Operative Strategies in Laparoscopic Surgery
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We also emphasize on the technique used for closure of the cystic duct with clip, two clips applied on the proximal part of the CD and one clip used on distal side. If space is less or CD is shorter, in these cases we applied clip obliquely away from the common bile duct. In group A, silk was tie applied and assured that it should not be loose to prevent any leakage. Another advantage of silk is that, it can be tied close to the common bile duct CBD.
Drain will be kept in all the patients in sub hepatic area. A total number of patients selected randomly and divided into two groups A and B. Patients in whom cystic pedicle was ligated using suture were assigned group A 60 cases , and the one in whom ligaclips were used were named under group B 60 cases. In group A, there were 24 males and 36 females, whereas in group B there were 23 males and 37 females. Both groups had cholelithiasis and acute attack was excluded using history, clinical examination and pre-operative imaging.
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Patients in whom cystic pedicle was ligated using suture were assigned group A, and the one in whom ligaclips were used were named under group B. Only in three cases there was bile in the discharge which remains only for four days. The mean operative time less in whom cystic artery and duct was closed with titanium clips as compared to the silk ligature which was significant. There were no major differences seen in both groups in terms of inpatient stay, post-operative complications and safety of the procedure Table 1 and 2.
Hospital stay in both groups was same i. On next day patient was allowed orally sips of water and by evening full diet and planned for discharge on 2 nd day of surgery. In four cases hospital stay was three to four days. The ligation with suture needs more expertise than the clip application. Silk has the more advantageous over the clip, as it will be cost-effective, economical and available freely especially in rural area.
So, the surgeon should be well versed with both methods Figure 1 and 2.
Operative Strategies in Laparoscopic Surgery
All patients observed post-operatively for any fever, wound infection, haemorrhage, any intra-abdominal collection and the length of stay in hospital. There were no major complications seen in both groups. Patients were followed for two weeks and would be inquired about fever, vomiting, scar pain or any collection inside the abdomen.
We compared the results of both studies in view of efficacy, safety, complications, cost-effectiveness and hospital stay. In both studies there were no complications seen except for the little prolonged timing in group A as compared to other group. Figure 1.
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Operative picture showing ligating the cystic duct and artery separately. Figure 2. Section revealed two cut parts as cystic duct and artery along with silk tie. Cholelithiasis and its consequences are the main cause of surgical entry into the peritoneal cavity. So widespread is this entity that it will not be out of place to say that cholecystectomy is routinely done. They stated that the CD ligation is safe, possible, practical and cost effective. They observed no leakage of bile from CD stumping where the harmonic scalpel was used.
Other alternate techniques include linear stapler, endoloops, knots, harmonic scalpels. Their study observed the harmonic scalpel can be used to shorten the duration of surgery and cost saving that is inherent in a technique using it as a single device. Another study stated that harmonic scalpel is useful to control the bleeding.
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The closure of cystic duct with newer methods may be an alternative to surgical clips. The time required for tie was varied from minutes. It will make feasible, easy for the surgeons to perform surgery that will show better cosmetic. They observed that CD leaks commonly seen in LC than open cholecystectomy. The purpose was to evaluate the bipolar sealing system ligature for closure of CD.
They declared that in LC, ligature was quick and helpful for closure and separation of cystic duct.
Operative Strategies In Laparoscopic Surgery
Various papers emphasize the role of ultrasound dissection in LC, where ultrasonic devices have been applied in removal of the gallbladder. LC is the commonly accepted technique which routinely used with conventional laparoscopic instruments. The harmonic scalpel is effective and advantageous over to clip application for closure of the CD. The opening pressure in cystic duct was more In LC different energy source instruments may be safe to use with a cautious dissection and sealing of the cystic duct.
They analysed the impact of coagulation instrument devices used during gallbladder removal.
We observed that silk suture is safe, cost effective but it required training as compared to clip application. But for clip application you required clip applicator which is again costly. There may be chances of slippage of clips or it may cause stricture formation if it involved the wall of the CBD though in our study we have not encountered such complications.
At end, the use of ligatures instead of ligaclips for LC, especially the interest in expanding its realization in rural areas with fewer resources. Mullana, Distt-Ambala Pin! Etiquetas Manuscritos Originales. Bemelman amc. That laparoscopic surgery alone or in combination with fast track peri-operative care is to be preferred over open surgery with standard care in patients having segmental colectomy for malignant disease.
Multicentre randomised double-blind active controlled parallel group trial. Total post-operative hospital stay including readmission within 30 days 2.
Medical and non-medical costs. Morbidity 2. Patient satisfaction measured by standardised questionnaires 3.
Readmission percentage. Aged between 40 and 80 years 2. Colorectal cancer including colon and rectosigmoid cancers 3. Informed consent. Prior midline laparotomy 2. Laparoscopic surgeon not available 4.