European Journal of Molecular & Clinical Medicine

Aim: To assess and grade the degree of difficulty in laparoscopic cholecystectomy and their postoperative outcome using intra operative scoring system devised.
Methodology: One hundred three consecutive patients who underwent elective laparoscopic cholecystectomy in our institute, were included in the study. Inclusion criteria was all the cases of elective laparoscopic cholecystectomy and exclusion criteria was cases in which directly open cholecystectomy was performed. Intraoperative findings were assessed on the basis of five key aspects which includes: 1) Gallbladder appearance and amount of adhesions; 2) Degree of distension/ contraction of the gallbladder; 3) Ease of access; 4) Local/septic complications; and 5) Time taken to identify the cystic artery and duct.
Results: Total 103 patients of laparoscopic cholecystectomy were included in this study. The severity score was between 2-4 in 63 (61.16%) patients and between 5-7 in 20 (19.41%) patients. Mild to moderate degree of difficulty was encountered in 80 (77.66%), severe degree in 20 (19.41%) and extreme degree of difficulty in 03 (2.91%) patients in performing cholecystectomy and conversion to open surgery were done in 08 (7.76%) patients with score between 6 to 8
Conclusion: This scoring system is useful and reliable. If the intraoperative severity score is more, the severity of cholecystitis increases and then it is more difficult to perform laparoscopic cholecystectomy

Aim: Purpose of the present study was to evaluate the risk in cases of laproscopic cholecystectomy
Methodology: A Medline search was conducted to review all published English literatures relevant to difficult cholecystectomy through 2009 to 2022. The search words were “laparoscopic cholecystectomy,” “difficult cholecystectomy,” “difficult laparoscopy,” “subtotal laparoscopiccholecystectomy,” “fundus first cholecystectomy,” and “causes of conversion of laparoscopic cholecystectomy.”
Results: Sixty-seven studies, which included 324,553 patients, were selected for this review. Five major categories of difficulty were identified. Conversion rate and iatrogenic injuries during laparoscopic cholecystectomy are still high despite significant improvement over the last 10 years. Depending on the technique of cholecystectomy, the degree of gall bladder inflammation, patient comorbidities, and surgical experience, the conversion rate was reported between 0.18% and 30%, whereas the incidence of iatrogenic injuries was from 0% to 0.6%. Subtotal cholecystectomy, antegrade and fundus first techniques, and pre-operative cholangiogram were associated with lower complications and conversion rate. Risk factors for difficulty were male sex, increased age, acute and thick wall chronic cholecystitis, wide and short cystic duct, cholecysto-digestive fistula, previous upper abdominal surgery, obesity, liver cirrhosis, anatomic variation, cholangiocarcinoma, and low surgeon’s caseload.
Conclusion: No consensus is found among surgeons on how to manage difficult laparoscopic cholecystectomy. Iatrogenic injuries and conversion rate can be reduced depending on the surgeon’s experience, special techniques, and intraoperative investigations

Background: Laparoscopic cholecystectomy is the procedure of choice for the majority of patients with gall bladder disease. Conversion to open technique is considered a major morbidity of laparoscopic cholecystectomy as it loses its supremacy over open technique once the conversion takes place. This study was conducted in an effort to determine the conversion rate and also identify the factors responsible for conversion of laparoscopic cholecystectomy to open cholecystectomy.
Materials & Methods: A clinical prospective study done on 50 patients presenting with cholelithiasis without choledocholithiasis; and with no contraindication for general anaesthesia were included in the study. Data recorded included demographic information, past medical history, indication for operation, duration of operation, reason for conversion and post-operative complications.
Results: The mean age in this study was 42.8 years. The sex distribution shows that the gall bladder diseases have a higher frequency in female than in males. Out of 50 patients, 35 patients (70%) had a chief complaint of pain in the right hypochondrium, 16 patients presented with epigastric pain. 8% of patients suffered from Diabetes mellitus whereas 6% of patients were Hypertensive. The average duration of surgery was 80.5 min. Average duration of post-op stay in successful cases was 4.2 days and in converted cases it was 6.3 days. A total laparoscopic surgery performed in 50 cases, out of which 10% cases converted to open cholecystectomy due to anatomic difficulty such as dense adhesion of calot’s triangle and anatomic variations (60%), bleeding from calot’s triangle (20%) and common bile duct injury (20%).
Conclusion: We conclude that laparoscopic cholecystectomy is a safe and minimally invasive technique, with only low conversion rate and the commonest cause of conversion in this study was the presence of dense adhesions at Calot's triangle.

Background: The erector spinae plane (ESP) blockade acts as a potent unilateral analgesic technique. The block is performed by injecting local anaesthetic drug in the plane between the erector spinae muscle and the vertebral transverse process, with its effect due to diffusion of the local anaesthetic into the paravertebral space through spaces between the adjacent vertebrae. It is a relatively safe and easy technique as compared to the thoracic epidural because our target in ESP blockade is the transverse process, which is identified easily and is distant from neural or major vascular structures and the pleura. Aim of the study: To assess the analgesic effect of ultrasound guided unilateral erector spinae blockade in open cholecystectomy Material and methods:We present a case series of ESP blockade under ultrasound guidance in nine patients scheduled for open cholecystectomy because surgeons chose to avoid laparoscopic surgery due to the increased risk of COVID-19 infection due to intraperitoneal aerosol generation. Results: All patients with postoperative ESP blockade maintained an NRS pain score of 03/10 for 24 h, except for those requiring emergency analgesia. The pain relief was excellent in all our patients and there were no complaints of nausea, vomiting. Conclusion: ESP blockade is proving to be a successful technique for intraoperative and postoperative analgesia.

Introduction: Cholecystectomy is performed either as an open or a laparoscopic route. Despite of a number of peri-operative and post-operative benefits of laparoscopic cholecystectomy, the traditional and invasive open cholecystectomy is still in frequent practice for various reasons. Therefore, this study was conducted to compare the effectiveness of SA for open cholecystectomy versus GA with respect to reducing post operative pain, analgesia requirement, respiratory complications and length of hospital stay.
Materials and Methodology: One hundred and forty patients were allocated randomly into two groups—SA group (spinal anaesthesia group, n = 70) and GA group (general anaesthesia group, n =70). And the two groups were divided as SA group underwent open cholecystectomy under spinal anaesthesia whereas GA group had undergone it under general anaesthesia.
Results: Out of all the 140 patients, 70 patients were allotted in each group, there were 120 females (85.85%) and 20 males (14.17%). Their age mostly ranged between 18 – 70 years, with a mean of 42.35 ± 12.66 years. There was no statistically significant difference between both the study groups with respect to age, sex distribution, body mass index (BMI) and ASA physical status. Intra-operatively, bradycardia and hypotension were more common in the SA group. Bradycardia less than 50/ min in 12 patients (16.66%) were treated by atropine 0.6mg IV. Bradycardia was the only side effect noted in both groups.
Conclusion: Since the conventional use of general anaesthesia in open cholecystectomy, this study displays that spinal anaesthesia is also a recommended alternative. It is therefore safe and more effective than general anaesthesia in providing prolonged post-operative pain-free interval, less analgesic/ opioid requirement and no reported respiratory problems.

Background: Laparoscopic cholecystectomy is considered the treatment of choice for symptomatic Cholelithiasis. However, of all Laparoscopic cholecystectomies, 1-13% requires conversion to an open for various reasons. Present study was aimed to Study various preoperative factors as predictors of laparoscopic cholecystectomies required conversion to  open route at our tertiary hospital.
Material And Methods: Present study was case record based, retrospective study, conducted among case records of patients who required conversion to open cholecystectomy from laparoscopic cholecystectomy was done.
Results: In present study, among 530 laparoscopic cholecystectomy (LC) procedures, 42 cases required conversion to open cholecystectomy (OC) and conversion rate was 7.92 %. In cases required conversion, indication for cholecystectomy were recent acute cholecystitis (40.48 %), recent obstructive jaundice (21.43%) and impacted stone (16.67 %). In cases required conversion, common intraoperative events observed were significant bleeding (47.62%), fibrosis (35.71%), dense adhesions at calot’s triangle (30.95%) and difficult port entry (26.19%). On analysis of preoperative risk factors age >50 years, Male gender, previous history of hospitalisation due to acute cholecystitis, Palpable gallbladder, BMI > 30 kg/m², history of previous laparotomy, USG findings of thick-walled GB (>4mm), and Pericholecystic collection were related to failed laparoscopic cholecystectomy surgery required conversion to open procedure.
Conclusion: Age >50 years, Male sex, previous history of hospitalisation due to acute cholecystitis, Palpable gallbladder, BMI > 30 kg/m², history of previous laparotomy, USG findings of thick-walled GB (>4mm), and Pericholecystic collection were found to be significant pre-operative predictive factors in laparoscopic cholecystectomies required conversion to abdominal route.

The first open cholecystectomy was performed by Langenbuch in1882 in Berlin. The first laparoscopic cholecystectomy was performed by Muhe in 1985. However the first laparoscopic cholecystectomy recorded in medical literature was performed in March 1987 by Mouret in Lyon, France. The technique was perfected a year later in March 1988 by Dubois in Paris. Preoperatively patient’s history was assessed with special reference to pain, fever, nausea, vomiting, dyspepsia, jaundice, mass per abdomen, weight loss and decreased appetite. A careful emphasis was made to record the physical findings particularly icterus tenderness in right hypochondrium and gallbladder mass. Laboratory testing and USG of gallbladder and CBD was done. CBD stone was ruled out by USG. Mean patient satisfaction score is significantly less in Group OPEN with P =0.009.Significant number of patients responded with good to excellent grading (80%) in LAP group when compared to those patients in group OPEN (44%).For statistical analysis purpose we combined excellent+good as above average, and average+poor as below average satisfaction. Significant numbers of patients are satisfied with laparoscopic surgery when compared with open surgery.

Background: Gallstone disease (GSD or Cholelithiasis) is a significant health problem
both worlds over (in both developing and developed nations). The main objective is
Laparoscopic cholecystectomy has rapidly become established as the popular alternative to
open cholecystectomy, but it should have a safety profile better than of open procedure.
Aims and objectives: The aim of this study was to compare conventional cholecystectomy
and laparoscopic cholecystectomy with respect to duration of procedure, complications,
postoperative pain, analgesic requirement and period of hospital stay.
Materials and Methods: This study consists of 52 patients who have undergone gallbladder
removal in GMC Budaun. 26 patients who have undergone laparoscopic cholecystectomy
and 26 patients who have undergone open cholecystectomy for a study period of one year
have been taken into the study In method 52 consecutive patients below 70 years presenting
with calculous cholecystitis with no evidence of CBD stones were randomized to undergo
open and laparoscopic cholecystectomy.
Results: 9 patients of LC and 10 patients of OC were males. Among LC 16 patients were
females and among OC group 15 were females, 28% of patients who underwent open
surgery had complications and 16% of patients who underwent laparoscopic surgery had
complications. The overall percentage of complications is lesser in laparoscopic surgery
than open surgery, The VAS was median grade 2 in LC group as compared to median
grade 4 in LC group. The NSAID’S were used for more days in OC group compared to LC
group, 23 patients who underwent laparoscopic cholecystectomy were discharged before 5
days. All patients who underwent OC stayed >5 days in hospital.
Conclusion: Herewe conclude in results, the duration of pain, rate of complications and
hospital stay were significantly lower in laparoscopic group. However the main advantages
of LC were reduced postoperative pain with less duration of analgesic intake, more rapid
recovery, reduced hospital stay and early return to normal work.

- Baquba Teaching Hospital – Diyala – Iraq, from January 2017 to December 2019. A total of 2749 patients of all age groups and both sexes who were found to have symptomatic gallstones were included in the study. Operative findings, causes of conversion and postoperative complications were recorded.
Result: Out of the 2749 patients who were included in this study, successful laparoscopic cholecystectomy was completed in 2711 patients, while conversion to open procedure was required in 38 patients (1.38 %). Among those who were converted to open surgery, the most common cause of conversion was dense adhesions around the gallbladder representing 42.1 % of causes of conversion.The next common cause of conversion was obscure anatomy at Calot's triangle in 31.58 % patients. Instrument failure was responsible for 10.53 % of conversions. Massive bleeding that could not be controlled laparoscopically was the cause of conversion in 7.89 % of patients and visceral injury was the cause in 5.26 % while the least common cause of conversion was wide cystic duct in 2.63% which was difficult to clip laparoscopically.
Conclusion: The risk of conversion to open surgery is always present and the decision about when to convert to laparotomy is an individual one, often subjective, made by the surgeon in the course of the procedure. The conversion rate in the present study was 1.38 % which is in the lower limit as compared to other studies, with causes similar to or approximating many national and international literatures.