ORIGINAL�ARTICLE ABSTRACT Objective: The study was conducted to assess the feasibility, safety, effectiveness, and postoperative complications of mini cholecystectomy in our setup. Study Design: It was a descriptive observational study design. nd th Place and Duration of Study: This study was conducted from 02 September 2013 to 30 September 2017 in the department of surgery, Pak Red Crescent Teaching Hospital, affiliated with Pak Red Crescent Medical & Dental College, Lahore. Materials and Methods: A total of 143 symptomatic patients with cholelithiasis, irrespective of age and sex were included in this by convenient sampling. The data of all patients were collected for age, sex, size of incision, operation time, complication, postoperative hospital stay and analyzed with SPSS version 21. Results: Out of 143 patients 132 (92.30%) were female and 11 (7.69%) were male. Mean age of the patients was 38±10.38 years. Average incision size was 4±0.65 cm. The mean operating time was 39.12±8.66 minutes. The mean hospital stay was 2 days. Minor post-operative complications like hemorrhage, minor biliary leak and superficial surgical site infection was seen in 7 patients. Conclusion: The present study shows that mini-cholecystectomy is effective, safe procedure with short operating time, fewer complication, less postoperative stay and it is feasible not only in chronic cholecystitis, but also in an acutely inflamed gallbladder even in empyema. Key Words: Cholelithiasis, Cholecystectomy, Gall Bladder, Mini Cholecystectomy. 4 parts of the third world countries. In early 1990s, it was shown that the conventional large subcostal incision in cholecystectomy could be replaced by a m u c h s m a l l e r i n c i s i o n , g i v i n g a s h o r t e r convalescence. This new modification was named as Mini-cholecystectomy. It was first described by 7 Dubois and Berthelot, and their favorable results were reported at the same time laparoscopic cholecystectomy was introduced into the UK in 8-10 1990. Most of the previous studies on mini- cholecystectomy done on chronic cholecystitis and excluded acute cholecystitis patients. We decided to analyze the safety and feasibility results of this procedure both in chronic and acute cases. The objective of this study was to assess the feasibility, s a f e t y, e f f e c t i v e n e s s , a n d p o s t o p e r a t i v e complications of mini cholecystectomy in our setup. Materials and Methods This Descriptive observational study was conducted nd th from 02 September 2013 to 30 September 2017 conducted in the department of surgery, Pak Red Crescent Teaching Hospital, affiliated with Pak Red Crescent Medical & Dental College, Lahore. The study was approved by the ethical review committee Introduction Cholecystectomy is one of the most common operations performed by departments of general or 1,2 gastro-intestinal surgery worldwide. Conventional cholecystectomy has enjoyed supremacy as treatment of choice for Gallstones almost more than 3 a century. The introduction of laparoscopy in 1990s 4 opened up a new chapter in the surgical history. The procedure progressed at such a speed that it has become the gold standard for management of 4 cholelithiasis. This procedure requires costly 5 equipment and need of additional training of the surgeon, moreover learning curve of this technique is very slow. Due to these factors this procedure has 6 still not replaced the open cholecystectomy in most The Rationality of Mini-Cholecystectomy: A Study of 143 Cases at Pak Red Crescent Teaching Hospital 1 2 3 Abid Hussain , Aqeel Ahmad , Kishwar Naheed Correspondence: Dr. Aqeel Ahmad Assistant Professor, Surgery Pak Red Crescent Medical and Dental College, Lahore E-mail: aqeelsurg@yahoo.com 1,2 3 Department of Surgery/ Gynecology and Obstetrics Pak Red Crescent Medical and Dental College, Lahore Funding Source: NIL; Conflict of Interest: NIL Received: Aug 23, 2017; Revised: Dec 08, 2017 Accepted: Dec 11, 2017 The Rationality of Mini-CholecystectomyJIIMC 2018 Vol. 13, No.1 8 i n c i s i o n , o p e r a t i o n t i m e , c o m p l i c a t i o n , postoperative hospital stay. Data were analysed using SPSS version 21. Descriptive statistics were applied. Frequency and percentage were calculated for categorical variables like gender whereas mean and standard deviation were calculated for numerical variables like age and incision size. Results Out of 143 patients, 132 (92.30%) were females and 11 (7.69%) were males. Mean age of the patients was 38 ± 10.38 years. Youngest patient was 16 years old and eldest was 70 years old. The minimum incision size was 3 cm and the maximum size was 5 cm. Average incision size was 4 ± 0.65 cm. The procedure was performed safely in all the cases and none of the p a t i e n t w a s c o n v e r t e d t o c o n v e n t i o n a l cholecystectomy. The mean operating time was 39.12 ± 8.66 minutes. The mean hospital stay was 2 days. During dissection dense Adhesions was found in 13 patients (9.09%) and obscure anatomy was encountered in 9 patients (6.29%), which were handled safely with meticulous dissection. Perioperative findings are given in Table I. of our institution. A total of 143 symptomatic patients with cholelithiasis, irrespective of age and sex were included in this by convenient sampling. Written informed consent was taken. Complete blood count, liver function test, viral screening and clotting profile were performed. A routine preoperative abdominal ultrasound scan was performed a day before surgery. Patients with CBD stones were excluded from the study. All operations were performed under general anesthesia. An equal or less than 5 cm transverse skin crease incision was made, starting from the midline approximately two finger breadths below xiphisternum, extending laterally towards the right subcostal margin. After division of the subcutaneous tissue, anterior rectus sheath, medial part of the rectus muscle and post rectus sheath were divided in turn. The peritoneum was picked up with two clips and divided between them. Gall bladder was located and grasped. In case of distended gall blabber, it was aspirated because the empty gall blabber is easier to grasp for dissection. Abdominal pack was inserted over the omentum and transvers colon and with the help of small deaver retractor it was retracted towards the pelvis. A second deaver retractor was placed over the abdominal pack, medial to the gall bladder and is used to retract segment 4 of the liver upwards, thus exposing the common bile duct and porta hepatis. Any adhesions between Hartmann's pouch, omentum and duodenum was divided carefully under direct vision. The calot's triangle was then dissected and cystic duct and artery was skeletonized and divided between the ligatures. Gall bladder was removed from its bed. The gall bladder bed was checked for hemostasis and for any accessory bile duct. A subhepatic drain was left for 24 hrs. The wound was closed in layers. Post-operative patients were encouraged to be ambulant and pass urine. All the patients were reassessed in the morning for any post-operative complication. Drain was removed 24 hrs after the operation. Oral fluid was allowed if there was no nausea and on adequate bowel sounds. On second post-operative day soft diet was allowed and patient th was discharged. They were called back on the 8 post-operative day for skin suture removal and reviewed fortnightly thereafter for one month. The data of all patients were collected for age, sex, size of Table I: Periopera�ve Findings Table II: Postopera�ve Complica�on Post-operative complications were seen in 7 patients (4.90%) the details are given in Table II. Post-operative minor ooze (hemorrhage) from gall bladder bed was stopped spontaneously. Post- operative minor biliary leak was managed conservatively. Wound infection was treated with removal of sutures and wound irrigation along with 9 The Rationality of Mini-CholecystectomyJIIMC 2018 Vol. 13, No.1 group. Shorter hospital stay also decreases the overall cost of the mini-cholecystectomy when 25,26 compared with traditional open cholecystectomy. Motivated (Encouraging) early mobilization can reduce hospital stay significantly. In our study the average hospital stay was two days which is 3,17,27 18,19 consistent with local and international data. The wound infection rate in our study was well below 28 with published regional data. Many studies found, it is a cost-effective 23,5 procedure. It is found more cost-effective than 29 Laparoscopic cholecystectomy and even from 3 0 , 3 1 c o n v e n t i o n a l o p e n c h o l e c y s t e c t o m y. Nevertheless, mini- cholecystectomy is not appropriate for obese patients, they are more s u i t a b l e c a n d i d a t e s f o r l a p a r o s c o p i c 1 cholecystectomy. More effort should be put in to improve the mini- cholecystectomy technique rather than by-passing it e s p e c i a l l y i n c e n t e rs w h e r e l a p a ro s c o p i c cholecystectomy is not available. With this technique we can still offer to the patients of rural population better cosmetically accepted scar, less morbidity and cost-effective procedure. Conclusion The present study shows clearly that mini- cholecystectomy is effective, safe procedure with short operating time, fewer complication, less postoperative stay and it is feasible not only in chronic cholecystitis, but also in an acutely inflamed gallbladder even in empyema. It may be recommended as a procedure of choice especially in rural centers, where laparoscopic facilities are not yet available. REFERENCES 1. Shulutko AM, Kazaryan AM, Agadzhanov VG. Mini- laparotomy cholecystectomy: technique, outcomes: a prospective study. Int J Surg. 2007; 5: 423-8. 2. Thomas S, Singh J, Bishnoi PK, Kumar A. 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It has a similar l eve l o f i nva s i ve n e s s to t h e l a p a ro s co p i c 13,14 approach. Amount of trauma inflicted by surgeon is directly proportional to the length of incision and 15 division of muscles. Many studies show small transverse incision for gall bladder surgery have 16 proved to be less painful than vertical incision. This reduction of abdominal wall trauma by use of short 17 incision should be accompanied by rapid recovery. We used transverse incision in our study, and in most of the cases the size was less than ≤ 5 cm which is 17,18,19 comparable with other studies. Most of the previous studies on mini-cholecystectomy excluded acute cholecystitis patients. However, we were able to perform the procedure in cases of acute inflammation, mucoceles and empyema. We performed decompression of gallbladder as a routine in all cases to facilitate the visualization and dissection of the triangle of Calot's. 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