Laparoscopic cholecystectomy : One surgeon ' s experience in 100 consecutive cases

IJ POKORNY. Laparoscopic cholecystectomy: One surgeon's experience in 100 consecutive cases. Can J Gastroenterol 1994;8(4):277,278. Initial 100 consecutive laparoscopic cholecystectomies performed by one surgeon were studied prospectively. The standard technique was modified in that the gallbladder removal was accomplished through the upper epigastric incision; there was no need to change the location of the camera. The conversion rate co open cholecystectomy was 2%. There were no major complications and no mortality. Minor complications occurred in 9% of che patients. Laparoscopic cholecysteccomy can be performed safely in a community hospital setting. Simplified technique of gallbladder extraction is recommended.

A ITER IN IT I AL SCEPTIC ISM, LAP- aroscop1c cholecystectomy is becoming the method of choice in the surgical treaLment of symptomatic gallbladder disease.Avoidance of abdominal incision, particularly in the recrus muscle and fascia!transection, as well as relatively minimal intraperironeal visceral manipulation , seem to lead to d ramaticall y improved postoperati ve recovery.
Laparoscopic cho lecystectomy requi.resspecial tra ining and experience, but can be mastered by most general surgeons performing biliary surgery.
As in other procedures, surgeon per- The standard method of laparoscopic cholecystectomy was modifi ed in that the ext raction of the gallbladder is carried out through the upper midline epigastric incision without changing the location of the camera at the umbilicus; this simplifies the procedure and does not lead co increased morbidity.

RESULTS
One hundred patients underwent laparoscopic c ho lecystectomy without major complications.Complications encountereJ were pncumothornx, one patient; subheparic hematoma, four; pneumonia, one; alcoholic withdrawal, two; and bile collection, one.The conversion rate was 2%.A drain was used in six cases (JV AC Quad lumen 1/8 inch).lmlicatio ns for drainage were difficulty dissecting in acute cholecystitis and increased oozing from gallbladder bed of blood o r bile.
The postoperative stay ranged from one to 30 days.Operaling time ranged from 30 to 360 mins (average 55 mins).

DISCUSSION
Laparoscopic cholecy~tectomy was adopted for elective cholecystectomy.The procedure was readily learned and after the first few cases generall y became easy co perform.As with a ll biliary surgery, careful dissection a nd recognition of artatomicu l structure~ in the operative area are essential to avo id potentially serious complications.The patients were also happy with the results -they recovered much faste r, left the hospita l ea rlier and returned to work after two to three weeks.
O Indications fur intraoperative cholangiography include history of jaundice, pancreatitis, ahnormal elevation of liver function Lesrs and ahnorm.ildilation of common bile duct.Routine cholangiography in all case~ is unnecessary.
The standard technique was modified in that the gallhla<lder was removed through the upper midline epiga~tric opening.This avoided changing rhe posit ion of the camera and saved some operative time.There were no comp I icmions related t.o this c hange of technique.
Overall experience with laparoscopic cholecystectomy is very favourahle.Mosr ge neral surgeons would agree that it has now replaced elective open cholecystcctomy.Resulb reported in the literature a lso suggest that laparoscopic cholecystectomy should be universally accepted as the method of choice for elective c ho lecystectomy for t he appropriate indications.

SUMMARY
Laparoscopic ch olecystectomy was used in the treatment of c h olelithiasis a nd chronic gallbladder disease in 100 consecut ive cases.All procedures were done by the same surgeon in a comm un ity hospita l setting.The technique of gallbladder extraction was modified in that Lhe ga llbladder wa~ removed t hrough t he upper epigastric incision.There was no mortality anJ very minimal morbidity.Both patient and surgeon satisfaction indices were high.The procedure is recommended as tbe method of ch oice for gallbladder removal in Lhe absence of contraindications.
d ifficult.ln these cases, the procedure required gradual careful dissection with mobilization of the adhesions and meticulous dissection of the cystic artery and cystic duct before clipping these structures.A lthough laparoscopic chol-POKORNY ecyscecromy is undoubteJly more diffi- ne case o( postoperative pneumo-