New aspects in laparoscopic cholecystectomy.

BACKGROUND

Laparoscopic cholecystectomy is the gold standard access. The aim of this study was to increase the safety of the procedure by using four new aspects.

METHODS

In this prospective study on 200 cases, four important points were used as a new technique to increase the safety of the operation, including: (1) Choosing the place of trocars, based on the ergonomic rule, which specifies a 120-degree angle between the two trocars in the surgeon's hands from outside and the trocar related to the telescope, and a 7-10-cm distance between each trocar and the position of the telescope and at least a 15-20-cm distance between the position of the telescope and the gallbladder, which is individualized in each case; (2) Starting with dissection from the Hartman's pouch at first and after encircling the Hartman's pouch, continuing to the cystic duct and artery to decrease the unavoidable risk of iatrogenic trauma to these structures (extensive dissection); (3) Ligating the cystic duct and artery by intracorporeal suturing to decrease the risk of bile leakage, ductal trauma, cystic artery bleeding, or inversion of clips into the duct; and (4) Removing the gallbladder through the umbilical trocar site to limit the number of trocars to three 5-mm trocars and one 10-mm trocar and also improving the cosmetic result.

RESULTS

All of the cases were chosen without any selection, but only 200 cases were analyzed because of the lack of data in the remaining 30 cases. In 20 of 200 cases, this technique was not practical in one or more of the above-mentioned aspects. Using ergonomic rules to select the sites of trocars made the operation easy and more convenient for the surgeon. One case of major bile duct trauma was reported in this study, compared to up to 4% of the classic form, confirms the importance of an extensive dissection in the Hartman's pouch. Ligation by suturing had not any leaking or bleeding, postoperatively, compared to up to 2.5% in the classic method. The cosmetic result was superior because of the deletion of subxiphoid trocar and our changing of one 10-mm trocar to a 5-mm trocar.

CONCLUSIONS

Using the above-mentioned new aspects is effective in decreasing the risk of ductal trauma or bile leak. Greater convenience for the surgeon as well as superior cosmetic results were evident, although this procedure requires great expertise during the operation.