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  1. 1. INTRODUCTION Laparoscopic cholecystectomy (LC) has been the gold standard for removal of the gallbladder since the early 1990. As technology has progressed; surgeons have begun to develop less invasive methods for this commonly performed procedure (Rawlings et al., 2010). (1) Recently, technical improvements have allowed many minimally invasive procedures to be adapted to a reduced number of incisions, and in many cases only one incision, single incision surgery is most common (Joseph et al., 2012).(2) Navarra first described the laparoscopic removal of a gallbladder through multiple ports in a single periumbilical incision in 1997 (Hall et al., 2012).(3) Single incision laparoscopic cholecystectomy also goes other terminologies,such as transumbilical Laparoscopic cholecystectomy, single port laparoscopic cholecystectomy, natural orifice transumbilical surgery (NOTUS) cholecystectomy and laparoendoscopic single site (LESS) cholecystectomy (osuagwu, 2013).(4) Although single incision laparscopic cholecystectomy (SILC) remains technically challenging for most surgeons, it can offer potential advantages, including less postoperative pain, shorter recovery time, improved cosmetic outcome, and higher patient satisfaction. Recent randomized controlled trials showed that SILC is a safe procedure with better cosmetic results as compared to conventional LC (Sato et al., 2013). (5) The indications for single incision laparoscopic cholecystectomy include the following:Biliary colic , Biliary dyskinesia , Gallbladder polyp larger than 1 cm , Porcelain gallbladder, In any single incision laparscopic cholecystectomy, it is 1
  2. 2. important to maintain a low threshold for conversion to a standard laparoscopic cholecystectomy or open cholecystectomy ( Bhandarkar et al., 2011 ) .(6) The contraindications of single incision laparoscopic cholecystectomy include the following: Absolute contraindications for single-port cholecystectomy are pregnancy and an American Society of Anesthesiologists (ASA) classification of 3(A patient with severe systemic disease) or 4 (A patient with severe systemic disease that is a constant threat to life). Relative contraindications include acute cholecystitis and previous upper abdominal surgical procedures. These patients should not be considered for single-port cholecystectomy, and a standard 4 ports laparoscopic cholecystectomy should be performed instead (Mutter et al., 2008). (7) The complications of single incision laparoscopic cholecystectomy include the following: Minor complications, treated conservatively, wound infection, umbilical abscess, seroma, skin laceration, subumbilical hematoma, perihepatic fluid collection and ileus. Conservative treatment was installed for all these complications and consisted of a wait and see policy or administration of antibiotics. Major complications, The most feared complication after laparoscopic cholecystectomy is bile duct injury. Other major, more frequent complications are haemorrhage, subhepatic abscesses and those lesions that require surgical intervention or stenting ( Fransen et al., 2012). (8) Operative Procedure: skin and subcutaneous tissues were passed through with a 20 mm transverse incision from the umbilicus in 120 subsequent patients. Fascia was slinged with notched clamps, and the abdomen was entered using a transverse fascia incision. A port manufactured for SILS (SILS port Covidien©) was placed. Intraabdominal pressure was elevated to 13 mmHg with insuflation. The abdomen was entered above the specific port with two (5 mm) and one (12 mm) trochars. A 5 mm, 30° laparoscope was used. The gallbladder was suspended using the grasper. The cystic 2
  3. 3. artery was dissected, taking special care with the dissection of the cystic duct. The relationship between the main bile duct and the cystic duct was displayed. The artery and the cystic duct were clipped with a medium clip from a 12 mm trochar divided with endoscopic scissors. The gallbladder was separated from the liver using a hook cautery and removed from the incision line. An endobag was not used in any of the patients. A laparoscopic exploration was then performed to ensure that no intraoperative complications occurred, such as bleeding or biliary leakage. After removing the port and releasing the residual carbon dioxide, the fascia defect was closed with loop prolene. The skin was sutured in an intradermic fashion using rapid Vicryl (Yilmaz et al., 2013). (9) The use of routine intraoperative cholangiography (IOC) is widely practiced during conventional four ports laparoscopic cholecystectomy (4PLC) to confirm biliary anatomy and allow for immediate management of unexpected choledocholithiasis (Yeo et al., 2011). (10) The use of IOC during SILC is, however, limited by the technical difficulties of the procedure through a single incision or, in some IOC systems, requirement of additional skin incision (Shibao et al., 2013). (11) The indications for intraoperative cholangiography (IOC) include a clinical history of jaundice, pancreatitis, elevated bilirubin level, abnormal liver function test results, increased amylase levels, a high lipase level, or dilated common bile duct on preoperative ultrasonography. Although these clinical features are widely accepted as indications for IOC, they have not been tested for their ability to predict choledocholithiasis (Livingston et al., 2005). (12) 3
  4. 4. SUBJECTS AND METHODS: 1- TECHNICAL DESIGN: Study design: * A prospective simple randomized clinical trials will be used in carrying out the study. Study setting: * This study will be conducted in Zagazig University Hospitals, as it is one of the major curative facilities in Sharkia Governorate with high patients rate. Population or subjects: * Patients with calcular cholecystitis in General Surgery Department. Data collection tools: * Laboratory investigations, Ultrasound or (ERCP and MRCP when indicated) Inclusion and exclusion criteria: *Any patient doing single incision laparoscopic cholecystectomy with cholangiography during the study period. Sampling: * Sample size will be patients . * Sample selection: simple randomized sample. 2-OPERATIONAL DESIGN: 4
  5. 5. Process: Informed consent regarding the study will be taken from every patient. Evaluation of the single incision laparoscopic cholecystectomy with intraopartive cholangiography technique. We will withdraw from the study by detection of the benefits of single incision laparoscopic cholecystectomy with intraopartive cholangiography. Time line: Practice 8 months parallel with the review Statistic 1 month Discussion 1 month Obstacles: 1. There will be expected difficulty in following up the patients after discharge from the hospital. We can solve this obstacle by taking patients' number telephones and addresses. 2. There will be expected missing of one of the benefits of single incision laparoscopic cholecystectomy with intraopartive cholangiography e.g. cosmesis. We can solve this by following the patient well after the operation. 3- ADMINISTRATIVE DESIGN: * Approval will be obtained from ethical committee in Faculty of Medicine, Zagazig University, and from patients included in the study. 5
  6. 6. 4- STATISTICAL DESIGN: * Data entry and analysis will be done using SPSS 10.0 statistical software package. RESULTS: * The results will be assessed and statistically analysed to detect the benefits of single incision laparscopic cholecystectomy with cholangiography. CONCLUSION: * We expect that the benefits of single incision laparscopic cholecystectomy with cholangiography that it can offer potential advantages, including less invasive, less postoperative pain, shorter recovery time, improved cosmetic outcome, higher patient satisfaction, confirm biliary anatomy and allow for immediate management of unexpected choledocholithiasis. RECOMMENDATIONS: * If single incision laparoscopic cholecystectomies with cholangiography requirements are easy available it is better to use the new technique. * Experienced Laparoscopic surgeons tend to operate on more operations with single incision laparoscopy. RATIONAL: * Gall stones are a major problem and cholecystectomy is the proven treatment of this problem so we try to find the least invasive and more benefit techniques. 6
  7. 7. * Single incision laparoscopic cholecystectomy in less invasive with more benefits. * So, we will study single incision laparoscopic cholecystectomy with cholangiography benefits. RESEARCH QUESTION: * What are the benefits of single incision laparscopic cholecystectomy with cholangiography? AIM: * To detect the short term outcome of single incision laparscopic cholecystectomy with cholangiography and see what is the benefits? OBJECTIVES: * The objectives in this study can be summarized in the following points: 1. To detect the safety of single incision laparscopic cholecystectomy with cholangiography. 2. To detect the benefits of single incision laparscopic cholecystectomy. 3. To detect the role of intaoperative cholangiography. 7
  8. 8. REFERANCES 1) Rawlings A, Hodgett S, Matthews B, Strasberg S, Quasebarth M and Brunt M (2010): Single-Incision Laparoscopic Cholecystectomy: Initial Experience with Critical View of Safety Dissection and Routine Intraoperative Cholangiography. J Am Coll Surg; 211:1–7. 2) Joseph M, Phillips M, Farrell T and Rupp C (2012): Single Incision Laparoscopic Cholecystectomy Is Associated With a Higher Bile Duct Injury Rate. Ann Surg; 256:1–6. 3) Hall H, Dennison A, Bilku D, Metcalfe M and Garcea G (2012): Single Incision Laparoscopic Cholecystectomy. Arch Surg. 7 147(7):657 666. 4) Osuagwu C (2013): A Review of Randomized Controlled Trials Comparing Single Port Laparoscopic Cholecystectomy with Conventional laparoscopic Cholecystectomy. World Journal of Laparoscopic Surgery; 6(2): 93_97. 5) Sato N, Shibao K, Akiyama Y, Inoue Y, Mori Y, Minagawa N, Higure A and Yamaguchi k (2013): Routine Intraoperative Cholangiography During SingleIncision Laparoscopic Cholecystectomy: a Review of 196 Consecutive Patients. J Gastrointest Surg ; 17:668–674. 6) Bhandarkar D, Mittal G, Shah R, Katara A and Udwadia T (2011): Singleincision laparoscopic cholecystectomy: How I do it? J Minim Access Surg; 7(1): 17–23. 7) Mutter D, Leroy J, Cahill R and Marescaux J (2008): A simple technical option for single-port cholecystectomy. Surg Innov. Dec; 15(4):332-3. 8) Fransen S, Stassen L and Bouvy N (2012): Single incision laparoscopic cholecystectomy: A review on the complications. J Minim Access Surg.; 8(1): 1– 5. 8
  9. 9. 9) Yilmaz H, Alptekin H, Acar F, Ciftci I, Tekin A and Sahin M (2013): Experiences of Single Incision Cholecystectomy: Int. J. Med. Sci.; 10(1):73-78. 10) Yeo D, Mackay S and Martin D (2011): Single-incision laparoscopic cholecystectomy with routine intraoperative cholangiography and common bile duct exploration via the umbilical port. Surg Endosc; 26:1122–1127. 11) Sato N, Shibao K, Akiyama Y, Inoue Y, Mori Y, Minagawa N, Higure A and Yamaguchi k (2013): Routine Intraoperative Cholangiography during Single-Incision Laparoscopic Cholecystectomy. J Gastrointest Surg; 17:668–674. 12) Livingston EH, Miller JA, Coan B and Rege RV (2005): Indications for selective intraoperative cholangiography. J Gastrointest Surg.; 9(9):1371-7. 9

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