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SURGICAL WEBSITES             KIDNEY SURGERY         POSTGRADUATE SURGERY LINKS 

BREAST DISEASE     Breast cancer Breast lump Breast awareness Breast calcifications  Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis                                                                                                                                                 

LIVER ABSCESS      Anatomy of liver Physiology of liver Method of examination of liver Haematology of liver disease. Amoebic liver abscess .Pyogenic liver abscess. Percutaneous needle aspiration of liver abscess. Case study.  Result Result continued  Discussion                                                                 

CHOLECYSTECTOMY    Introduction   Historical Review  Anatomy of Gallbladder Physiology of Gallbladder Physiologic effects of pneumoperitoneum Pathology  of Gallbladder Investigations Pre- operative preparation of laparoscopic cholecystectomy Contraindications  Treatment modalities for gallstones.  Anaesthesia                                                                                                                       

INGUINAL HERNIA    HOW SURGICAL OPERATION IS DONE     THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT      SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA     BRONCHOGENIC CARCINOMA     TETANUS AND ANAEROBIC INFECTIONS 

CONTRAINDICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY

 

            The list of absolute and relative contraindications to performance of laparoscopic cholecystectomy is decreasing with increasing experience in the use of this procedure ¹⁰⁰. There are relative few absolute and relative contraindications to laparoscopic cholecystectomy.

 

A.     ABSOLUTE CONTRAINDICATIONS:

            The following are the absolute contraindications

 

i.                     UNFIT TO SUSTAIN GENERAL ANAESTHESIA:

The patient should be fit enough to tolerate general anaesthesia.

 

ii.                   PREGNANCY:

            Since the effects of pneumoperitoneum on the developing foetus are unknown, laparoscopic cholecystectomy should not be attempted in pregnant females. Soper has recommended laparoscopic cholecystectomy safe till early second trimester only in the cases with severe biliary symptoms and provided the surgeon is very experienced with insufflation pressure of less than 12 mmHg with monitoring of fetal pulse in perioperative period ¹⁰¹.

 

iii.                  ACUTE CHOLANGITIS:

            Patients with acute cholangitis generally have an obstructed ductal system that cannot be readily cleared via laparoscope. In such patients the common bile duct should be drained by open surgery, endoscopic techniques ¹⁰² or under percutaneous radiologic guidance, depending on the expertise available and the condition of the patient.

 

iv.                 SEPTIC PERITONITIS / SEPTIC SHOCK:

            Patient with abdominal sepsis or generalised peritonitis often will have some sort of abdominal catastrophe that may or may not be limited to biliary tract. Under such circumstances a surgical exploration should be performed.

 

v.                   SEVERE BLEEDING DISORDERS:

Patients with major bleeding disorders should be excluded. Although a number of techniques for ensuring haemostasis during laparoscopic surgery are available, they are less effective in the face of major blood loss. Thus patients with uncorrectable coagulopathies should undergo an open procedure since the surgeon will be better equipped to control major haemorrhage during an open laparotomy.

 

vi.                 PANCREATITIS

It is advisable to delays cholecystectomy in presence of pancreatitis ¹⁰³.

 

vii.                JAUNDICE

 

viii.              CHOLECYSTOENTERIC FISTULA

 

ix.                 DOUBT OF MALIGNANCY

 

B. RELATIVE CONTRAINDICATIONS

            Patient with one or more of the relative contraindications should be evaluated on a case by case basis. The experience of the operative team is perhaps the most important factor. Many patients having relative contraindications are now undergoing laparoscopic cholecystectomy.

 

i.           ACUTE CHOLECYSTITIS:

It is the most commonly encountered relative contraindication. The inflammation and oedema that accompany acute cholecystitis often distorts the normal tissue planes surrounding the gall bladder and cystic duct. Such patients are told laparoscopic cholecystectomy will be attempted but there is a possibility of converting the procedure into an open laparotomy. Laparoscopic cholecystectomy is technically achievable in the majority of patients with acute cholecystitis. The conversion rate is high but, if the procedure is completed successfully, postoperative recovery is more rapid than that after open surgery. However, the method carries a higher incidence of complications and should be attempted only by experienced surgeons ¹⁰⁴.

 

ii.         PRIOR UPPER ABDOMINAL SURGERY:

       Individual with prior upper abdominal surgery has adhesions which may preclude safe dissection around the porta hepatis and increase the possibility of injury during insertion of the insufflation needle.

 

iii.        INFLAMMATORY BOWEL DISEASE:

       It poses a challenge to the surgeon since extensive inflammatory adhesions make the dissection difficult.

 

iv.       ABDOMINAL MALIGNANCY:

       Malignant adhesions make the visualisation of the gall bladder and dissection in the cystic duct region difficult or impossible.

 

v.         ADVANCED LIVER DISEASE:

       Laparoscopic cholecystectomy also may prove to be technically difficult in patients with advanced liver disease (i.e. cirrhosis). The diseased liver may be enlarged and immobile, making exposure of the cystic and common bile ducts difficult.

 

vi.       UNTREATED CHOLEDOCHOLITHIASIS:

       In patients with suspected common bile duct stones a preoperative endoscopic retrograde cholangiopancreatogram [ERCP] proceeded to endoscopic sphincterotomy and stone extraction will be done ¹⁰⁵ but if it failed or patient did not gone all through this process than laparoscopic cholecystectomy is very difficult. Whether an additional cholecystectomy is performed routinely or electively, the high risk of additional procedures after endoscopic management precludes it is used as the optimal therapy in patients with symptomatic common bile duct stones, except in those with severe cholangitis ¹⁰⁶.

 

vii.      COEXISTING MEDICAL ILLNESS:

       Patients who are not considered candidates for open laparotomy due to coexisting medical illness or poor prognosis should not routinely be considered candidates for laparoscopic cholecystectomy. Under such circumstances this less invasive procedure is not necessarily safer since conversion to open cholecystectomy is always a possibility. People have tried laparoscopic cholecystectomy with different co-morbid conditions and have published their results especially with the view that minimally invasive nature is less harmful. Surgical treatment of patients with biliary lithiasis and chronic renal failure on hemodialysis can be safely performed with appropriate operative indications and noninvasive surgical techniques ¹⁰⁷. Therefore with the recent advancement and increased expertise over the field the absolute and relative contraindications are decreasing and some times it seem to be subjective.

 

viii.    MINOR BLEEDING DISORDER:

 

ix.       OBESITY:

It is a relative contraindication to laparoscopic cholecystectomy. Although insufflation and trocar insertion may prove more difficult because of abdominal wall adipose tissue, the actual operative procedure often is more difficult than in thinner patients. Exposure may be somewhat compromised by fat in the omentum and transverse colon mesentery; however, this generally is not a major limiting factor. It is advisable for the inexperienced laparoscopic surgeon to avoid operating on such patients however, there does not appear to be any specific contraindication to laparoscopic cholecystectomy. In fact, these patients recover remarkably well following laparoscopic cholecystectomy as compared to open procedure. Laparoscopic cholecystectomy has been documented safe and effective in obese patients ¹⁰⁸.