Technical Report: A Modification in Laparoscopic Cholecystectomy Technique for Left-handed Surgeons

MMATERIALS AND SURGICAL TECHNIQUE

In the standard method, the patient is placed supine on the operating table with the surgeon standing at the patient’s left side. A 10-mm trocar is inserted through the supraumbilical incision. The laparoscope with the attached video camera is passed through the umbilical port and the abdomen inspected. Three additional ports are placed under direct vision. A 10-mm port is placed in the epigastrium, a 5-mm port in the middle of the clavicular line, and a 5-mm port in the right flank, in line with the gallbladder fundus.⁴

The most important changes compared to the standard method are about trocar placing. Like the standard method, the left-handed surgeon stands on the left side of the patient and the first aid stand beside him and the monitor to be placed on the right side in front of the surgeon. Initially, a 10-mm trocar is placed in the umbilicus to enter the camera. The next is a 5-mm trocar placed in the epigastrium and subxiphoid. The most important change is done in the third step where a 10-mm trocar is placed in the left paramedian between the umbilicus and sub coastal border on the midclavicular line. The biggest change has been created in its place so that the new trocar location can improve alignment with the left hand of the surgeon and through which the surgeon will be able to guide the dissector tool easily and without interference with the cameraman. And with his right hand from subxiphoid can provide adequate exposure. The next trocar is optional. According to the anatomy of the gallbladder, its presence and absence is determined. As the standard method, it is a 5-mm trocar placed on the midaxillary line about the umbilicus (Fig. 1).

After obtaining informed consent, forty surgeries using the modified method are done by the author who himself is a left-handed general surgeon with experience of more than 200 laparoscopic cholecystectomies, and forty surgeries are done using the standard American method by the same surgeon from August 2017 to August 2018. The patients with documented acute cholecystitis, and choledocholithiasis, and biliary pancreatitis were excluded. Overweight patients (body mass index > 30) were also excluded from the study. None of our patients had any history of previous abdominal surgical intervention. Preoperative checkups, such as CBC (complete blood count), kidney function tests, liver function tests, ECG (electrocardiogram), chest radiograph, and ultrasonography (confirmed the presence of gallbladder stones) was done. Preoperative prophylactic antibiotics were also given in all patients. So this modified technique in comparison to the standard method (American) that is taught to general surgery residents was much smoother, faster, and with fewer side effects in the hands of a left-handed surgeon (Table 1).

There were two complications (5%) totally and only in the conventional method. Both were minor. One of them was diffuse hemorrhagic ooze from the liver bed and the other was bilious ooze from the gallbladder bed. The complications were managed intraoperatively by supplying the proper hemostasis and prolonged drainage (10 days). There was not any major bile duct injury in this study. There was one (2.5%) case with conversion to open surgery in the conventional method because of the vague anatomy of the biliary tree and bilious oozing from the gallbladder bed. This study aimed to introduce a modified approach for left-handed surgeons and comparing this approach with standard practice in future studies will be presented.