A PROSPECTIVE COMPARATIVE STUDY BETWEEN TUMESCENT AND CONVENTIONAL DISSECTION OF CALOT TRIANGLE IN LAPAROSCOPIC CHOLECYSTECTOMY AT A TERTIARY CARE HOSPITAL IN GANGTOK SIKKIM

The gallbladder is a partially intraperitoneal structure that lies attached to the undersurface of the liver on segments IVB and V¹. It is 7 to 10 cm in length, holds 30 to 60 mL of bile as a reservoir, and is divided into neck, infundibulum with Hartmann pouch, body, and fundus.² On the side of the gallbladder that is attached to the liver, there is no peritoneal covering; a fibrous lining known as the cystic plate occupies this space. Bile is drained via a cystic duct to the common bile duct (CBD). The gallbladder is being suspended by the fundus to expose the infundibulum and porta hepatis³. Cholelithiasis is the most common disease of gallbladder and biliary tree, affecting 10% to 15%    of the population. Similarly, Sikkim also has a high prevalence of cholelithiasis.1 Gallstones are generally classified into two major subtypes, cholesterol and pigment stones, depending on the principal solute that precipitates into a stone.⁴ Four major factors explain most gallstone formation: supersaturation of secreted bile, concentration of bile in the gallbladder, crystal nucleation, and gallbladder dysmotility. The three types of gallstones, cholesterol stones, pigment stones and mixed stones, have different pathophysiology of development. Inadequate contraction of gall bladder or dysfunctional sphincter of Oddi can contribute to suboptimal bile flow and produce transient stasis, prompting stone formation. Gall stones are often asymptomatic but become symptomatic when they obstruct a visceral structure such as a cystic duct.⁵ However, gallstones often remain asymptomatic, only found incidentally on imaging.  Cholecystectomy laparoscopic is the treatment of choice for gallstone disease. Laparoscopic cholecystectomy, first done by Muhe in 1985 (using a direct scope) and later in 1987 by Mouret, is one of the most performed general surgery procedures⁶. Laparoscopic cholecystectomy has a 0.1% to 0.5% mortality and 2% to 3% morbidity. Laparoscopic surgery results in smaller incisions, less pain, and shorter hospitalization when compared to traditional open cholecystectomy, which has significantly increased the number of these procedures done worldwide.  Use of saline Tumescent in the dissection of calot’s triangle has been shown to result in decreased duration of surgery than the conventional technique⁷.One of the most important among these is meticulous confirmation of Strasberg's critical view of safety. But this can only be achieved after the dissection of the Calot’s triangle has been completed.The dissection of the Calot’s triangle can be hazardous and difficult in several cases⁸. To minimize this, surgeons use various combinations of sharp and blunt dissection techniques using a plethora of techniques, instruments and power sources. Electro-surgery, ultrasonic dissection and hydro-dissection are a few of these techniques⁹. But this has never been attempted for surgeries of the extra-hepatic biliary apparatus, especially cholecystectomy. Thus, the current study was planned not only to evaluate the feasibility of this technique but also compare it to the conventional method of dissection¹⁰.

AIM

The  objective of the study is to compare the duration of the surgery between tumescent or conventional dissection of Calot’s triangle dissection during laparoscopic cholecystectomy.

The mean age of this study population was 37.22 and 39.76 years in group 1 and 2 respectively, which was not significant, this finding is also similar to the previous study conducted in our hospital where the mean age was 37.09 years. The male to female ratio was 0.15:1 and 0.21:1 in group 1 and 2 respectively. This also aligns with the well-established predominance of gallstone disease in females, attributed to estrogenic activity that increases cholesterol concentration in bile, leading to stone formation.

The co-morbidities observed in the study population were documented, with hypertension being the most prevalent, followed by diabetes mellitus and hypothyroidism. Prior research has shown a connection between diabetes mellitus, dyslipidaemia, metabolic syndrome, and gallstone disease. A study from North India identified gallstone disease as a lifestyle disorder, establishing its association with diabetes mellitus, hypertension, and hypercholesterolemia. Additionally, recent studies have indicated that hypothyroidism can lead to secondary hypercholesterolemia, thereby increasing the risk of gallstone formation. No similar studies were done in the past which could evaluate the comparison of pre-operative parameters like haemoglobin, total leukocyte count, serum bilirubin and alkaline phosphatase in tumescent cholecystectomy laparoscopic. The difference was not significant in pre-operative blood and USG abdomen parameters in this study.

In this study, we compared our findings with those from other surgical fields where tumescence has been applied successfully. In the discussion section of our thesis, we observed a statistically significant difference in the ease of calot’s triangle dissection between the two groups with a Linkert scale score of 4.59 in group 1 and 6.59 in group 2. This finding suggests that the technique applied to group 2 had a notable impact on the dissection process. It was noted that while the tumescence group benefited from an easier dissection process, there was a corresponding increase in the distortion of Calot’s triangle anatomy with p value of 0.028. This distortion is a significant finding as it may complicate the identification of crucial structures during surgery, potentially increasing the risk of complications but there was no statistically significant complication noted in our study groups intra-operatively and post-operatively. The ease of dissection in the tumescence group weighed against the potential drawback of anatomical distortion with a p-value of 0.177 on comparison of distortion of anatomy and the ease of dissection of Calot’s triangle. Further research is recommended to explore techniques that can mitigate these distortions while maintaining ease of dissection.  General Surgery Lubna H.¹¹ demonstrated that hydro-dissection using a suction irrigation probe is a safe and effective technique for clearing difficult anatomy in Calot’s triangle, with improved delineation of crucial anatomical structures. Rethinasamy et al.¹² demonstrated the successful application of the tumescent technique in the excision of refractory arteriovenous malformations. Vascular Surgery The study reported that the use of tumescence eliminated the need for preoperative embolization and drastically reduced intra-operative blood loss, thereby facilitating safer surgical excision with improved operative outcomes.

In comparison it was noted that the total duration of surgery did not show statistically significant difference between the two groups with total time of 65.04 minutes and 63.50 minutes in conventional and tumescent groups respectively. While on the other hand there was a statistically significant reduction in the duration of Calot’s triangle dissection in the tumescent group with a p -value of 0.024. The mean duration of Calot’s triangle dissection was 18.65 in the conventional group and 15.96 minutes in the tumescent group. This suggests that the tumescence technique specifically enhances efficiency in the dissection of a calot's triangle, even though it does not affect the overall duration of surgery.  Intra-operative adhesions noted in 23.92% in Group 1 and 17.39% in Group 2.

Intra-operative cuschieri difficulty grade was 1 in 50% group 1 and 67.39% in group 2, cuschieri grade 2 was noted in 50% group 1 and 32.60 group 2 participants respectively.

Intra-operative gall bladder perforation and bile spillage were 32.60% and 34.78%, 28.26% and 26.08% in group 1 and 2 respectively. Stone spillage was present in 10.86% and 2.17% in group 1 and 2 respectively.

Intra-operative mean blood loss was 11.30ml and 8.20ml in group 1 and 2 respectively.

There was no statistically significant difference noted between the two groups.

Based on the findings of this study, it was observed that the use of tumescence significantly facilitated the dissection of Calot's triangle. However, there was a noted distortion of the anatomy of Calot's triangle upon visualization following the application of tumescence. The study indicated that the instillation of tumescence in the sub-serosal plane of Calot's triangle resulted in a considerable reduction in the time required to dissect this anatomical area. Despite this improvement, the total duration of the procedure remained unaffected. But further studies need to be done with a larger sample size to validate this.

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