Outcomes of laparoscopic cholecystectomy in acute cholecystitis

Objective: To study the morbidity and mortality of early laparoscopic cholecystectomy in acute cholecystitis by comparing its results with laparoscopic cholecystectomy in chronic cholecystitis and simple cholelithiasis

Study Design: Quasi-experimental study

Place and Duration of Study: Pakistan Naval Ship [PNS] Shifa Hospital Karachi and Combined Military Hospital [CMH] Lahore Pakistan, from Nov 2009 to Jan 2013

Material and Methods: Total 398 patients with symptomatic gall stone disease were included in the study after exclusion of patients with upper abdominal surgery, perforated gallbladder with abscess formation, cardiopulmonary disease, equipment failure and those with choledocholithiasis. Cholecystectomy was performed using a three port technique in most of the cases. On the basis of per-operative findings regarding degree of inflammation of gallbladder, all patients were divided into three groups irrespective of duration of symptoms i.e. acute cholecystitis group, chronic cholecystitis group and no inflammation group. The collected data included age, sex, diagnosis, history of previous surgery, co-morbidities, conversion to open surgery and its reasons, operative time, post-operative hospital stay and complications. Statistical comparison was performed using the chi square test. Statistical significance with value of p was less than 0.05 was considered significant

Result: Out of 398 patients, 31.2% had acute cholecystitis, 10.1% had chronic cholecystitis and 58.8% had no inflammation of gall bladder. Complication rates and conversion rates were higher in chronic cholecystitis group as compared to acute cholecystitis group and no inflammation group. Similarly, mean hospital stay was also highest in chronic cholecystitis group

Conclusion: Early laparoscopic cholecystectomy was found safe in acute cholecystitis in expert hands and should be performed in all cases of acute cholecystitis rather than delayed interval cholecystectomy

Validity of modified alvarado scoring system [mass] in the diagnosis of acute appendicitis

Objective: To determine the validity of Modified Alvarado Scoring System [MASS] in the diagnosis of acute appendicitis. Study Design: Cross sectional validation study. Place and Duration of Study: Department of Surgery Combined Military Hospital [CMH] Kohat Pakistan, from Nov 2013 to Oct 2014

Material and Methods: A total of 248 patients fulfilling the inclusion criteria were enrolled in the study after getting the informed written consent. Modified Alvarado Score of all patients was calculated on a proforma which included migratory right iliac fossa pain, anorexia, nausea/vomiting, tenderness in right iliac fossa, rebound tenderness, elevated temperature and leucocytosis [>10 x 109/L]. Surgeries were performed by residents and consultant surgeons. Decision to operate upon was not only on the MASS of the patients rather it was on overall clinical condition of the patients using different scoring systems. Where required aid of different laboratory investigations, ultrasonography, CT scan and laparoscopy was also taken. After surgery histopathological examination of resected specimens was performed. Pre operative modified alvarado score and post operative histopathological results were endorsed on a proforma. A two by two table was used to determine the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of MASS

Results: Out of total 248 patients, 183 [73.8%] patients were males and 65 [26.2%] were females. Male to female ratio was 2.8:1. Sensitivity of MASS in this study was 89.39%, Specificity 84.06%, positive predictive value 93.57%, negative predictive value 75.32% and diagnostic accuracy was 87.90%

Conclusion: Modified alvarado score is a highly sensitive test with fair degree of specificity for the early diagnosis of acute appendicitis especially in the adults. It is particularly helpful for young doctors and in the peripheral hospitals where more sophisticated investigations are not available

Rate and reasons of conversion of laparoscopic cholecystectomy to open cholecystectomy? A prospective analysis of 450 consecutive laparoscopic cholecystectomies

Objective: To assess the rate and causes of conversion of laparoscopic to open cholecystectomy [OC] in 450 patients who underwent laparoscopic cholecystectomy [LC] by the same surgeon in tertiary care teaching hospitals

Study Design: Descriptive study

Place and Duration of Study: The study was conducted initially at Pakistan Navalship [PNS] Shifa, Karachi and later at Combined Military Hospital, Lahore from November 2009 to June 2013

Material and Methods: All the patients of both genders and of any age group, undergoing LC for gall bladder pathology whether acute or chronic, acalculous or calculous were included in this study by convenient sampling. The exclusion criteria were choledocholithiasis, malignancy, and patients who willingly opted for open cholecystectomy. All the patients were operated by the same experienced laparoscopic surgeon. The number and sizes of the ports varied from patient to patient and was on the choice of the operating surgeon. A detailed proforma was filled which included the demographic data of the patients, indications for cholecystectomy, histories of previous abdominal surgery, their comorbidities [if any], operating time, intraoperative findings, complications, post-operative hospital stay and rate and reasons for conversion to open cholecystectomy [if required]

Results: Out of 450 consecutive patients for whom LC was attempted by a single surgeon, 7 patients [1.6%] were converted to OC. There were 380 female and 70 male patients [F: M ratio 5.4:1]. Their mean age was 44.6 +/- 13.5 years, ranging from 9-82 years. All patients who required conversion to OC were females. The mean operating time was 38.9 +/- 16.2 minutes [range 15-120 minutes]. The reasons for conversion included cystic artery bleeding2, liver bed bleeding1, common hepatic duct injury1, cholecystoduodenal fistula1, severe adhesions caused by tissue inflammation and fibrosis of Calot's triangle1 and cystic duct avulsion1

Conclusion: The overall rate of conversion to OC was 1.6%. Laparoscopic cholecystectomy is a safe procedure with very little chances of conversion to open even in acute cases, when performed by an experienced surgeon

Comparison of direct trocar insertion with other techniques for laparoscopy

Objective: To assess the safety of direct trocar insertion [DTI] before creating pneumoperitoneum in laparoscopic procedures

Study Design: An observational study

Place and Duration of Study: Combined Military Hospital [CMH] Kohat, Pakistan from November 2013 to January 2015

Methodology: All the cases undergoing laparoscopy at the study centre in the above duration were included in the study after approval from the Hospital Ethical Committee and informed written consent. Out of the 200 cases, DTI was successfully used to establish peritoneal access in 190 cases, while open Hassen's technique [OL] was used in ten cases. Body mass index [BMI] of all the patients was calculated before surgery. All the cases were performed under general anaesthesia with adequate relaxation. A 10 mm permanent re-useable sharp metallic trocar was inserted through umbilical scar after lifting the abdominal wall using towel clamps. Studied variables included age, gender, BMI, operations, history of previous surgery, number of attempts for DTI and complications

Results: Mean age of the patients in DTI group was 46.58 +/- 13.94 years, while 48.70 +/- 10.08 years in OL group. Female to male ratio in DTI group was 1.43:1; and 2.33:1 in OL group. Increase in BMI had a relation with number of unsuccessful attempts of DTI, so obesity was the main reason of failure of DTI

Conclusion: DTI is a safe and effective method of peritoneal access for laparoscopy with very low failure rate related to BMI and minimal complications

Complications of laparoscopic cholecystectomy: an analysis of 400 consecutive cases

To analyze the complications of first 400 laparoscopic cholecystectomies [LC] for patients with symptomatic gall stone disease at a tertiary care hospital. Quasi-experimental study. PNS Shifa Karachi and CMH Lahore, Pakistan from Nov 2009 to Jan 2013. A prospective analysis of complications occurring in first 400 consecutive laparoscopic cholecystectomies by a single consultant/ unit at a tertiary care hospital was made. Out of total 421 patients presenting with symptomatic gall stone disease in a single unit, 21 cases that underwent open cholecystectomy were excluded from the study. Laparoscopic Cholecystectomies were performed using three port and four port technique and data including age, sex, diagnosis, number of trocar placements, conversion to open surgery and its reasons, operative time, post-operative hospital stay and complications was collected on personal computer and analyzed using Statistical package for social sciences [SPSS] version 13. Total 400 patients were included in study with median age of 44 years. Female to male ratio was 5.3: 1. Depending upon the preoperative diagnosis and laparoscopic findings, patients had diagnosis of Chronic cholecystitis/ biliary colic 68.25%, acute cholecystitis 23.75%, empyema gall bladder 7.25%, gallstone pancreatitis 0.5% and mucocele gallbladder 0.25%. Median operating time was 30 min. Median hospital stay was 1 days [range 1- 20 days]. Conversion rate was 1.25%. Postoperative complications included bleeding 0.5%, biliary peritonitis due to cystic duct leak 0.25%, biloma 0.25%, sub hepatic abscess 0.25%, subcutaneous fat necrosis right flank at drain site 0.25%, umbilical trocar site infection 2%, keloid at umbilical port site 0.25% and incisional hernia at umbilicus 0.25%. There was one hospital death due to myocardial infarction on 2[nd] post-operative day. Laparoscopic Cholecystectomy is associated with some serious complications which can be avoided with adequate training of surgeons as well as knowledge of mechanism of typical complications