Laparoskopik kolesistektomide Calot üçgeninin lateralden mediale disseksiyonunun değerlendirilmesi: Vaka-kontrol çalışması

Yıl 2018, Cilt: 2 Sayı: 1, 27 - 31, 16.02.2018

Oğuz Uğur Aydın , Necdet Deniz Tihan , Mehmet Zafer Sabuncuoğlu , Özgür Dandin , Fatih Serkan Yeğen Ahmet Ziya Balta Dursun Özgür Karakaş

https://doi.org/10.28982/josam.388093

Cited By: 3

Öz

Amaç: Laparoskopik kolesistektomide Calot üçgeninin diseksiyonunun intraoperatif sonuçlarını; klasik yöntemle ve sistik kanalın arkasından sistik artere doğru, lateralden mediale yapılan disseksiyonla karşılaştırmayı amaçladık.

Yöntem: Grup 1'de (n = 60) periton; önde Hartmann poşunun anterior yüzeyi boyunca kese lateral yüzeyine dek disseke edildi. Grup 2'de (n = 60) peritoneal diseksiyon, sistik kanalın arka tarafından sistik artere doğru, lateralden mediale doğru yapıldı. Hastaların demografik özellikleri, sistik kanal disseksiyon süresi, sistik arter disseksiyon zamanı ve intraoperatif kanama miktarı da dahil olmak üzere veriler kaydedildi.

Bulgular: Medyan sistik kanal ve sistik arter diseksiyon süreleri sırasıyla 308,00 (IQR = 68-927) sn ve 403,50 (IQR = 98-1045) sn idi. Grup 1'de sistik kanal ve sistik arter diseksiyonu için bu değerler sırasıyla 347,90±186,33 ve 469,73±225,02 sn idi. Grup 2'de median sistik kanal ve sistik arter diseksiyon süreleri sırasıyla 285,50 (IQR = 68-927) sn ve 389,50±143,28 saniye idi. Calot üçgeni disseksiyon zamanında (p sırasıyla 0,122, 0,075) ve gruplar arasındaki intraoperatif kan kaybı miktarı arasında istatistiksel olarak anlamlı fark yoktu (p=0,852).

Tartışma: Bu tekniğin laparoskopik kolesistektomi yapılan hastalarda kabul edilebilir bir süre içinde güvenli bir şekilde uygulanabileceğini düşünmekteyiz. Aynı zamanda laparoskopik kolesistektomiye yeni başlayanlar, sol elini kullanan cerrahlar ile safra ve vasküler anomalileri olan hastalar için güvenli bir alternatif seçenek olarak göründüğünü düşünmekteyiz.

Anahtar Kelimeler

Laparoskopik kolessistektomi, Lateral disseksiyon, Medial disseksiyon, Calot üçgeni

Assessment of lateral to medial dissection of Calot’s triangle in laparoscopic cholecystectomy: A case-control study

Öz

Aim: We aimed was to compare intraoperative results of the dissection of the Calot’s triangle through classical method and the dissection starting from the posterior side of the cystic duct toward the cystic artery along lateral to the medial surface in LC.

Methods: In Group 1 (n=60), peritoneum was dissected anteriorly along medial to the lateral surface of the Hartmann’s pouch. In Group 2 (n=60), the peritoneal dissection started from the posterior side of the cystic duct toward the cystic artery along lateral to the medial surface of the Hartmann’s pouch. Data including demographic characteristics of the patients, cystic duct dissection time, cystic artery dissection time, and intraoperative bleeding amount were recorded. 

Results: The median cystic duct and cystic artery dissection times were 308.00 (IQR=68-927) sec and 403.50 (IQR=98-1045) sec, respectively. In Group 1, these values were 347.90±186.33 and 469.73±225.02 sec for cystic duct and cystic artery dissection, respectively. In Group 2, the median cystic duct and cystic artery dissection times were 285.50 (IQR=68-927) sec and 389.50±143.28 sec, respectively. There was no statistically significant difference in the Calot’s triangle dissection time (p=0.122 and p=0.075, respectively) and intraoperative blood loss amount between the groups (p=0.852).

Conclusions: Our study results suggest that this technique can be safely performed in an acceptable time in LC patients. It also appears to be a safe alternative option for residents, left-handed surgeons, and patients with biliary and vascular abnormalities.

Anahtar Kelimeler

Laparoscopic cholecystectomy, Lateral dissection, Medial dissection, Calot’s triangle

Kaynakça

• 1. Cai X-J, Ying H-N, Yu H, Liang X, Wang Y-F, Jiang W-B, et al. Blunt Dissection: A Solution to Prevent Bile Duct Injury in Laparoscopic Cholecystectomy. Chin Med J. 2015;128:3153-3157.
• 2. Strasberg SM. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. Am Coll Surg. 1995;180:101-125.
• 3. De Silva W, Sivananthan S, De Silva D, Fernando N. Biliary tract injury during cholecystectomy: a retrospective descriptive review of clinical features, treatment and outcome. Ceylon Med J. 2006;51:132-136.
• 4. Thompson M, Benger J. Cholecystectomy, conversion and complications. HPB Surg. 2000;11:373-378.
• 5. Abdalla S, Pierre S, Ellis H. Calot's triangle. Clinical Anatomy. 2013;26:493-501.
• 6. Patil S, Rana K, Kakar S, Mittal A. Unique origin of cystic artery from celiac trunk and its importance in laparoscopic cholecystectomy. J Morphol Sci. 2013;30:200-202.
• 7. Raj PK, Castillo G, Urban L. Laparoscopic cholecystectomy: fundus-down approach. J Laparoendosc Adv Surg Tech A. 2001;11(2):95-100.
• 8. Sekimoto M, Tomita N, Tamura S, Ohsato H, Monden M. New retraction technique to allow better visualization of Calot's triangle during laparoscopic cholecystectomy. Surg Endosc. 1998;12(12):1439-1441.
• 9. Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg. 2002;9:543-547.
• 10. Hubert C, Annet L, van Beers BE, Gigot J-F. The “inside approach of the gallbladder” is an alternative to the classic Calot’s triangle dissection for a safe operation in severe cholecystitis. Surg Endosc. 2010;24:2626-2632.
• 11. Bornman P, Terblanche J. Subtotal cholecystectomy: for the difficult gallbladder in portal hypertension and cholecystitis. Surgery. 1985;98:1-6.
• 12. Bickel A, Shtamler B. Laparoscopic subtotal cholecystectomy. J Laparoendosc Surg.y 1993;3:365-367.
• 13. Lau WY, Lai EC, Lau SH. Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg. 2010;80:75-81.
• 14. Nagral S. Anatomy relevant to cholecystectomy. J Minim Access Surg. 2005;1(2):53-58.
• 15. Lamah M, Karanjia N, Dickson G. Anatomical variations of the extrahepatic biliary tree: review of the world literature. Clin Anat. 2001;14(3):167-172.
• 16. Kato K, Matsuda M, Onodera K, Kobayashi T, Kasai S, Mito M. Laparoscopic cholecystectomy from fundus downward. Surg Laparosc Endosc. 1994;4(5):373-374.
• 17. Vettoretto N, Saronni C, Harbi A, Balestra L, Taglietti L, Giovanetti M. Critical view of safety during laparoscopic cholecystectomy. JSLS. 2011;15(3):322-325
• 18. Ng WT, Book KS, Leung SL, Tam KW. A new retraction technique to allow better visualization of Calot's triangle during laparoscopic cholecystectomy. Surg Endosc. 1999;13:1252-1253.
• 19. Strasberg SM, Eagon CJ, Drebin JA. The "hidden cystic duct" syndrome and the infundibular technique of laparoscopic cholecystectomy--the danger of the false infundibulum. J Am Coll Surg. 2000;191:661-667.
• 20. Kunasani R, Kohli H. Significance of the cystic node in preventing major bile duct injuries during laparoscopic cholecystectomy: a technical marker. J Laparoendosc Adv Surg Tech A. 2003;13(5):321-323.
• 21. Sari SY, Tunali V, Tomaoglu K, Karagöz B, Güneyi A, Karagöz İ. Can bile duct injuries be prevented? "A new technique in laparoscopic cholecystectomy". BMC Surg. 2005;5:14.
• 22. Wijsmuller A, Leegwater M, Tseng L, Smaal H, Kleinrensink GJ, Lange J. Optimizing the critical view of safety in laparoscopic cholecystectomy by clipping and transecting the cystic artery before the cystic duct. Br J Surg. 2007;94(4):473-474.
• 23. Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C. One thousand laparoscopic cholecystectomies in a single surgical unit using the “critical view of safety” technique. J Gastrointest Surg. 2009;13(3):498-503.
• 24. Almutairi AF, Hussain YA. Triangle of safety technique: a new approach to laparoscopic cholecystectomy. HPB Surg. 2009;2009:476159.
• 25. Hannan MJ, Hoque MM. Laparoscopic cholecystectomy without handling the cystic artery: a new approach to minimize complications. J Laparoendosc Adv Surg Tech A. 2011;21(10):983-986.
• 26. Ohashi S, Taniguchi E, Takiguchi S. Brush dissection technique in laparoscopic cholecystectomy. Surg Endosc. 1999;13(3):311-312.