp a thick walled gallbladder. The specialized needle drivers and holders are required. Hydrodissection is a boon to a safe surgery. One should not hesitate to create accessory ports for a speedy, safe and efficient outcome. One should be trained in suturing and knotting to encounter any difficulty that may arise while performing the procedure. Last, but not the least, one should always put in a drain in difficult circumstances. The proper positioning of patient adds ease to the surgeon. Partial or subtotal cholecystectomy sometimes proves to be the only alternative to the surgeon. One should not hesitate to leave the posterior wall intact in situations like fibrotic, intrahepatic

and gangrenous gallbladders to avoid sinus opening and consequent bleeding.

The various complications and the technical difficulties that we have come across from our experience of working with simple or difficult gallbladders for the last 10 years can be

It is a challenge to operate in the face of adhesions that could arise due to severe inflammatory conditions of gallbladder and as a result of any previous surgery. Owing to the operative scars in the lower abdomen designed for one or the other surgery, some amount of omental and bowel adhesions are very much common. In these situations it is better to avoid umbilicus as the initial site of veress needle insertion. It is better that one either resorts to open laparoscopy or else choose a safe site for the creation of pneumoperitoneum. One can even choose the site of the proposed epigastric port, slightly above the transpyloric plane in the midline. Some surgeons feel comfortable doing it in the left hypochondrium 2 cm below the subcostal margin in the midclavicular line with the due care to rule out spleenomegaly. One should not hesitate to use accessory ports to release the lower abdomen adhesions. The benefit of entering the abdomen this way avoids any inadvertent injury at the umbilicus as the port is put under visual guidance. The optical port can then be shifted from the epigastric to the umbilical site. One can also encounter small incisional hernias at the previous scar site which can then be repaired using polypropylene suture with or without mesh depending upon the size of the

**4. Complications and technical difficulties** 

analyzed and discussed under the following categories

**4.1 The problems related to the access to the operative site** 

hepatic duct and anomalous insertion of the cystic duct.

**3. Safety measures** 

**4.1.1 Adhesions** 

huge stone impacted in the cystic duct, Hartmann's pouch adherent to the common

subsequently. Suture is future in laparoscopy. One needs to understand that difficult laparoscopy is a step ahead in this craft.

#### **2. Risk factors**

'Safety saves' is a golden principle in handling any surgical or operative procedure. A good navigator knows the trick of saving himself from the tides of misfortune. The risk is a part of surgical play and cannot be avoided but dealt with meticulously. The risk factors can be called the predictors of difficulty while performing the surgery. The clinical risk factors on history would be a stocky male patient, the reason of which is not clear till date, previous upper abdominal surgery, cirrhosis of liver, previous/present acute cholecystitis and/or acute pancreatitis, previous interventions like percutaneous drainage or cholecystostomy. A robust male patient is difficult to handle with respect to port creation, so is a very thin and lean patient. In the former the first port creation is difficult as lot of force is required for lifting the abdominal wall and then to to thrust in the first trocar while as in the latter, the possibility of intraabdominal injuries is common should the force required to put in the trocar not be guarded. The closely placed ports also pose a problem in the face of a simple gallbladder as it might result in sword fighting of the instruments.

Ultrasonography is a very important tool not only for diagnosing the gallbladder pathology but also predicting the difficulty during surgery. It is mandatory on the part of surgeon to know about the wall thickness, status of gallbladder (distended/contracted), solitary/multiple stones, cystic duct length and diameter, intrahepatic/extrahepatic gallbladder and above all the status of the common bile duct. The ultrasonic criteria for a difficult cholecystectomy can be categorized as under:


The risk factors that can arise while performing laparoscopic cholecystectomy are usually technical in nature. They can be enumerated as below


huge stone impacted in the cystic duct, Hartmann's pouch adherent to the common hepatic duct and anomalous insertion of the cystic duct.

#### **3. Safety measures**

14 Advances in Laparoscopic Surgery

subsequently. Suture is future in laparoscopy. One needs to understand that difficult

'Safety saves' is a golden principle in handling any surgical or operative procedure. A good navigator knows the trick of saving himself from the tides of misfortune. The risk is a part of surgical play and cannot be avoided but dealt with meticulously. The risk factors can be called the predictors of difficulty while performing the surgery. The clinical risk factors on history would be a stocky male patient, the reason of which is not clear till date, previous upper abdominal surgery, cirrhosis of liver, previous/present acute cholecystitis and/or acute pancreatitis, previous interventions like percutaneous drainage or cholecystostomy. A robust male patient is difficult to handle with respect to port creation, so is a very thin and lean patient. In the former the first port creation is difficult as lot of force is required for lifting the abdominal wall and then to to thrust in the first trocar while as in the latter, the possibility of intraabdominal injuries is common should the force required to put in the trocar not be guarded. The closely placed ports also pose a problem in the face of a simple

Ultrasonography is a very important tool not only for diagnosing the gallbladder pathology but also predicting the difficulty during surgery. It is mandatory on the part of surgeon to know about the wall thickness, status of gallbladder (distended/contracted), solitary/multiple stones, cystic duct length and diameter, intrahepatic/extrahepatic gallbladder and above all the status of the common bile duct. The ultrasonic criteria for a

5. An acutely inflamed gallbladder, pericholecystic fluid collection and air in the gallbladder (emphysematous cholecystitis), xanthogranulomatous cholecystitis, acute

The risk factors that can arise while performing laparoscopic cholecystectomy are usually

8. Abnormality can also arise due to anomalous anatomy of hepatobiliary system like situs inversus, malposition of the gallbladder, arterial anomalies and short cystic duct, a

gallbladder as it might result in sword fighting of the instruments.

difficult cholecystectomy can be categorized as under:

technical in nature. They can be enumerated as below

3. Acutely inflamed and tense gallbladder

4. Gallbladder packed with stones 5. Thick walled gallbladder 6. Fibrotic gallbladder 7. Gallbladder mass.

1. Difficult entry to the right hypochondrium owing to the adhesions.

2. Difficulty in exposure can also arise due to diseased gallbladder and Liver.

1. Thick walled gallbladder. 2. Contracted gallbladder

3. Gallbladder packed with stones. 4. A large calcified gallbladder

gangrenous cholecystitis. 6. Left sided gallbladder. 7. Sessile gallbladder.

laparoscopy is a step ahead in this craft.

**2. Risk factors** 

The difficulty encompasses a gamut of factors that arise from the patient, the surgical scene and the surgeon himself. The various safety measures in performing a safe laparoscopic cholecystectomy should not be undermined and left to the oblivion. The surgeon needs to give a due importance and weightage to all those techniques that will safeguard him for a smooth travel. One should resort to open laparoscopy in all those difficulties which make closed laparoscopy dangerous for the patient. The surgeon needs to be familiar with the angled scopes. Intraoperative cholangiography or laparoscopic ultrasound, if available, needs to be performed to identify the biliary anatomy and common duct stones. The adequate instrumentation is the key to a successful procedure. Toothed graspers are required to retract or grasp a thick walled gallbladder. The specialized needle drivers and holders are required. Hydrodissection is a boon to a safe surgery. One should not hesitate to create accessory ports for a speedy, safe and efficient outcome. One should be trained in suturing and knotting to encounter any difficulty that may arise while performing the procedure. Last, but not the least, one should always put in a drain in difficult circumstances. The proper positioning of patient adds ease to the surgeon. Partial or subtotal cholecystectomy sometimes proves to be the only alternative to the surgeon. One should not hesitate to leave the posterior wall intact in situations like fibrotic, intrahepatic and gangrenous gallbladders to avoid sinus opening and consequent bleeding.

#### **4. Complications and technical difficulties**

The various complications and the technical difficulties that we have come across from our experience of working with simple or difficult gallbladders for the last 10 years can be analyzed and discussed under the following categories

#### **4.1 The problems related to the access to the operative site**

#### **4.1.1 Adhesions**

It is a challenge to operate in the face of adhesions that could arise due to severe inflammatory conditions of gallbladder and as a result of any previous surgery. Owing to the operative scars in the lower abdomen designed for one or the other surgery, some amount of omental and bowel adhesions are very much common. In these situations it is better to avoid umbilicus as the initial site of veress needle insertion. It is better that one either resorts to open laparoscopy or else choose a safe site for the creation of pneumoperitoneum. One can even choose the site of the proposed epigastric port, slightly above the transpyloric plane in the midline. Some surgeons feel comfortable doing it in the left hypochondrium 2 cm below the subcostal margin in the midclavicular line with the due care to rule out spleenomegaly. One should not hesitate to use accessory ports to release the lower abdomen adhesions. The benefit of entering the abdomen this way avoids any inadvertent injury at the umbilicus as the port is put under visual guidance. The optical port can then be shifted from the epigastric to the umbilical site. One can also encounter small incisional hernias at the previous scar site which can then be repaired using polypropylene suture with or without mesh depending upon the size of the

Laparoscopic Management of Difficult Cholecystectomy 17

Trendelenberg position augment the risk of deep vein thrombosis. Obesity poses a difficulty for the beginners so far as the insertion of veress needle and first trocar is concerned. Calot's triangle is usually loaded with thick fat hence the identification of cystic duct and artery should be done carefully. Precautions that avoid any untoward event while operating on a

1. Adequate padding of the pressure points should be done. Lanz transumblical veress needle insertion technique may be applied. Two Lanz tissue holding forceps can be used to lift the umbilicus and with adequate muscle relaxation the surgeon can safely go into the abdomen perpendicular to the umbilicus after making a small incision. One should take proper care not to injure the skin at the site while lifting or holding the umbilicus. The surgeon needs to have a control on the thrust on insertion of Veress needle and the

2. Sometimes the trocar length is a problem of concern for access. However, we have never used other than conventional trocars. The problem lies in the insertion of trocar. The amount of tension required to introduce trocar in abdominally obese patient is also a matter of concern. Most of the times the trocar might go into the parities and not into the abdominal cavity as such. Additionally, the trocar may go in an oblique fashion which

3. Sometimes a thick fat laden falciform ligament creates a problem for the epigastric port.

4. The fat laden Calot's triangle sometimes obscures the anatomy. The dissection might sometimes cause torrential bleed from cystic artery if left unidentified. One can put a gauze piece and pack the area, relax for a minute and then proceed. The other way round is to get the fundus of gallbladder to the Calot's triangle and compress the area. 5. Sometimes the left lobe of the liver is enlarged and obscures the operating field. Left lateral tilting with placement of a sandbag behind the right costal margin moves it away from the field of surgery. However, from our working experience in such troubled matters we have learnt that the surgeon needs to be tricky to use his epigastric working

A good navigator before embarking on his job should know his domain for a successful and smooth outcome. The technical difficulties that can arise while performing Laparoscopic cholecystectomy are varied in number. It is not possible to describe them in detail.

Sometimes when the endoscope moves in, the surgeon doing diagnostic laparoscopy cannot find the gallbladder due to extensive adhesions. These adhesions between the inferior surface of the liver and the posterior parietal peritoneum together with hepatic flexure of colon and the omentum collectively seem to bury the gallbladder behind them. The duodenum may be adherent to the infundibulum. There may be even a fistulous communication between gallbladder and stomach or duodenum. The crux of the technique lies in moving in with suction nozzle and hydrodissection. The electrocautery should be carefully used. The surgeon needs to resort to careful sharp and blunt dissection. The fistulous communication needs to be

In difficult situations one can use a percutaneous silk stitch to lift it up.

direction of the needle should be towards the pubic symphysis.

patient with abdominal obesity are as follows:-

creates difficulty in dissection for the surgeon.

port as a retractor as well as a dissector.

**4.2.1 Hidden gallbladder** 

**4.2 Technical difficulties that arise during cholecystectomy** 

Nevertheless, few of them do need a mention as under:-

defect. Most of the previous surgeries done for appendix, ulcer disease or pancreas create a significant problem for the first port access. It is wise to resort to Hasson's technique or else go to the site that lies diagonal to the previous scar. The conversion rates to the tune of 25% have been reported in patients with extensive upper abdomen adhesions2 .We do not recommend complete lysis of all the adhesions but would suggest only the obstructing adhesions to be lysed to clear the path for the camera port. All the bleeding points have to be controlled during adhesiolysis. These ports can be interchanged as camera and working trocars in order to get better exposure. We have an experience of going to laparoscopic cholecystectomy in patients with previous right upper paramedian incisions. We invariably would succeed to have a peep into the organ by a safe manipulation and rotation of the laparoscope to create a window through the adhesion. However, it may not be out of place to mention that the subsequent travel to the operative site for the camera assistant is a difficult job. The camera assistant needs to understand the negotiation of camera for a smooth and speedy outcome. Some surgeons use special trocars like visi-port or opti-view trocars to avoid any injury. But, they add cost to the procedure. Many studies have shown that the incidence of hollow viscus injury following open access for pneumoperitoneum and closed veress needle technique are the same.3

Inflammatory adhesions are very common due to acute cholecystitis or acute pancreatitis; but luckily they are usually flimsy and can easily be dealt with the suction nozzle. However, if the adhesions are dense, one should resort to the careful sharp dissection and control the diffuse self limiting oozes either with mild electrocautery or with a gauze piece. The predictors of dense adhesions in the subhepatic space from our experience can be grouped as under:-


It is recommended, however, in face of dense adhesions, one can resort to additional ports, retrograde fundus-first technique or even modified cholecystectomy.

#### **4.1.2 Incisional hernias**

During laparoscopic cholecystectomy a surgeon can also deal with any concomitant hernias due to previous scars. However, one needs to understand and follow the principles of hernia repair. The problem of hernia is dealt with according to the site and size of the defect. The placement of mesh has to be avoided for small defects and in acute inflammatory or infective cases. The small hernias in and around umbilicus can usually be managed laparoscopically. We have a good experience of dealing with cholecystectomy and concomitant epigastric hernias laparoscopically in a single stage.

#### **4.1.3 Morbid obesity**

Obesity is associated with increased incidence of gallstone disease and it may also pose a problem of access. The patients who are morbidly obese are at risk of anesthetic and postoperative complications. The surgery in these patients is associated with a high incidence of pulmonary and thrombotic complications.4 Pneumoperitoneum and steep

defect. Most of the previous surgeries done for appendix, ulcer disease or pancreas create a significant problem for the first port access. It is wise to resort to Hasson's technique or else go to the site that lies diagonal to the previous scar. The conversion rates to the tune of 25% have been reported in patients with extensive upper abdomen adhesions2 .We do not recommend complete lysis of all the adhesions but would suggest only the obstructing adhesions to be lysed to clear the path for the camera port. All the bleeding points have to be controlled during adhesiolysis. These ports can be interchanged as camera and working trocars in order to get better exposure. We have an experience of going to laparoscopic cholecystectomy in patients with previous right upper paramedian incisions. We invariably would succeed to have a peep into the organ by a safe manipulation and rotation of the laparoscope to create a window through the adhesion. However, it may not be out of place to mention that the subsequent travel to the operative site for the camera assistant is a difficult job. The camera assistant needs to understand the negotiation of camera for a smooth and speedy outcome. Some surgeons use special trocars like visi-port or opti-view trocars to avoid any injury. But, they add cost to the procedure. Many studies have shown that the incidence of hollow viscus injury following

open access for pneumoperitoneum and closed veress needle technique are the same.3

1. Peptic ulcer surgery. 2. Right hemicolectomy. 3. Previous gastric surgery. 4. Hydatid cyst of liver. 5. Pancreaticodudenectomy. 6. Liver abscess surgery.

**4.1.2 Incisional hernias** 

**4.1.3 Morbid obesity** 

Inflammatory adhesions are very common due to acute cholecystitis or acute pancreatitis; but luckily they are usually flimsy and can easily be dealt with the suction nozzle. However, if the adhesions are dense, one should resort to the careful sharp dissection and control the diffuse self limiting oozes either with mild electrocautery or with a gauze piece. The predictors of dense adhesions in the subhepatic space from our experience can be grouped as under:-

It is recommended, however, in face of dense adhesions, one can resort to additional ports,

During laparoscopic cholecystectomy a surgeon can also deal with any concomitant hernias due to previous scars. However, one needs to understand and follow the principles of hernia repair. The problem of hernia is dealt with according to the site and size of the defect. The placement of mesh has to be avoided for small defects and in acute inflammatory or infective cases. The small hernias in and around umbilicus can usually be managed laparoscopically. We have a good experience of dealing with cholecystectomy and

Obesity is associated with increased incidence of gallstone disease and it may also pose a problem of access. The patients who are morbidly obese are at risk of anesthetic and postoperative complications. The surgery in these patients is associated with a high incidence of pulmonary and thrombotic complications.4 Pneumoperitoneum and steep

retrograde fundus-first technique or even modified cholecystectomy.

concomitant epigastric hernias laparoscopically in a single stage.

Trendelenberg position augment the risk of deep vein thrombosis. Obesity poses a difficulty for the beginners so far as the insertion of veress needle and first trocar is concerned. Calot's triangle is usually loaded with thick fat hence the identification of cystic duct and artery should be done carefully. Precautions that avoid any untoward event while operating on a patient with abdominal obesity are as follows:-


#### **4.2 Technical difficulties that arise during cholecystectomy**

A good navigator before embarking on his job should know his domain for a successful and smooth outcome. The technical difficulties that can arise while performing Laparoscopic cholecystectomy are varied in number. It is not possible to describe them in detail. Nevertheless, few of them do need a mention as under:-

#### **4.2.1 Hidden gallbladder**

Sometimes when the endoscope moves in, the surgeon doing diagnostic laparoscopy cannot find the gallbladder due to extensive adhesions. These adhesions between the inferior surface of the liver and the posterior parietal peritoneum together with hepatic flexure of colon and the omentum collectively seem to bury the gallbladder behind them. The duodenum may be adherent to the infundibulum. There may be even a fistulous communication between gallbladder and stomach or duodenum. The crux of the technique lies in moving in with suction nozzle and hydrodissection. The electrocautery should be carefully used. The surgeon needs to resort to careful sharp and blunt dissection. The fistulous communication needs to be

Laparoscopic Management of Difficult Cholecystectomy 19

Fig. 1. Showing bleeding from one of the opened up sinues in the liver bed

Fig. 2. Showing the application of pressure and counterpressure over a gauze.

For a surgeon operating on the gallbladder, common bile duct needs to be safeguarded. Utmost care needs to be exercised to avoid ductal injury, whether a surgeon adopts open or laparoscopic approach to gallbladder. Ductal injuries do not only add morbidity to the

**4.2.4 Ductal injury** 

looked for and if present should be repaired by intracorporeal suturing. If the gallbladder is hugely distended and tense, an initial decompression may ease the surgeon. However, we strongly recommend that mildly distended gallbladders should not be decompressed as the surgical planes become difficult to negotiate for the surgeon with the instruments. If the gallbladder is too thick and rigid, it is difficult for the surgeon to hold the gallbladder with his left hand and may further increase the difficulty. One can use toothed grasper to hold thickened gallbladder. Small and fibrotic gallbladders also add frustration to the surgeon and one needs to be patient to handle them safely.

#### **4.2.2 Difficult retraction**

The thick walled gallbladder is a problem for the assistant to hold and retract. The wall thickness beyond 4mm is a predictor of difficult retraction. Specialized toothed graspers with long and wide mouth can facilitate laparoscopic cholecystectomy. Similar maneuvers are also helpful in contracted gallbladder and gallbladders packed with stones. Long gallbladders, usually comma shaped, also pose a problem in retraction.

#### **4.2.3 Bleeding**

Bleeding is inherent to any surgical procedure. However, managing it intraoperatively is sometimes challenging for the surgeon. From our experience of 1000 laparoscopic cholecystectomies we have learnt that bleeding in no way should be considered an immediate reason for conversion. However, in rare circumstances, one should not hesitate to convert on account of profuse bleeding should the life of the patient be in jeopardy. During surgery bleeding may occur from injury to cystic artery or right hepatic artery. The bleeding from Calot's vascular arcade is usually mild and self limited which can be controlled by initial compression, clearing the field by suction nozzle followed by application of a clip, ligature or rarely electrocautery. The golden principle in laparoscopy look, hook and cook should always be kept in mind. Bleeding from cystic artery is sometimes profuse. Herein lies the test of patience of the surgeon. One should not panic and apply clips without having adequate vision. The cranial traction from the fundus of the gallbladder is released and the infundibulum is used to compress the bleeder. A gauze piece can also help in this situation. Most often bleeding stops due to spasm of the vessel. If bleeding is persistent one should be ready with the suction cannula to suck out the blood clots and with the left hand grasper, grasp the bleeding vessel. Meanwhile, after the area is clean, the clips are applied to the bleeder. Sometimes there is injury to the right hepatic artery which can be clipped if the liver is normal and there is no portal vein thrombosis. Bleeding can also arise from gallbladder bed which is usually diffuse ooze and can be controlled with an electrocautery (figure1). We have found that gel foams do not help much where as surgicel (oxydized cellulose polymer) is most effective in controlling bleeding from the liver bed. We also advocate packing of liver bed in case of opening up of a sinus with surgicel on top of which a wet-gauze should be placed and compressed by right hand forceps. Then the counter pressure should be maintained by the left hand forceps on the liver. This bimanual compression should be maintained continuously by watch for a period of 5 minutes (figure 2). We strongly believe that any kind of sinus bleed dealt in this way can be handled and conversion to open approach avoided to a great extent.

looked for and if present should be repaired by intracorporeal suturing. If the gallbladder is hugely distended and tense, an initial decompression may ease the surgeon. However, we strongly recommend that mildly distended gallbladders should not be decompressed as the surgical planes become difficult to negotiate for the surgeon with the instruments. If the gallbladder is too thick and rigid, it is difficult for the surgeon to hold the gallbladder with his left hand and may further increase the difficulty. One can use toothed grasper to hold thickened gallbladder. Small and fibrotic gallbladders also add frustration to the surgeon and

The thick walled gallbladder is a problem for the assistant to hold and retract. The wall thickness beyond 4mm is a predictor of difficult retraction. Specialized toothed graspers with long and wide mouth can facilitate laparoscopic cholecystectomy. Similar maneuvers are also helpful in contracted gallbladder and gallbladders packed with stones. Long

Bleeding is inherent to any surgical procedure. However, managing it intraoperatively is sometimes challenging for the surgeon. From our experience of 1000 laparoscopic cholecystectomies we have learnt that bleeding in no way should be considered an immediate reason for conversion. However, in rare circumstances, one should not hesitate to convert on account of profuse bleeding should the life of the patient be in jeopardy. During surgery bleeding may occur from injury to cystic artery or right hepatic artery. The bleeding from Calot's vascular arcade is usually mild and self limited which can be controlled by initial compression, clearing the field by suction nozzle followed by application of a clip, ligature or rarely electrocautery. The golden principle in laparoscopy look, hook and cook should always be kept in mind. Bleeding from cystic artery is sometimes profuse. Herein lies the test of patience of the surgeon. One should not panic and apply clips without having adequate vision. The cranial traction from the fundus of the gallbladder is released and the infundibulum is used to compress the bleeder. A gauze piece can also help in this situation. Most often bleeding stops due to spasm of the vessel. If bleeding is persistent one should be ready with the suction cannula to suck out the blood clots and with the left hand grasper, grasp the bleeding vessel. Meanwhile, after the area is clean, the clips are applied to the bleeder. Sometimes there is injury to the right hepatic artery which can be clipped if the liver is normal and there is no portal vein thrombosis. Bleeding can also arise from gallbladder bed which is usually diffuse ooze and can be controlled with an electrocautery (figure1). We have found that gel foams do not help much where as surgicel (oxydized cellulose polymer) is most effective in controlling bleeding from the liver bed. We also advocate packing of liver bed in case of opening up of a sinus with surgicel on top of which a wet-gauze should be placed and compressed by right hand forceps. Then the counter pressure should be maintained by the left hand forceps on the liver. This bimanual compression should be maintained continuously by watch for a period of 5 minutes (figure 2). We strongly believe that any kind of sinus bleed dealt in this way

gallbladders, usually comma shaped, also pose a problem in retraction.

can be handled and conversion to open approach avoided to a great extent.

one needs to be patient to handle them safely.

**4.2.2 Difficult retraction** 

**4.2.3 Bleeding** 

Fig. 1. Showing bleeding from one of the opened up sinues in the liver bed

Fig. 2. Showing the application of pressure and counterpressure over a gauze.

#### **4.2.4 Ductal injury**

For a surgeon operating on the gallbladder, common bile duct needs to be safeguarded. Utmost care needs to be exercised to avoid ductal injury, whether a surgeon adopts open or laparoscopic approach to gallbladder. Ductal injuries do not only add morbidity to the

Laparoscopic Management of Difficult Cholecystectomy 21

Fig. 4. Showing Critical view of safety in a situs inversus case

**viscera** 

**4.3 The problems related to the concomitant disease of gallbladder and nearby** 

problem during dissection. The ones that need a mention herein are as follows:-

**4.3.1 Impacted stone, hydrops, empyema, early Mirrizi's of gallbladder** 

to the fatigue of the surgeon (figure 7).

The gallbladder surgery has taken repute of many surgeons even at the distal end of their careers. A wise surgeon is one who thinks that the gallbladder, he operates on is his first one, amidst of huge experience he may carry in dealing with this organ. The difficulty while operating on an inflamed gallbladder cannot be defined. However, one needs to dissect safely to ease down the procedure. There are many problems and diseases of gallbladder that pose technical difficulties for the surgeon to remove this organ. One cannot generalize the principles for handling difficult gallbladders as each one of them poses a peculiar

In a situation where a huge stone is impacted in the neck of the gallbladder with resultant hydrops or empyema, the easy way out to handle such a gallbladder is to aspirate it after opening the fundus with a hot hook to perform suction irrigation (figure 5). One can make an incision on the neck of the gallbladder approximately 2-3 cm above the junction of cystic duct and the neck. This incision should be generous enough to allow for the exteriorization of the stone like an enucleation of the mass (figure 6). We have usually found that in such cases the cystic duct is either small or absent. In these big stones impacted at the neck or pouch, technical problem lies in holding the pouch by the left hand and consequent addition

Mirrizi's syndrome needs a mention. This syndrome was first described in 1948 by P.L. Mirrizi. He talked about an unusual complication of gallstones impacted either in the cystic

patient but can even at times prove to be fatal. If the injury is recognized intraoperatively and treated immediately, the patient may do well. In our series of 1000 cholecystectomies done by laparoscopic approach fortunately we never encountered one. Nevertheless, two of our patients presented either with a bilioma (8th – 10th postoperative day) or biliary peritonitis (5th-7th postoperative day). Both of these were managed by re-laparoscopy wherein clearing the bile from the peritoneal cavity and putting in a wide bore 28F tube drain was done. One of these had a persistent leak through the drain till 35th postoperative day. The patient was later on subjected to ERCP and a biliary stent was put in which was then removed in the third month. Small biliomas in the Morrison's pouch or suprahepatic space can also be drained by percutaneous ultrasound guided technique. The ductal injury is a catastrophe that can result and hepaticojejunostomy can prove to be the only alternative for the operating surgeon. Sometimes accessory duct of Luscka is a cause for bilioma that a surgeon might not have recognized and dealt with in the initial go. In such a circumstance, re-laparoscopy with identification of accessory duct and clipping is recommended. If there is any bile leak which lasts beyond 5th postoperative day, distal block either with a stone or stenosis is likely. Our policy is to do ERCP and sphincterotomy with the extraction of the stone and stenting. In all such cases it takes just 24 hours for the leak to stop.

#### **4.2.5 Malposition of the gallbladder**

Sometimes the site of gallbladder other than the routine poses a challenge for the surgeon to operate. In dealing with such an exigency, many surgeons have come up with their own innovations with a view to facilitate and ease dissection. In situs inversus patients the surgeon stands in between the legs and the ports are placed mirror images of the routine ports (figure 3, 4). Here the epigastric is 5mm in size and the left subcostal port can be a 10 mm for the right hander's to facilitate clip application. The same arrangement of ports can be used in cases of left lobe gallbladder.

Fig. 3. Showing mirror image ports in Situs Inversus

patient but can even at times prove to be fatal. If the injury is recognized intraoperatively and treated immediately, the patient may do well. In our series of 1000 cholecystectomies done by laparoscopic approach fortunately we never encountered one. Nevertheless, two of our patients presented either with a bilioma (8th – 10th postoperative day) or biliary peritonitis (5th-7th postoperative day). Both of these were managed by re-laparoscopy wherein clearing the bile from the peritoneal cavity and putting in a wide bore 28F tube drain was done. One of these had a persistent leak through the drain till 35th postoperative day. The patient was later on subjected to ERCP and a biliary stent was put in which was then removed in the third month. Small biliomas in the Morrison's pouch or suprahepatic space can also be drained by percutaneous ultrasound guided technique. The ductal injury is a catastrophe that can result and hepaticojejunostomy can prove to be the only alternative for the operating surgeon. Sometimes accessory duct of Luscka is a cause for bilioma that a surgeon might not have recognized and dealt with in the initial go. In such a circumstance, re-laparoscopy with identification of accessory duct and clipping is recommended. If there is any bile leak which lasts beyond 5th postoperative day, distal block either with a stone or stenosis is likely. Our policy is to do ERCP and sphincterotomy with the extraction of the

stone and stenting. In all such cases it takes just 24 hours for the leak to stop.

Sometimes the site of gallbladder other than the routine poses a challenge for the surgeon to operate. In dealing with such an exigency, many surgeons have come up with their own innovations with a view to facilitate and ease dissection. In situs inversus patients the surgeon stands in between the legs and the ports are placed mirror images of the routine ports (figure 3, 4). Here the epigastric is 5mm in size and the left subcostal port can be a 10 mm for the right hander's to facilitate clip application. The same arrangement of ports can

**4.2.5 Malposition of the gallbladder** 

be used in cases of left lobe gallbladder.

Fig. 3. Showing mirror image ports in Situs Inversus

Fig. 4. Showing Critical view of safety in a situs inversus case

#### **4.3 The problems related to the concomitant disease of gallbladder and nearby viscera**

The gallbladder surgery has taken repute of many surgeons even at the distal end of their careers. A wise surgeon is one who thinks that the gallbladder, he operates on is his first one, amidst of huge experience he may carry in dealing with this organ. The difficulty while operating on an inflamed gallbladder cannot be defined. However, one needs to dissect safely to ease down the procedure. There are many problems and diseases of gallbladder that pose technical difficulties for the surgeon to remove this organ. One cannot generalize the principles for handling difficult gallbladders as each one of them poses a peculiar problem during dissection. The ones that need a mention herein are as follows:-

#### **4.3.1 Impacted stone, hydrops, empyema, early Mirrizi's of gallbladder**

In a situation where a huge stone is impacted in the neck of the gallbladder with resultant hydrops or empyema, the easy way out to handle such a gallbladder is to aspirate it after opening the fundus with a hot hook to perform suction irrigation (figure 5). One can make an incision on the neck of the gallbladder approximately 2-3 cm above the junction of cystic duct and the neck. This incision should be generous enough to allow for the exteriorization of the stone like an enucleation of the mass (figure 6). We have usually found that in such cases the cystic duct is either small or absent. In these big stones impacted at the neck or pouch, technical problem lies in holding the pouch by the left hand and consequent addition to the fatigue of the surgeon (figure 7).

Mirrizi's syndrome needs a mention. This syndrome was first described in 1948 by P.L. Mirrizi. He talked about an unusual complication of gallstones impacted either in the cystic

Laparoscopic Management of Difficult Cholecystectomy 23

Fig. 6. Infundibulotomy done to remove the impacted stone.

Fig. 7. Hydrops of the gallbladder

duct or Hartmann's pouch and causing compression on the common hepatic duct to produce obstructive jaundice. The cause of jaundice is quite obvious either due to compression of the stone on the main duct or by a fistulous communication between Hartmann's pouch and the common hepatic duct. It occurs in 0.1 – 1.4% of all patients undergoing cholecystectomy. The clinical presentation is history of recurrent cholangitis, jaundice, right upper quadrant pain and abnormal liver function tests. Sometimes it may present as pancreatitis or acute cholecystitis. The presence of malignancy has to be excluded by computed tomography scan. It is wise to perform ERCP to study the ductal system before performing cholecystectomy in these patients. The laparoscopic management of Mirrizi's syndrome, once considered as a contraindication, can now be easily dealt with by an experienced laparoscopic surgeon confident in intracorporeal suturing and knotting. No doubt, it is a surgical challenge as the gallbladder is contracted and the visualization of biliary anatomy is poor due to extensive adhesions. The common bile duct may be mistaken for cystic duct and the chances of ductal injuries are more. Lastly, if the fistulous communication is not recognized, biliary peritonitis may occur.

Fig. 5. Stone impacted at Hartmann's pouch.

duct or Hartmann's pouch and causing compression on the common hepatic duct to produce obstructive jaundice. The cause of jaundice is quite obvious either due to compression of the stone on the main duct or by a fistulous communication between Hartmann's pouch and the common hepatic duct. It occurs in 0.1 – 1.4% of all patients undergoing cholecystectomy. The clinical presentation is history of recurrent cholangitis, jaundice, right upper quadrant pain and abnormal liver function tests. Sometimes it may present as pancreatitis or acute cholecystitis. The presence of malignancy has to be excluded by computed tomography scan. It is wise to perform ERCP to study the ductal system before performing cholecystectomy in these patients. The laparoscopic management of Mirrizi's syndrome, once considered as a contraindication, can now be easily dealt with by an experienced laparoscopic surgeon confident in intracorporeal suturing and knotting. No doubt, it is a surgical challenge as the gallbladder is contracted and the visualization of biliary anatomy is poor due to extensive adhesions. The common bile duct may be mistaken for cystic duct and the chances of ductal injuries are more. Lastly, if the fistulous

communication is not recognized, biliary peritonitis may occur.

Fig. 5. Stone impacted at Hartmann's pouch.

Fig. 6. Infundibulotomy done to remove the impacted stone.

Fig. 7. Hydrops of the gallbladder

Laparoscopic Management of Difficult Cholecystectomy 25

the retraction becomes difficult. There are more chances of injury to the common bile duct in handling this eventuality. One needs to be tricky to handle such a situation. The surgeon needs to have first glimpse of the gallbladder by releasing the adhesions. Additional port placement may help in this case. The retrograde technique may be then performed but should be done carefully. Intraoperative cholangiography may be done, if possible. The cystic duct is usually thick walled and difficult to occlude by clips. One should either use an endoloop or transfix the cystic duct after milking the duct towards the gallbladder to displace any stone, if present.

This is an incidental finding during laparoscopic cholecystectomy and can account for 0.5- 7% cases done laparoscopically for biliary disease (figure 9).6 The diagnosis is suspected by noting the presence of air in the biliary tree associated with contracted gallbladder. The conditions where air is present within the biliary tree are infections by gas forming organisms, incompetent sphincter of Oddi, congenital anomalies, ERCP with sphincterotomy. Cholecystoduodenal, cholecystogastric and cholecystocolic are the common internal biliary fistulae. The common symptoms are pain, fever, diarrhea and jaundice. The most common cause for internal biliary fistulae is gallstones (90%) whereas; peptic ulcer, malignancy and trauma account for the rest 10% of the cases. Ultrasonography is useful and CT scan may show contracted, thick walled gallbladder with stones, pneumobilia and duodenal thickening. ERCP may localize the fistulous tract. Barium meal, enema and

It is a challenge for the surgeon to perform laparoscopic cholecystectomy in a patient with hepatic disorders especially cirrhosis. In near past this used to be considered a relative

**4.3.4 Cholecystoenteric fistula** 

colonoscopy may be useful in the diagnosis.

Fig. 9. Cholecystoenteric fistula.

**4.3.5 Disorders of liver** 

#### **4.3.2 Acute gangrenous cholecystitis**

Operating on acute cholecystitis should always be under taken by an experienced surgeon. One day or the other, one may come across an acute gangrenous cholecystitis (figure 8). One should remove all the inflammatory adhesions from the fundus of the gallbladder. It is safe to proceed with high pressure hydro-irrigation applied through a suction cannula in order to open up planes which are then further dissected using a grasper and scissors with electrocautery; staying away from the duodenum at all the times. Most of the surgeons might not go to dissect till the common bile duct is visible. They strongly feel that the dissection should be limited to the neck of the gallbladder. Even after the removal of the gallbladder, one may encounter a profuse continuous bleed from the liver bed possibly due to opening up of one of the sinuses as the planes are not clear. We usually use 2x2 cm gauze piece and a surgicel is left over the sinus for a period of five minutes to curtail the crisis. The spilt stones are usually a problem in handling such gallbladders. We recommend using a sterile endobag, if available, to remove the specimen and the stones together. After removal of the specimen, the port tract should be irrigated thoroughly.

Fig. 8. Acute gangrenous cholecystitis.

#### **4.3.3 Chronic cholecystitis**

Handling a case of chronic cholecystitis is not easy too. The scleroatrophic cholecystitis is a challenge for the surgeon owing to a totally contracted, fibrosed and densely covered gallbladder with adhesions. The anatomical identification of structures is difficult. The initial fundus grasping is difficult. It is mandatory that fundus be released off the adhesions carefully. The loss of tissue planes is a problem in these cases because of repeated attacks of acute inflammation. The gallbladder is sometimes filled with stones or is a stone in itself and the retraction becomes difficult. There are more chances of injury to the common bile duct in handling this eventuality. One needs to be tricky to handle such a situation. The surgeon needs to have first glimpse of the gallbladder by releasing the adhesions. Additional port placement may help in this case. The retrograde technique may be then performed but should be done carefully. Intraoperative cholangiography may be done, if possible. The cystic duct is usually thick walled and difficult to occlude by clips. One should either use an endoloop or transfix the cystic duct after milking the duct towards the gallbladder to displace any stone, if present.

#### **4.3.4 Cholecystoenteric fistula**

24 Advances in Laparoscopic Surgery

Operating on acute cholecystitis should always be under taken by an experienced surgeon. One day or the other, one may come across an acute gangrenous cholecystitis (figure 8). One should remove all the inflammatory adhesions from the fundus of the gallbladder. It is safe to proceed with high pressure hydro-irrigation applied through a suction cannula in order to open up planes which are then further dissected using a grasper and scissors with electrocautery; staying away from the duodenum at all the times. Most of the surgeons might not go to dissect till the common bile duct is visible. They strongly feel that the dissection should be limited to the neck of the gallbladder. Even after the removal of the gallbladder, one may encounter a profuse continuous bleed from the liver bed possibly due to opening up of one of the sinuses as the planes are not clear. We usually use 2x2 cm gauze piece and a surgicel is left over the sinus for a period of five minutes to curtail the crisis. The spilt stones are usually a problem in handling such gallbladders. We recommend using a sterile endobag, if available, to remove the specimen and the stones together. After removal

Handling a case of chronic cholecystitis is not easy too. The scleroatrophic cholecystitis is a challenge for the surgeon owing to a totally contracted, fibrosed and densely covered gallbladder with adhesions. The anatomical identification of structures is difficult. The initial fundus grasping is difficult. It is mandatory that fundus be released off the adhesions carefully. The loss of tissue planes is a problem in these cases because of repeated attacks of acute inflammation. The gallbladder is sometimes filled with stones or is a stone in itself and

**4.3.2 Acute gangrenous cholecystitis** 

Fig. 8. Acute gangrenous cholecystitis.

**4.3.3 Chronic cholecystitis** 

of the specimen, the port tract should be irrigated thoroughly.

This is an incidental finding during laparoscopic cholecystectomy and can account for 0.5- 7% cases done laparoscopically for biliary disease (figure 9).6 The diagnosis is suspected by noting the presence of air in the biliary tree associated with contracted gallbladder. The conditions where air is present within the biliary tree are infections by gas forming organisms, incompetent sphincter of Oddi, congenital anomalies, ERCP with sphincterotomy. Cholecystoduodenal, cholecystogastric and cholecystocolic are the common internal biliary fistulae. The common symptoms are pain, fever, diarrhea and jaundice. The most common cause for internal biliary fistulae is gallstones (90%) whereas; peptic ulcer, malignancy and trauma account for the rest 10% of the cases. Ultrasonography is useful and CT scan may show contracted, thick walled gallbladder with stones, pneumobilia and duodenal thickening. ERCP may localize the fistulous tract. Barium meal, enema and colonoscopy may be useful in the diagnosis.

Fig. 9. Cholecystoenteric fistula.

#### **4.3.5 Disorders of liver**

It is a challenge for the surgeon to perform laparoscopic cholecystectomy in a patient with hepatic disorders especially cirrhosis. In near past this used to be considered a relative

Laparoscopic Management of Difficult Cholecystectomy 27

We recommend an early cholecystectomy in a patient with multiple small stones to avoid recurrent bouts of pancreatitis. It may also be useful to categorize the patients into mild and severe degrees for directing appropriate management. Currently the best method to assess the severity of acute pancreatitis is contrast enhanced computed tomography scan. It is understood that biliary pancreatitis is due to a transient block of the ampulla of Vater by a migrating stone from gallbladder. It is a proven fact that the stone passes to the duodenum in majority of cases within hours of the onset of pancreatitis. If the acute process is increasing and reveals persistent obstruction, ERCP should be performed. Endoscopic sphincterotomy and extraction of the stone allows the acute pancreatitis to settle down. In mild pancreatitis laparoscopic cholecystectomy can be performed safely at the initial admission within first week depending on the condition of the patient. It is wise also to have an intraoperative cholangiogram as the risk of concurrent common bile duct stones is 14-20% associated with biliary pancreatitis. It may not be out of place to mention the value of MRCP and ERCP in severe cases. Currently an endoscopist and a laparoscopist work together to manage the problem of common bile duct stones as laparoscopic exploration of common bile duct is

Here the gallbladder wall is deposited with calcium. The prevalence in cholecystectomy specimens ranges from 0.06 – 0.08%. 7,8 It usually occurs in elderly persons with gallstones who are predominantly females. X-ray abdomen may show a calcified lesion in the right upper quadrant. Ultrasonography and CT scan rule out the presence of an associated carcinoma. It increases the risk of carcinoma gallbladder by 12.5 – 60%.4 However, it is still debatable. The removal of gallbladder is the treatment of choice. It is a technically demanding surgery. However, adequate care should be taken to prevent dissemination of malignant cells in the abdominal cavity and port site, if present. The specimen bags are

Carcinoma of the gallbladder is estimated to be present in 1% of cholecystectomy specimens. It is the most common malignancy of the biliary tract. It is usually common in females.4 85% of the cases are associated with the gallstones. It is recommended by the current medicine that a gallbladder polyp of more than 10mm size should undergo cholecystectomy.4 The smaller polyps should be followed up at 6 monthly periods and any increase in size is an indication for cholecystectomy. The incidental gallbladder carcinoma is diagnosed postoperatively by the histopathological examination of the specimen removed for the gallstone disease. During surgery it is advocated that the surgeon should avoid inadvertent disruption of gallbladder to avoid spillage of malignant cells into the peritoneal cavity and

We strongly believe that every difficulty has a loop-hole that needs to be exploited to ease down the procedure. Before embarking on difficult cholecystectomies, a surgeon needs to be trained in all the technical aspects of laparoscopy. A due care should be given to suturing

the gallbladder should be removed in an endobag to avoid portal metastasis.

considered a high risk procedure in the phase of acute biliary pancreatitis.

**4.3.7 Porcelain gallbladder** 

essential for gallbladder retrieval.

**4.3.8 Carcinoma gallbladder** 

**5. Conclusion** 

contraindication for the procedure as the mortality following cholecystectomy is 20 times more in cirrhotic than in non cirrhotic livers due to uncontrolled bleeding during surgery and deterioration of hepatic function in the postoperative period. With the passage of time, laparoscopic approach has now become the preferred procedure for symptomatic cholelithiasis in cirrhosis of liver in most of the hospitals. The reasons being that laparoscopy has an advantage of less blood loss, shorter operative time and a shorter length of hospitalization over the open approach. The liver function should be optimized before embarking on this procedure. The technical problems for the surgeon operating in the face of cirrhosis of liver are the adhesions with increased neovascularity, the problem of traction of liver, inadequate exposure of hilum, gallbladder bed with high risk of bleeding.

The periumblical collaterals might be a source of bleeding during initial trocar insertion. It is wise to use infraumblical route for Veress needle insertion. In case of portal hypertension the surgeon should alert himself and resort to minimum adhesiolysis. If possible, harmonic scalpel is effective in the process of adhesiolysis. If it is not available either bipolar cautery or clipping of the tortuous veins is highly recommended.

Retraction of liver may pose a problem to the surgeon as a result of hard fibrosis and contraction.

In situations where hilum cannot be exposed as a result of inadequate cranial traction on gallbladder the reasonable exposure should be obtained by lifting the body of the gallbladder instead of the fundus.

At times, the separation of posterior wall of the gallbladder from the liver bed is difficult or dangerous. In such circumstances, laparoscopic subtotal cholecystectomy or modified cholecystectomy is a sigh of relief to the surgeon.5 Herein, we leave the posterior wall of the gallbladder intact with the liver and the mucosa is removed either by mucosectomy or by electrofulgration.

For a safe outcome, we recommend that for laparoscopic cholecystectomy in a patient of cirrhosis of liver, the hepatic dysfunction needs to be addressed first. Harmonic scalpel is extremely useful compared to monopolar electrocautery. Bleeding from the gallbladder bed can be treated by argon plasma coagulation, if available or using surgicel as a packing material in bleeding sinuses of the liver. Lastly, cholecystostomy should not be ignored in situations where cholecystectomy is dangerous.

#### **4.3.6 Biliary pancreatitis**

This is one of the difficult situations a surgeon can encounter in dealing with gallstone disease. Patients may also harbor a common duct stone. The cholecystectomy should be performed in the recovery phase which is around 10-60 days.4 Any stone in the common bile duct detected by intraoperative cholangiogram or laparoscopic ultrasound can be managed simultaneously. In situations like progressive biliary obstructions, non responding cholangitis and drug resistant pancreatitis with a stone in the distal common bile duct, one should go for MRCP followed by ERCP. The technical problems in biliary pancreatitis for the surgeon is extensive adhesions, highly edematous cystic pedicle and hepatoduodenal ligament, presence of ascitic fluid, pseudocystic pancreas in retrogastric position. In situations like these, interval cholecystectomy is advised.

contraindication for the procedure as the mortality following cholecystectomy is 20 times more in cirrhotic than in non cirrhotic livers due to uncontrolled bleeding during surgery and deterioration of hepatic function in the postoperative period. With the passage of time, laparoscopic approach has now become the preferred procedure for symptomatic cholelithiasis in cirrhosis of liver in most of the hospitals. The reasons being that laparoscopy has an advantage of less blood loss, shorter operative time and a shorter length of hospitalization over the open approach. The liver function should be optimized before embarking on this procedure. The technical problems for the surgeon operating in the face of cirrhosis of liver are the adhesions with increased neovascularity, the problem of traction

The periumblical collaterals might be a source of bleeding during initial trocar insertion. It is wise to use infraumblical route for Veress needle insertion. In case of portal hypertension the surgeon should alert himself and resort to minimum adhesiolysis. If possible, harmonic scalpel is effective in the process of adhesiolysis. If it is not available either bipolar cautery

Retraction of liver may pose a problem to the surgeon as a result of hard fibrosis and

In situations where hilum cannot be exposed as a result of inadequate cranial traction on gallbladder the reasonable exposure should be obtained by lifting the body of the

At times, the separation of posterior wall of the gallbladder from the liver bed is difficult or dangerous. In such circumstances, laparoscopic subtotal cholecystectomy or modified cholecystectomy is a sigh of relief to the surgeon.5 Herein, we leave the posterior wall of the gallbladder intact with the liver and the mucosa is removed either by mucosectomy or by

For a safe outcome, we recommend that for laparoscopic cholecystectomy in a patient of cirrhosis of liver, the hepatic dysfunction needs to be addressed first. Harmonic scalpel is extremely useful compared to monopolar electrocautery. Bleeding from the gallbladder bed can be treated by argon plasma coagulation, if available or using surgicel as a packing material in bleeding sinuses of the liver. Lastly, cholecystostomy should not be ignored in

This is one of the difficult situations a surgeon can encounter in dealing with gallstone disease. Patients may also harbor a common duct stone. The cholecystectomy should be performed in the recovery phase which is around 10-60 days.4 Any stone in the common bile duct detected by intraoperative cholangiogram or laparoscopic ultrasound can be managed simultaneously. In situations like progressive biliary obstructions, non responding cholangitis and drug resistant pancreatitis with a stone in the distal common bile duct, one should go for MRCP followed by ERCP. The technical problems in biliary pancreatitis for the surgeon is extensive adhesions, highly edematous cystic pedicle and hepatoduodenal ligament, presence of ascitic fluid, pseudocystic pancreas in retrogastric position. In

of liver, inadequate exposure of hilum, gallbladder bed with high risk of bleeding.

or clipping of the tortuous veins is highly recommended.

contraction.

electrofulgration.

**4.3.6 Biliary pancreatitis** 

gallbladder instead of the fundus.

situations where cholecystectomy is dangerous.

situations like these, interval cholecystectomy is advised.

We recommend an early cholecystectomy in a patient with multiple small stones to avoid recurrent bouts of pancreatitis. It may also be useful to categorize the patients into mild and severe degrees for directing appropriate management. Currently the best method to assess the severity of acute pancreatitis is contrast enhanced computed tomography scan. It is understood that biliary pancreatitis is due to a transient block of the ampulla of Vater by a migrating stone from gallbladder. It is a proven fact that the stone passes to the duodenum in majority of cases within hours of the onset of pancreatitis. If the acute process is increasing and reveals persistent obstruction, ERCP should be performed. Endoscopic sphincterotomy and extraction of the stone allows the acute pancreatitis to settle down. In mild pancreatitis laparoscopic cholecystectomy can be performed safely at the initial admission within first week depending on the condition of the patient. It is wise also to have an intraoperative cholangiogram as the risk of concurrent common bile duct stones is 14-20% associated with biliary pancreatitis. It may not be out of place to mention the value of MRCP and ERCP in severe cases. Currently an endoscopist and a laparoscopist work together to manage the problem of common bile duct stones as laparoscopic exploration of common bile duct is considered a high risk procedure in the phase of acute biliary pancreatitis.

#### **4.3.7 Porcelain gallbladder**

Here the gallbladder wall is deposited with calcium. The prevalence in cholecystectomy specimens ranges from 0.06 – 0.08%. 7,8 It usually occurs in elderly persons with gallstones who are predominantly females. X-ray abdomen may show a calcified lesion in the right upper quadrant. Ultrasonography and CT scan rule out the presence of an associated carcinoma. It increases the risk of carcinoma gallbladder by 12.5 – 60%.4 However, it is still debatable. The removal of gallbladder is the treatment of choice. It is a technically demanding surgery. However, adequate care should be taken to prevent dissemination of malignant cells in the abdominal cavity and port site, if present. The specimen bags are essential for gallbladder retrieval.

#### **4.3.8 Carcinoma gallbladder**

Carcinoma of the gallbladder is estimated to be present in 1% of cholecystectomy specimens. It is the most common malignancy of the biliary tract. It is usually common in females.4 85% of the cases are associated with the gallstones. It is recommended by the current medicine that a gallbladder polyp of more than 10mm size should undergo cholecystectomy.4 The smaller polyps should be followed up at 6 monthly periods and any increase in size is an indication for cholecystectomy. The incidental gallbladder carcinoma is diagnosed postoperatively by the histopathological examination of the specimen removed for the gallstone disease. During surgery it is advocated that the surgeon should avoid inadvertent disruption of gallbladder to avoid spillage of malignant cells into the peritoneal cavity and the gallbladder should be removed in an endobag to avoid portal metastasis.

#### **5. Conclusion**

We strongly believe that every difficulty has a loop-hole that needs to be exploited to ease down the procedure. Before embarking on difficult cholecystectomies, a surgeon needs to be trained in all the technical aspects of laparoscopy. A due care should be given to suturing

**3** 

*Korea* 

Jin-Young Jang

**Laparoscopic Pancreatic Surgery** 

*Department of Surgery, Seoul National University College of Medicine, Seoul,* 

Pancreatic surgery has higher morbidity and mortality than other forms of gastrointestinal tract surgery, due to associated problems like pancreatic fistula formation and loss of pancreatic function. Until recently laparoscopic surgery of the pancreas was limited to laparoscopic staging or to the evaluation of periampullary cancer for detecting small metastatic nodules or local invasion (Jang et al., 2007; Schachter et al., 2000). Advances in laparoscopic techniques and instrumentation have expanded the role of laparoscopic surgery to a degree that could not have been imagined such as Whipple's procedure

Recent reports on laparoscopic surgery of the pancreas are encouraging and support the advantages of laparoscopy. We believe that well selected enucleation and laparoscopic distal pancreatectomy, with or without spleen preservation, are acceptable and recommendable for the treatment of benign or low grade malignant diseases of the pancreas. Moreover, surgeons and laparoscopic industries have developed new techniques and devices that increase convenience, ease, and safety of complicated laparoscopic surgeries, and these efforts will undoubtedly increase the role of laparoscopic or minimal invasive surgery for

In this chapter, we will discuss the current status of the laparoscopic pancreatic surgery and

Although laparoscopic pancreatic surgery is considered to be an advanced and demanding procedure, many surgeons have tried laparoscopic distal pancreatectomy due to its technical simplicity and its avoidance of the need for anastomosis as compared with other difficult pancreatectomy (Table 1) (Weber et al., 2009; Mabrut et al., 2005; Melotti et al., 2007; Vijan et al., 2010; Fernandez-Cruz et al., 2007; Røsok et al., 2010; DiNorcia et al., 2010; Jayaraman et al., 2010; Kooby et al., 2008; Song et al., 2011; Velanovich, 2006; Misawa et al., 2007; Teh et al., 2007; Kim et al., 2008; Matsumoto et al., 2008; Eom et al., 2008; Nakamura et al., 2009).

Most of reports demonstrate the feasibility of laparoscopic approach with acceptable

the role of its associated procedures for the treatment of pancreatic disease.

**1. Introduction** 

(Gagner & Gentileschi, 2001).

the treatment of pancreatic disease.

morbidity (10~30%) and nearly no mortality.

**2. Pancreatic resection 2.1 Distal pancreatectomy** 

skills. Every gallbladder should be dealt with as if the surgeon, regardless of the experience, is operating on the first gallbladder. The general principles in laparoscopy and the critical view of safety should always be born in mind. The theatre staff especially the cameraman should be properly trained. The instruments should be quite friendly and a surplus of them should be available. The surgeon should have had a good amount of experience with simple gallbladders before handling the difficult ones. With the advent of gratifying improvements in the imaging technology, instrumentation and innovative techniques, the difficult gallbladders now fall in the domain of simple surgeries. However, the intrinsic error in the surgical technique cannot be avoided and whenever it comes onto that, open approach should always be given a weightage.

#### **6. References**

[1] Mushtaq Chalkoo.,2009. Laparoscopic Cholecystectomy in a Mucocele of Gallbladderwith a Phrygian Cap- A Case Report,[online]. Available at: web address:

http://www.google.co.in/search?sourceid=chrome&ie=UTF8&q=phyicians+acade my+online+mushtaq+chalkoo

