Digestive Diseases

Biography

Biography: Nagendra Prasad

Abstract

Laparoscopic cholecystectomy is one of the most commonly performed laparoscopic surgeries worldwide. The spectrum of the disease ranges from simple symptomatic cholelithiasis with minimal edema, adhesions in calots triangle, ruptured and gangrenous gallbladder with dense adhesions involving stomach, transverse colon and anterior abdominal wall to Mirrizzi Syndrome. There is no uniform consensus as to predictors of preoperative difficult GB and conversion to open cholecystectomy. Few indicators have been proposed but they are not applicable in all the cases leaving a room for intra-operative surprises. Few of the preoperative indicators established from various studies in literature are thickened gall bladder wall (> 4 mm), presence of palpable tender mass and raised TLC along with deranged LFT in my experience of more than 400 cases, few other indicators as predictors of preoperative difficulty and possible conversion to open cholecystectomy have been noticed. Male gender, multiple attacks and increasing periodicity of attacks, presence of cholangitis and gall stone pancreatitis, post ERCP, presence of elevated liver enzymes, initial severe first attack and palpable tender mass are predictors on history and examination. Raised temperature >100°F; elevated TLC>10000; altered LFT, pericholecytic fluid and free fluid in Morrison’s pouch (however minimal), contracted GB, cirrhotic liver, impacted stone at Hatmann’s pouch are suggestive of difficult laparoscopic cholecystectomy. A previous surgery only increases the difficulty for entering abdomen but actually does not mean difficult GB dissection. All said and done, even in the absence of above findings, one might encounter difficult gall bladder dissection, hence every case has to be treated on its individual merit and one should always be ready for a difficult dissection.