Lift Laparoscopic Cholecystectomy: Ideal for New Converts to Laparoscopic Surgery

INTRODUCTION

Laparoscopic cholecystectomy is one of the surgeries that can offer a significant advantage over open surgery, and many centers all over the world have converted to laparoscopic methods. Within 5 years from 1990 to 1995, the percentage of cholecystectomies performed laparoscopically increased from 10% to 80% in the USA [1]. However, in rural areas, most of the cholecystectomies are done by the open method. In a study by Dr. Elias Engelking [2], many of the surgeons working in rural areas have a desire to convert to laparoscopic surgeries, but the conversion is impeded by the steep learning curve and non-availability of cost-effective equipment [3].

Lift laparoscopic surgery is a method that has the advantages of sturdy instruments and lower costs, and it is easier to learn. We describe the method of doing lift laparoscopic cholecystectomy that we demonstrated at a live workshop in Midnapore Medical College.

METHOD

The portion of the lift apparatus that attaches to the table is fixed at the level of the right shoulder. The patient is positioned prone, with lateral supports. A 2-cm vertical incision is made at the lower part of the umbilicus and is widened to comfortably pass the index finger.

The intra-abdominal portion of the lift is inserted carefully anticlockwise, and it is then fixed to the lift apparatus. The anterior abdominal wall is lifted under vision making sure that there is no omentum or bowel between the lift and the anterior abdominal wall.

Two 5-mm ports are placed on either side of the lifting ring—one in the midaxillary line on the right side and one in the midclavicular line on the left side. Figure 1 shows the placement of the ports, and Figure 2 shows the surgery in progress.

Figure 1: The incision and port sites Figure 2: Surgery in progress
incision and port sites surgery in progress

The camera and another instrument can be comfortably passed through the umbilical incision. The gall bladder is dissected using a combination of laparoscopic and long open surgical instruments.
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DISCUSSION

The use of carbon dioxide for laparoscopic surgery does have small but definite complications, as well as hemodynamic and metabolic changes. Post operative adhesions and pain are also a problem with carbon dioxide insufflations. However, these are of greater concern for long duration surgeries.

In addition to not having these complications associated with pneumoperitoneum and carbon dioxide, lift laparoscopic surgeries have the following advantages:

  • The instruments are sturdy, and the initial investment is not high. Hence it is affordable for rural surgeons
  • Since open surgical instruments and traditional ways of dissection are used, it is easier for new rural laparoscopic surgeons to learn
  • Surgeons can take their time, as anesthesia is not complicated, and the physiological changes do not occur as they do with gas insufflations
  • In rural areas, there is no need to worry about the gas cylinders becoming empty when surgery takes a long time, or about gas leaks
Gnanaraj-64 Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
Sunti Dr. Sungtiakum Jamir is one of the early surgeons to do the rural surgery DNB course in India. He is from Nagaland and worked in mission hospitals after his graduation. He is now settled in Switzerland married to a gynecologist there and is actively involved in the Surgical Services Initiate to take modern surgery to the poor and the marginalized.

References (click to show/hide)

  1. Steiner CA, Bass EB, Talamini MA, Pitt HA, Steinberg EP. Surgical rates and operative mortality for open and laparoscopic cholecystectomy in Maryland. N Engl J Med. Feb 10 1994;330(6):403-8.
  2. Dr. Elias EngelKing: Development of Laparoscopic surgery in Rural India, a Pilot study: http://india2005.org/UserFiles/study/Development_of_Laparoscopic_Surgery_in_Rural_India.pdf [accessed on April 10, 2014]
  3. Jesudian Gnanaraj: Laparoscopic surgery in rural areas. ANZ Journal of Surgery 2007, 77 (799-800)


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2 Comments

  1. Dr. Vijay Sharma
    Posted Oct 2015 at 6:16 am | Permalink

    Is there any hands on training for Lift Cholecystectomy.

  2. Dr. J. Gnanaraj
    Posted Oct 2015 at 1:06 pm | Permalink

    The hands on training is for the gas less laparoscopic surgery for which first the online course is completed and the hands on training could be planned. http://mdcurrent.in/courses/

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