Direct Trocar Insertion: an Efficient Access Technique for Laparoscopic Cholecystectomy

Aim: To evaluate the feasibility and safety of direct trocar insertion for gaining access to peritoneal cavity in laparoscopic cholecystectomy. Methods: An Observational study was conducted at Surgical unit II Ghulam Mohammad Mahar Medical College Hospital Sukkur from January 2016 to December 2020. Two thousand one hundred twenty (n=2120) patients were included in the study. All the patients who underwent laparoscopic cholecystectomy were included in the study. Informed and written consent was obtained from every patient to participate as study subject. Data was analyzed on SPSS version 16. Mean +/- standard deviation was calculated for age, first port access time and time to establish pneumoperitoneum. Results: Under general anesthesia with patient in supine posture, abdominal access gained by first making small incision of 10mm in skin and subcutaneous fat at sub umbilical region with No. 11 scalpel and then by direct trocar insertion followed by creation of pneumoperitoneum. Cholecystectomy performed. Study variables included first port access time, no. of attempts for DTI, extraperitoneal CO2 insufflation, port site bleeding, visceral injury, port site infection and port site hernia and were recorded on predesigned proforma. Variables like extraperitoneal CO2 insufflation, port site bleeding and visceral injury were expressed as percentage. Conclusion: We conclude that direct trocar insertion is the safe, quick and effective method for creation of pneumoperitoneum and should be employed routinely in all laparoscopic procedures. Keywords: Laparoscpy, Cholecystectomy, Trocars

344 Managing Clinical Rarities: A Unique Case of Non-Inflamed Appendix in A Port Site Hernia

Introduction Port site hernias containing the appendix are sporadically described in the literature, with most cases presenting with acute appendicitis. Cases of a normal appendix being found in such hernias are extremely rare and rarely published. Here we describe a patient with a port site hernia containing a non-inflamed appendix. The lack of similar recorded cases makes this a unique case to highlight and discuss. Case Description 81-year-old lady, with adenocarcinoma of the upper rectum, underwent a laparoscopic high anterior resection in late 2018. With 12 mm ports placed in Umbilicus and RIF. 5mm ports placed in RUQ and LUQ. The 12 mm ports were closed with deep suture closure and the skin was closed using clips. Computerised tomography (CT) imaging at one year showed local cancer recurrence and a small abdominal wall hernia in the right iliac fossa. During subsequent resection surgery, a RIF port site hernia was identified intraoperatively. The hernia sac consisted of an uninflamed appendix. The hernia was reduced and an appendicectomy was performed with the hernia being closed with interrupted suture closure. Histology of the appendix confirmed no evidence of inflammation. Discussion When a clinical rarity is encountered there is often minimal literature to guide management and decisions must be made based on surgical principles and clinical reasoning. Although here an appendicectomy was performed, resection of a normal appendix remains a contentious point in the surgical field. This case demonstrates a potential management option to guide surgeons who encounter this clinical rarity in their future practice.

Complications of Laproscopic Cholecystectomy in Patients of Acute Cholecystitis

Objective: To determine the complications of laparoscopic cholecystectomy in patients of acute cholecystitis. Study Design: Prospective study. Place & Duration: Department of Surgery, Lady Reading Hospital, Peshawar for duration of six months from January 2020 to June 2020. Methods: Total 120 patients of both genders with ages 20 to 60 years were included in this study. Patients’ detailed demographics were recorded after taking written consent. Patients with history of abdominal surgery were excluded. All the patients underwent laparoscopic cholecystectomy for gall bladder diseases. Post-operative pain was analyzed by VAS. Complications were recorded at 5th postoperative day. Data was analyzed by SPSS 24.0. Results: Out of 120 patients 30 (25%) patients were males and 75% patients were females. Most of the patients 50 (41.67%) were in the age group 31 to 40 years followed by 37 (30.83%) patients were ages between 41 to 50 years. 70 (58.33%) patients had surgical size port incision was 5mm and 50 (41.67%) patients had 10mm. Mean pain score was 2.24+1.1 at 5th postoperative day. Wound infection was found in 10 (8.33%). Port site hernia was found in 12 (10%). Conclusion: Laparoscopic cholecystectomy is safe and effective treatment procedure with no major complications. Keywords: Laparoscopic Cholecystectomy, Acute Cholecystitis, Wound Infection, Port Site Hernia, Pain

Minimally invasive peritoneal dialysis catheter insertions with concomitant cholecystectomy or hernioplasty: Surgical technique and our experiences

Introduction: Peritoneal dialysis is a well-accepted replacement therapy in patients with end-stage renal disease. There are many different options adopted on how to insert a peritoneal dialysis catheter. In our institution, a laparoscopic insertion has become the method of choice for providing peritoneal dialysis access in adult patients. The aim of this study was to analyze surgical outcomes of patients after laparoscopically assisted placement of a PD catheter some of them after concomitant cholecystectomy or hernioplasty. Methods: We have evaluated 70 consecutive patients from 1st of October 2015 to 30th of April 2020 who underwent laparoscopic insertion of a peritoneal dialysis catheter. Demographic data, details about surgery and about peri- and postoperative complications were gathered. Results: Out of 70 enrolled patients, 15 had gallstones (21%) and underwent concomitant laparoscopic cholecystectomy. Three patients (4%) had abdominal wall hernia and underwent concomitant hernioplasty. We observed no perioperative complications connected with any of the performed procedures. There was one early postoperative complication: an early leak of dialysate fluid. Late complications were observed in nine patients (13%): mechanical catheter problems (two patients), peritonitis (three patients), skin exit-site infections (two patients), peri-catheter leak (one patient), and port-site hernia (one patient). Conclusions: For all patients with concomitant gallbladder disease or abdominal wall hernias we suggest to perform synchronous surgeries, due to finding no more complications after concomitant procedures in comparison to patients in whom only a PD catheter was inserted. Concomitant procedures are done to spare patients two separate procedures and to avoid possible complications. We also suggest using the cholecystectomy first, PD catheter insertion second approach for having excellent peri- and postoperative results.

Pseudomyxoma peritonei presenting with port site hernia

Pseudomyxoma peritonei (PMP) is a rare disease with an incidence of two per million. Acute appendicitis, ovarian mass, and abdominal distension are the most common presentations. A 72-year-old male patient with a history of laparoscopic cholecystectomy was admitted to the hospital with abdominal pain and increased supraumbilical port site swelling. Radiological examination revealed a mass in the terminal ileum and severe intraabdominal mucinous fluid. Intraabdominal gelatinous fluid protruding from the port site defect and a mass in the distal ap-pendix were observed during operation. He underwent a right hemicolectomy, ileocolic anasto-mosis and peritoneal debridement; cytoreductive surgery was administered two months later due to mucinous tumor of the appendix. There are only a few case reports describing PMP presen-ting with an incisional hernia after open surgical procedures. To the best of our knowledge, this report describes the first case of PMP presenting with a port site hernia after a laparoscopic in-tervention.

Assessment of Port Site Complications in Laparoscopic Surgery – A Prospective Descriptive Study from Western Odisha

BACKGROUND Laparoscopic surgery has brought about a paradigm shift in modern surgical care. It has varied applications in gastrointestinal surgery, urological surgery, gynaecological surgery and oncosurgery. Better cosmesis, less post-operative pain, hence reduced need for post-operative analgesia, shorter recovery period and faster return to daily activities are its advantages. However, certain complications like port site infection, hemorrhage, hernia, TB or metastasis are morbid complications that undermine its benefits. In this study, we wanted to identify the various port site complications in patients undergoing laparoscopic surgery for different diseases in our hospital and assess its incidence. METHODS This is a prospective descriptive study. 125 patients admitted to the Department of General Surgery from November 2018 to October 2020 who fulfilled the inclusion and exclusion criteria underwent elective laparoscopic surgeries. They were observed post-operatively for various port site complications. All the data was entered into the Microsoft Excel 2007 software and further analysis was done using SPSS software version 24.0 (IBM Inc. Chicago). A P - value of less than 0.05 was considered statistically significant. RESULTS Of 125 patients that underwent laparoscopic surgery, 9 patients (7.2 %) developed complications specific to port site upon a follow-up of 3 months. Complications observed were port site infection (n = 4, 3.2 %), port site hemorrhage (n = 2, 1.6 %). Port site hernia, port site tuberculosis (TB), umblical port site hernia and mild subcutaneous emphysema were observed in one patient each (0.8 %). Scar abnormalitites were seen in 3 patients (2.4 %). CONCLUSIONS Laparoscopy is associated with minimal complications. However rare these complications are, they take away from the advantages of the laparoscopic surgery and the reputation of the hospital and surgeon alike. Apt patient selection, meticulous surgical technique, proper sterilization of the laparoscopic instruments and effective antibiotics use can further reduce the incidence of complications. KEYWORDS Laparoscopy, Port Site Complications, Infection, Hernia, Hemorrhage

Analysis of Port Site Complications & Measures to Prevent them

Background: Port site complications following elective laparoscopic surgeries are rare. Port site infection is the most common complication. Objectives: The study was conducted to analyze port site complications occurring in the patients undergoing laparoscopic surgeries and measures to prevent them. Patients and Methods: Total 408 patients who underwent various laparoscopic surgeries were included in the study. Follow up was done for 3 months postoperatively. Port site was examined for any complication. Result: Out of 408 patients 24 patients (5.88%) developed port site complications. 14 patients developed post site infection, 4 patients had port site discharge with sinus formation, 4 patients developed port site bleeding and 2 patients had port site hernia. No case of port site metastasis or visceral injury while port insertion were found. No patient had port site omental entrapment. Conclusion: Minimally invasive surgery is a safe and effective with minimal complication.

IS UMBILICAL TUBE TECHNIQUE THE BEST METHOD TO GAIN INTRAPERITONEAL ACCESS? A PROSPECTIVE ANALYSIS OF 1532 CASES

Background: Intraperitoneal access in laparoscopic surgery is the first and most important step to start a procedure. Many methods have been described in literature for the same. We share our experience of umbilical tube technique using a vertical infra umbilical or supra umbilical incision for the better cosmetic result. Methods: This study is a retrospective study of laparoscopy performed for various indications. Umbilical tube technique was performed. In 1532 cases performed from July2016to January 2019. A vertical incision was used instead of a commonly performed curve incision to access the umbilical tube. A vertical incision is again taken after exposing the junction of rectus sheath and umbilical tube. Vertical incision is again taken over the tube to gain access to peritoneal cavity. The closure is done in a similar way with skin closed in subcuticular fashion. No Institutional Review Board (IRB) approval was required for this paper. Result: The technique is found to be safe, can be performed with technical ease as anatomy is well defined, good cosmesis is achieved. The longest follow up is for a period of one year. No incidence of port site hernia or infection was seen. Conclusion: The umbilical tube technique using a vertical incision is found to be safe and effective, can be reproduced with technical ease. In our opinion this method can be considered as a standard approach to intraperitoneal access. Keywords: umbilical tube, intraperitoneal access, port site infection, port site hernia. Laparoscopy.