Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Archana Dambal

"Journal of clinical and diagnostic research is a welcome change in publishing practices. It aims to reach out to the grass-root level researchers who do not lack in experience, clinical material and ideas, but lack in their knowledge in English language and statistics. The journal achieves it's aim by supporting in these exact domains.
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Dr. Archana Dambal
Department of General Medicine,
Belgaum Institute of Medical Sciences,Belgaum, Karnataka,INDIA,
On 30 Nov 2018




Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : June | Volume : 3 | Issue : 3 | Page : 1548 - 1552

Safety of Laparoscopic Cholecystectomy in High Risk Patients

FANAEI S.A*, MEHRVARZ S H *, ZIAEE S. A**

*(M.D) Assosiate Professor of Surgery, Attending Surgeon, Deptt. of Surgery, Baqiyatallah University of Medical Science,Tehran,(Iran)ESSR Member,** (M.D )Biostatics and analyst, Medical Doctor.Erfan Hospital,Tehran,(Iran)

Correspondence Address :
Dr Ziaee, Emergency Dep., Erfan Hospial, Bakshayesh Str., West Sarv Sq., Sadat Abad 1998884349 Tehran,(Iran) Tel & Fax: 098 21 22357142
E.mail: Sali_ziaee@yahoo.com

Abstract

Background: Previous abdominal surgery has been reported as a contraindication related to laparoscopic cholecystectomy.
Methods: A total of 135 patients were distributed into group I (Gallstone, n = 50) and group II (Cholecystitis with a previous history of abdominal surgery or high risk patients, n = 85). The data were analyzed for open conversion rates, operative times, intra- and postoperative complications and hospital stay.
Results: The patients were classified into the following 2 groups: group 1: patients without a history of previous abdominal surgery (n_50) and group 2: patients with risk factors related to LC (n_85). Patients in the control group (II) had a longer operating time (63 ± 19.3 min vs. 52± 25.4), a higher open conversion rate (4.7% vs. 2%), and a longer postoperative stay (1.8± 1.6 days vs. 1.1±1.9) than group I, respectively. But, there was no significant difference between both the groups in characteristic variables. However, higher conversion rates as well as a longer hospital stay for patients with previous upper abdominal surgery than for those without previous upper abdominal surgery, were detected in our study. Iatrogenic injury was not detected in both groups.
Conclusions: Previous abdominal operations or high risk situations are not a contraindication to safe laparoscopic cholecystectomy.

Keywords

Laparoscopic Cholecystectomy, abdominal surgery, High risk

How to cite this article :

FANAEI S A, MEHRVARZ S H, ZIAEE SA. SAFETY OF LAPAROSCOPIC CHOLECYSTECTOMY IN HIGH RISK PATIENTS. Journal of Clinical and Diagnostic Research [serial online] 2009 June [cited: 2019 Aug 22 ]; 3:1548-1552. Available from
http://jcdr.net/back_issues.asp?issn=0973-709x&year=2009&month=June&volume=3&issue=3&page=1548-1552&id=513

Introduction
The absolute contraindications for laparoscopic cholecystectomy from the 1980s (pregnancy, previous abdominal surgery, bowel obstruction, coagulopathy, obesity, cirrhosis, inability to tolerate general anaesthesia, choledocholithiasis, and acute cholecystitis) have also become today's relative contraindications (1).

Up to half of the patients undergoing attempted laparoscopic cholecystectomy would have had prior abdominal surgery (1) Previous upper abdominal surgery does not always result in adhesions that will prevent safe right upper quadrant access. The surgeon must consider the best means for obtaining access to the abdominal cavity.

With increasing experience, however, many surgeons have felt that laparoscopic cholecystectomy is feasible for such patients. As a result, we reviewed our database specifically to investigate the effect of some risk factors on laparoscopic cholecystectomy.

Material and Methods

Patients and Methods
The study included 135 well-documented patients with gallstones (102 women, 33 men; age, 20 years to 80 years; mean age 41.5) who underwent LC at our surgical department between May 2007 and April 2008. The patients were classified into the following 2 groups: group 1: patients without a history of previous abdominal surgery (n_50) and group 2: patients with any risk factor related to LC which included (n_85) a history of upper abdominal surgery (n_11), patients with a history of lower abdominal surgery (n_5) and patients with acute cholecystitis (n_34) and chronic cholecystitis (n_35).Risk factors defined as mentioned above. Those with bowel obstruction, coagulopathy, obesity, cirrhosis, inability to tolerate general anaesthesia and pregnancy were excluded from our study.Previous abdominal surgery through a midline or paramedian incision was classified as upper abdominal surgery, when the scar extended above the umbilicus and as lower abdominal surgery when the scar was located below the umbilicus. Transverse or oblique abdominal incisions also were classified on the basis of their relationship to the umbilicus, as upper or lower abdominal surgery.

All patients underwent elective LC. Preoperative laboratory analysis of the patients included white blood cell count, total serum bilirubin, alkaline phosphatase, aspartate transaminase, alanine transaminase, and amylase. Each was in normal ranges in all patients. Preoperative Endoscopic Retrograde Cholangiopancre-atography(ERCP) was performed selectively, based on preoperative clinical or laboratory indicators of common duct stones or dilated common duct on ultrasonography. The same surgical team performed all operations and all of the patients underwent surgery by the same surgeon (C.S.) with standard 4-port and 2-handed techniques. Surgeons with experience of doing more than 250 LCs over the last 5 years performed the LC.

The standard Veress needle technique was used to enter the abdominal cavity in the patients without previous abdominal surgeries and upper abdominal surgery (group1). The Hasson technique, which involves entering the abdominal cavity under direct vision through a larger incision in the navel skin, the fascia, and the peritoneum, was used for the patients with previous abdominal surgeries. A finger was introduced to remove adhesions and a purse- string suture was placed in the fascia to close the orifice around the cannula, which allows the preservation of the pneumoperito-neum (group 2). Once the peritoneal cavity was reached safely, only those adhesions that truly interfered with visualization of the area of interest were lysed. If at any point during the operation, the surgeon thought that the patient could be better served by an open cholecystectomy, conversion to the open technique was performed. After entering the abdominal cavity, adhesions attached to the midline incision line and to associate intraperitoneal sites or organs were identified and graded for severity.

The operative times of patients in each group were compared. These data were not only affected by the conversion rates, but also indirectly showed the difficulty of the operations. Because of this, we compared the operative times of patients who underwent successful LC (converted patients excluded). Conversion to open, operative time, postoperative hospital stay, and any operative or postoperative complications were evaluated. In addition, the factors contributing to the conversion from a laparoscopic to an open procedure were evaluated to determine the impact of the prior surgery on conversion.

The Standard Laparoscopic Cholecystect-omy procedure was performed. Adhesions of GB were separated by blunt, sharp and hydro dissection and by use of suction cannula and gauze piece. Distended GBs were decompressed by suction and aspiration. The Cystic Duct and Cystic Artery were identified, ligated and divided with endoclips. Wide Cystic Ducts were suture ligated and divided. The Fundus first method and sub total cholecystectomies were performed for unclear anatomy of Calot’s triangle. GBs were dissected from the GB fossa by the use of hook/spatula/scissors. Haemostasis was done by using monopolar cautery. GBs were extracted through the epigastric port. GB fossas were re-examined and suction dried. Drains were kept through a 5 mm port at the anterior axillary line. Port closure was used for port site bleeding. Skin closure was done with skin stapler or suture.

Statistical Analysis
The data was presented as means ± standard deviation. The Qualitative data were evaluated by the Fisher’s exact test. One-way analysis of variance (ANOVA) was used for comparison of means. Statistically, P_0.05 was considered significant. The SPSS version 11.0 for Windows was used for statistical analyses.

Results

The 2 groups were similar with respect to age and sex (P>0.05).

No statistically significant difference was noted among the groups with respect to the conversion rate, operation time and complication rate (P>0.05) (Table/Fig 1) in (Table/Fig 2) patients with upper abdominal surgery as compared to group1. Patients with previous upper abdominal surgery had the longest mean operative time (75 min vs. 52 min) and higher conversion rate (9% vs. 2%) than group 1 respectively (P<0.05).

The major causes of conversions were dense adhesions in the Calot’s triangle or an uncertain anatomy of the biliary tree. The causes of conversions are summarized in (Table/Fig 3). Our study showed that two converted patients with upper abdominal surgery (supraumblical midline incision) had had a previous gastrectomy. The conversion was directly attributable to adhesions. The conversion was directly attributable to uncertain anatomy in this case. In the cholecystitis patients (n_2), conversion to an open procedure was performed because of a failed pneumoperitoneum and dense adhesions in the Calot’s triangle respectively. Adhesions were found in 90% (11 patients with acute and 13 patients with chronic cholecystitis, 11 patients with previous abdominal surgery) and 4% (2 patients in group 1) of patients and adhesiolysis was required in 64% (55 of 85 patients in group2), and 0% of these patients in group 1. No statistically significant difference was noted between the two groups with respect to the mean adhesion grades (P>0.05).No complications occurred that was directly attributable to adhesiolysis. The mean postoperative hospital stay in group 1 was 1.1 days. This was similar to that in the other group (P>0.05).No operative complications occurred in any of the groups.

The complication rates among the groups were not statistically different (P>0.05). The number and type of complications in the groups are summarized in (Table/Fig 4).

Discussion

In this study, we evaluated a large series of consecutive patients treated by laparoscopic cholecystectomy in a single institution, to examine the impact of some risk factors on the performance of laparoscopic cholecystectomy. Risk factors based on previous studies were defined. But there were some controversies, especially regarding the previous abdominal surgery. Initial studies reporting limited numbers of patients undergoing laparoscopic cholecystectomy after previous abdominal surgery, have suggested that the procedure is feasible without an increased risk of complications (2),(3),(4),(5),(6), and in particular, that previous surgery appears to have no effect on the operating time or the open conversion rate (7). Other studies have however shown, that prior upper abdominal surgery is a significant risk factor for open conversion and either intraoperative or postoperative complications (8),(9).In our study, we compared the data between the two groups. One time patients with any risk factor were compared to the risk factor group and other patients with a history of previous upper abdominal surgery were compared to group 1.The reason for this comparison was that previous studies had shown that there was no difference between the lower abdominal surgery group and the group with no history of abdominal surgery.

Our findings are in agreement with those of A. J. Karayiannakis, et al. (10), who reported higher conversion rates as well as a longer hospital stay for patients with previous upper abdominal surgery than for those without previous upper abdominal surgery (Table/Fig 2), although the operative times were similar in both groups. However, there were no significant differences between patients without a history of abdominal surgery and patients with risk factors. Nusret Akyurek et al. (11) believed that LC could be performed safely in patients with previous upper or lower abdominal surgery, if they do not have such conditions as acute cholecystitis, pancreatitis, CBD stones, and morbid obesity.

Previous upper abdominal surgery has been listed as a concern because of adhesion formation, which causes the bowel or other abdominal structures to adhere to the undersurface of the abdominal wall. The potential for bowel injury during trocar placement or difficulty in the visualization of the hepatobiliary structures, has dissuaded some surgeons from using the laparoscopic procedure in patients with previous abdominal surgery (6),(7),(8),(9),(10)(11), (12). On the other hand, the chances of unwanted “surprises,” such as dense adhesions, awaiting the surgeon during LC, are the same as those encountered during open cholecystectomy. However, Kuldip Singh et al. showed that adhesion was the main reason for conversion in upper abdominal surgery (13). They mentioned that an experienced surgeon is able to lower this rate of conversion by his experience.

We believe that open insertion of the umblical ports minimizes the risk of organ injury and allows adhesiolysis in patients with previous abdominal surgery. Once the peritoneal cavity has been reached safely, the presence and extent of any adhesions will become apparent. The surgeon must resist the common tendency to excessively eliminate adhesions. Only those adhesions that truly interfered with visualization of the area of interest or would prevent the placement of subsequent cannulas under vision should be lysed. In this study, adhesions were found in 90% and 2.35% of patients respectively, especially in those who had any risk factor or no previous abdominal surgery, adhesiolysis required in 64% and 0% of these cases respectively. No complications were directly attributable to adhesiolysis. Akyurek et.al (10) believed that the majority of adhesions from prior abdominal surgery do not alter the anatomy of the abdominal right upper quadrant and do not negatively impact the performance of a successful laparoscopic cholecystectomy. However, patients who had undergone abdominal surgery had increased difficulty during LC in terms of adhesions in the upper abdomen. But no statistically significant difference was noted in LC success rates between patients with previous upper or lower abdominal surgery in our study. We believe that with increased experience, surgeons will be able to overcome this difficulty.

The number of complications was similar among groups. In this study, operative time was longer in patients with previous upper abdominal surgery. Longer operative times are likely to be associated with an increased need for adhesiolysis.

Based on our study, LC can be performed safely in patients with previous upper or lower abdominal surgery. Previous abdominal surgery is not a contraindication for safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a prolonged operation time.

References

1.
. Curet MJ. Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy. Surg Clin North Am. 2000;80: 1093-1110.
2.
. Diez J, Delbene R, Ferreres A The feasibility of laparoscopic cholecystectomy in patients with previous abdominal surgery.HPB Surg 1998; 10: 353–56.
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. Goldstein SL, Matthews BD, Sing RF, Kercher KW, Heniford BT Lateral approach to laparoscopic cholecystectomy in the previously operated abdomen. J Laparoendosc Adv Surg Tech A 2001;11: 183–86
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. Miller K, Ho¨ lbling N, Hutter J, Junger W, Moritz E, Speil T Laparoscopic cholecystectomy for patients who have had previous abdominal surgery. Surg Endosc 1993; 7: 400–3.
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