Trop Doct 2008;38:213-216
doi:10.1258/td.2007.070277
© 2008 Royal Society of Medicine Press
Laparoscopic cholecystectomy in a small rural hospital in Kashmir Valley, India
Iqbal Saleem Mir MS *
Mir Mohsin MS *
Tafazul Majid MS *
Khurshid Wani MS *
Mehmood-ul-Hasan MD 
Omar Kirmani MD 
Javed Naqshbandi MD 
Mohammed Maqbool MS ¶
* Minimal Access Surgery Unit;
Anaesthesia Unit, Government Gousia Hospital;
Department of Radiology, SMHS Hospital, Srinagar;
Anaesthesia Unit, District Hospital, Budgam;
¶ District Hospital, Kupwara, Kashmir, India, 190010
Correspondence to: Dr Iqbal Saleem Mir, Minimal Access Surgery Unit, Government Gousia Hospital, Srinagar, Kashmir Email: iqbalsurg{at}yahoomail.com
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SUMMARY
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This study evaluates the feasibility of performing laparoscopic
cholecystectomy in order to reduce the expenditure in a 28-bed
sub-district hospital in Kashmir, India. We report on a prospective
clinical trail involving patients with gall bladder disease
reported to the hospital from June 2005 till May 2007.
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Introduction
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The advantages of laparoscopic cholecystectomy (LC) over open
cholecystectomy, in terms of limited postoperative pain, reduction
in hospitalization time, recovery periods and improved cosmetic
results, have been established in a number of studies.
1–3 There have been few reports of complications, and most surgeons
and patients prefer LC to open cholecystectomy.
4,5 Unfortunately,
access to laparoscopic surgery and other related procedures
is limited in most rural health centres in developing countries.
Gall stone disease is a very common ailment in Kashmir and there is a huge backlog of patients who develop further complications while awaiting treatment. In view of the patient load, especially in the rural areas, the Directorate of Health Services Kashmir selected the Government Gousia Hospital (GGH) as the first laparoscopic centre to cater for the rural population. GGH was allotted a basic operating laparoscopic set and LC was started in June 2005. At first, there was only one surgeon who had been trained in laparoscopic surgery and who also had work experience in other centres. However, the other team members were made familiar with the electronic equipment and the hand instruments. An indigenous endotrainer was designed from an empty cardboard carton of 5% dextrose bottles, to train the team members (which included paramedics) in the theatre procedures. Team members attended training seminars which included video clips of various laparoscopic procedures, clips showing how to deal with any problems with the equipment and how to manage complications. Emphasis was laid on the safety of the patient and the equipment.
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Methods
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GGH is a 28-bed subdistrict hospital attached to the rural health
department of Kashmir, India. Since January 2004 the hospital
had provided primary and secondary care in the core specialties
of surgery, orthopaedics, ophthalmology, obstetrics and anaesthesiology.
The prevalence of cholelithiasis is high in the area and acute
cholecystitis is the most common indication for admission to
the emergency department. Cholecystectomy, especially by the
open route, is the most common operation performed in the elective
settings. From June 2005 the hospital was able to provide LC
to patients with gall bladder disease.
The selection of the patients for surgery was made preoperatively on the basis of history, physical examination and radiological and laboratory diagnostic evidence of gall bladder disease. Transabdominal ultrasonography was focused on the characteristics of the gall stones (size, number and location), the size of the gall bladder, the thickness of the wall, the diameter and presence of any stones or worms in the common bile duct and an assessment of the liver and pancreas.
The exclusion criteria included:
- cases of acute cholecystites attending the hospital after 72 hours the attack;
- an ultrasound documented gall bladder wall thickness of >4 mm;
- multiple previous upper abdominal operations;
- coagulopathies;
- ASA grade III and over.
Those patients who had ultrasound documented
choledocholithiasis, or who had a history of jaundice with raised
alkaline phosphatase and an ultrasound documented common bile
duct (CBD) diameter of more than 9 mm, were sent to the tertiary
centre for an endoscopic retrograde cholangiopancreatographic
(ERCP) examination prior to taking them up for a LC.
At least one of the donors and patient's blood was cross-matched in the closest district hospital. Most of the patients were admitted on the day of surgery and were allowed to have liquids up to six hours before the operation. Informed consent was obtained from the patients and, in case of minors, from their attendants after a detailed discussion of the benefits and possible complications of LC. Voiding of urine before surgery was ensured in every patient.
Procedure
All operations were performed under general endotracheal anaesthesia using drugs with clear-headed recovery. In early cases, a standard four port LC was done. Later, only three ports were used. A thorough laparoscopic assessment of the intraperitoneal organs was carried out before proceeding. The Sulcus of Ruvier was used as a guide for the location of Calot's triangle. The dissection of the cystic pedicle was initiated by lifting a thin fold of peritoneum posteriorly and creating a wide posterior window in the Calot's triangle. The gall bladder–cystic duct junction (the critical anatomical landmark) was identified. No attempts were made to dissect at cystic duct-CBD junction to avoid inadvertent injury. In patients where the anatomy in the Calot's triangle could not be clearly identified, fundus first dissection was done using a spatula. In cases where there was a dilated cystic duct with multiple small stones, the cystic duct was partially opened and milking was done using laparoscopic right-angled forceps. Usually, 20º vicryl sutures were placed both on the cystic duct and the cystic artery before cutting in between. This was done because of the danger of the internalization of clips into the CBD – which has been reported by some authors – and to reduce the costs of the titanium clips. A fan retractor placed through an additional 5 mm port and 30º telescope was used in grossly obese patients in order to obtain a clear view. The gall bladder was removed through the epigastric port after reducing the stone load. In the case of infected or thick-walled gall bladders the specimen were removed in self-made low-cost polythene bags using the covers of nasogastric tubes instead of costly endopouches.
Drains were placed selectively. The liver bed and the port wounds were infiltrated with long-acting local anaesthetic. Antibiotic prophylaxis was ensured with two perioperative doses of third generation cephalosporins given intravenously. Postoperative analgesia was achieved with diclofenac (200 mg sustained release daily). All patients were given oral liquids and were encouraged to eat in the evening after the operation, provided there was no nausea or vomiting.
The drain was usually removed after 24 hours if drainage was minimal. The majority of the patients were discharged on the first postoperative day if they lived locally – those living in outlying communities were encouraged to stay in the town for 48 hours. The patients were reviewed at one and four weeks postoperatively in the surgical outpatient department.
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Results
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This series involved 384 patients aged from 12 to 82 years,
all of whom presented to GGH, Kashmir, for LC for symptomatic
cholelithiasis. There were 288 females and 96 males in our series
with a ratio of 3:1. There were 121 patients (32%) who had undergone
previous abdominal or pelvic surgery (the most common being
a lower segment cesarean section). Accordingly, the insertion
point of the Veress needle and the first trocar was adjusted
to avoid the risk of perforation or injury to the bowel.
Sixteen patients underwent successful preoperative ERCP for choledocholithiasis and were then subjected to LC. The average operating time from insertion of Veress needle until closure of all ports was 45 minutes (ranging from 12 to190 minutes), and the mean length of postoperative hospital stay was approximately 22 hours (ranging from 20 to 48 hours). After the completion of the procedure, 39 patients required tube drainage for various reasons.
There were no deaths in our series. Six cases were converted to open cholecystectomy after failed laparoscopy (two had bleeding from the cystic artery which could not be controlled laparoscopically; early in the series two had dense adhesions at Calot's which required conversion to the open operation; one had to be converted due to faulty camera; one was converted in the immediate postoperative period after 14 hours due to bleeding from a slipped clip from the cystic artery). There were no CBD injuries or major postoperative complications. The most common intraoperative complication (24) was perforation of the gall bladder with stone spillage (Table 1). Four patients had epigastric port site infections but none had evidence of deep space or systemic infection. They were managed by local toilet only. The most common postoperative complaint was right shoulder tip pain which lasted for three to five days. Each patient was diagnosed by histopathological examination of the specimen as having acute/chronic cholecystites.
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Discussion
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LC has now become the operation of choice for symptomatic cholelithiasis.
1,4,6 Numerous publications, mostly from large surgical centres, have
reported on the operative technique and the complications and
benefits of LC.
1–3,7,8
The introduction of LC to small rural hospitals.2,6–8 comes with specific problems that have to be addressed beforehand. These problems include the following.
The cost-effectiveness of introducing the service in a small rural hospital
The relatively high start-up costs (i.e. the laparoscopic equipment and the training of medical and paramedical staff) have to be weighed against the number of cases found in the area. Initially the patients shy away from this procedure but this can be overcome. Training and proper case selection, especially early in the series, will result in minimal intra- and postoperative complications. Instead of ‘learning on the job’ it is important to train the staff on an indigenously built endotrainer. Further reduction in the costs is possible, both for the patient as well as the hospital, by using reusable trocars and cannulae, reusable instruments, intracorporeal ligatures instead of costly titanium clips and polythene bags or condoms in place of endobags.3 To prevent injuries due to blunting of the tip, the trocars have to be sharpened after every 30–40 procedures. All these methods were used to reduce the cost to the patients without any increase in the complication rate. This was very important as the majority of the local population lived below the poverty line and could not afford the additional expense incurred by using the disposable instruments.
Dealing with major complications after LC
Laparoscopy and LC are invasive procedures associated with a range of minor and major complications.9 Comparative statistical analysis of the incidence of damage to the major extrahepatic biliary tract during LC and open cholecystectomy have indicated a higher incidence and more extensive damage to the extrahepatic bile duct system during LC. Reconstructive surgery after LC-related bile duct injuries has correspondingly been more difficult. When major LC-related complications do occur, small rural surgical units could be open to the suggestion that LC should be performed only in larger surgical units. However, CBD injuries can be avoided if the surgical team sticks to the following basic principles of laparoscopic surgery:
- the identification of Sulcus of Ruvier;
- making a wide posterior window;
- decompressing a tense gall bladder;10
- using proper traction;
- using hydrodissection with saline;
- using the fundus first technique in difficult cases;4,11
- keeping a low threshold for conversion to open procedure.
By following these procedures, we did not have
any CBD injuries in our series of 384 patients.
Bleeding is one of the most frequent and dangerous complications of LC. Clinically significant bleeding occurs in 0.5% of patients undergoing LC.4 In our series, bleeding was observed in nine (2.4 %) patients, but in most cases it was easily controlled. Only two (0.52%) patients had clinically significant bleeding that required conversion to the open procedure at the time of the initial operation. We had to re-explore one patient who showed features of hypovolumia after 14 hours, even though there was no evidence of bleeding through the tube drain. The cause of bleeding was found to be a slipped clip on the cystic artery. This underlines the importance of the routine placement of drains in order to detect bleeding. Though bleeding is a potentially catastrophic complication, it is also the most preventable complication as it is largely avoided if the surgeons have received proper training. Patience during dissection at the Calot's triangle with due attention given to haemostasis can, to a large extent, reduce the incidence of troublesome bleeding.
Wound infection, usually involving the umbilical cannulation site through which the gall bladder is extracted, occurs in 0.3–1% of cases.6,12,13 Port site infection was seen in four (1.04%) of our patients, and all were treated successfully with local wound toilet and oral antibiotics. The average hospital stay was 22 hours. Recent studies have demonstrated that LC can be performed as one day-surgery.14,15 In our series, this was true in most of the cases.
Perforation of gall bladder with stone spillage occurs quite frequently. Aspiration of a distended gall bladder prior to dissection can reduce this.10 It is wiser to stick close to gall bladder wall during dissection avoiding possible injury to the liver sinus which can cause to profuse bleeding. An attempt should be made to remove all the spilled stones as unretrieved stones can cause a variety of complications.16 Thorough saline lavage should be performed in such cases. The antibiotic cover should be continued for seven days in the postoperative phase.
Because surgeons and patients prefer LC to open cholecystectomy – and because this procedure is cost-effective, cosmetically superior and produces far less morbidity – access to LC is important even in rural communities. The results in small rural centres should be comparable with those seen in tertiary care centres if all the precautions are taken and the team is experienced.17–19
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Conclusion
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The successful performance of LC requires proper training, discipline,
skills and technology and the ongoing monitoring of competency.
But we believe this series demonstrates that procedural training
and ongoing practice assessment can provide timely, safe and
appropriate access to the latest surgical techniques even in
small rural hospitals. The success and complication rate in
this consecutive series of 384 attempted LCs (six conversions
to open cholecystectomy, 378 successfully completed LCs associated
with minor complications) compares favourably with the results
achieved in tertiary care centres. Similar results should be
reproducible in other comparable rural surgical units. The complication
rate can be minimized by sticking to the basic principles of
laparoscopic surgery. Minimizing the costs by using reusable
instruments, self-made endobags and intra corporeal ligatures
benefit patients in developing world countries where the daily
income is less then US$ 2 a day.
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Acknowledgements
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We thank Mir Muneeb for his help in preparing this report. We
are also grateful to Dr Muzaffar Jan, Director Kashmir Health
Services, for his help throughout this study.
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References
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SUMMARY
Introduction
