Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Local infiltration versus Laparoscopic e guided transverse abdominis plane block in laparoscopic cholecystectomy e double blinded randomized control trial(Elsevier, 2018) Siriwardana, R.C.; Kumarage, S.K.; Gunetilleke, M.B.; Thilakarathne, S.B.BACKGROUND: Transverse abdominal plane block (TAP) is a new technique of regional block described to reduce postoperative pain in laparoscopic cholecystectomy (LC). Recent reports describe an easy technique to deliver local anesthetic agent under laparoscopic guidance. METHODS: This randomized control trial was designed to compare the effectiveness of additional laparoscopic guided TAP block against the standard full thickness port site infiltration. 45 patients were randomized in to each arm after excluding emergency LC, conversions, ones with coagulopathy, pregnancy and allergy to local anesthetics. All cases were four ports LC. Interventions - Both groups received standard port site infiltration with 3-5ml of 0.25% bupivacaine. The test group received additional laparoscopic guided TAP block with 20ml of 0.25% bupivacaine subcostaly, between the anterior axillary and mid clavicular lines. As outcome measures the pain score, opioid requirement, episodes of nausea and vomiting and time to mobilize was measured at 6 hourly intervals. RESULTS: The two groups were comparable in the age, gender, body mass index, indication for cholecystectomy difficulty index and surgery duration. The pain score at six hours (P = 0.043) and opioid requirement at six hours (P =0.026) was higher in the TAP group. These were similar in subsequent assessments. Other secondary outcomes were similar in the two groups. CONCLUSION: Laparoscopic-guided transverses abdominis plane block does not give an additional pain relief or other favorable outcomes. It can worsen the pain scoresItem Morphological variations of cystic artery in triangle of calot in laparoscopic cholecystectomy: experience in tertiary care surgical unit in South Asian country.(Quest Journals Inc., 2016) Abeysuriya, V.; Kumarage, S.K.; Hasan, R.; Wijesinghe, J.A.A.S.INTRODUCTION: The knowledge and realization of the frequency and multiplicity of abnormalities of the cystic artery is a perquisite for safe laparoscopic cholecystectomy. OBJECTIVE: To describe the morphological characteristics of the cystic artery in the triangle of Calot. METHODS: Descriptive-prospective cross sectional study was performed in 200 patients, who underwent laparoscopic cholecystectomy for symptomatic gallbladder disease, to observe variations cystic artery. RESULTS: Eighty-nine percent (178/200) of the cystic arteries originated as a single artery from the right branch of the hepatic artery. Five percent (10/200) had two cystic arteries originating separately from right hepatic artery while 5 % (10/200) of cystic arteries passed anterior to the common hepatic duct and 1%(2/200) traversed over cystic duct. Majority, 41%(82/200) of the patients right hepatic artery was ling in the triangle of Calot’s. Two percent (4/200) of the patients had right hepatic artery running over the common hepatic duct. CONCLUSION: It has been observed that the variation of the cystic artery in the triangle of Calot is not infrequent and this knowledge will enhance the safe laparoscopic cholecystectomy.Item Experience on endoscopic management of Iatrogenic bile duct injuries following laparoscopic cholecystectomy(Quest Journals Inc., 2016) Hasan, R.; Abeysuriya, V.; Navarathne, N.M.M; Wijesinghe, J.A.A.S.INTRODUCTION: Clinically significant bile leaks due to iatrogenic bile duct injuries following laparoscopic cholecystectomy is not infrequent. Endoscopic procedures have become the treatment of choice for the management of biliary leakage following iatrogenic bile duct injuries. GENERAL OBJECTIVE: To assess the therapeutic outcome of endoscopic therapy of the patients who had iatrogenic biliary injury and biliary leakage following laparoscopic cholecystectomy. METHODS: Prospective descriptive study was performed on32 patients who underwent therapeutic endoscopic procedures for iatrogenic injuries following laparoscopic cholecystectomy for symptomatic gall stone disease in the National Hospital of Sri Lanka. Bile leaks were diagnosed by the presence of persistent abdominal pain, jaundice with cholangitis, abdominal distension and persistent bile flow to the skin surface through and around the existing drains. All the patients underwent abdominal ultra-sonography or CT scan. The presences of bile leaks were confirmed by ERCP. RESULTS: Patients who had bile leaks were diagnosed by, persistent abdominal pain 30 % (9/30), jaundice with cholangitis 6.6% (2/30), abdominal distension 16.6% (5/30), and persistent bile flow to the skin surface through and around the existing drains, 46.6%(14/30). The median duration between initial surgery and detection of bile leak was 3 days (range 0-12 days). Twenty-three patients 76.6% had high-grade bile leaks and 7(23.4%) had low-grade leaks. The iatrogenic bile duct injuries were; cystic duct injuries 10(33.3%) (3 high grade: 7 low grade bile leaks), the common bile duct injuries 16(53.3%) and the right hepatic duct injuries 4(13.3%). All patients were subjected to therapeutic procedures, which consisted of Sphincterotomy with stone extraction followed by biliary stenting (10 patients), Sphincterotomy with biliary stenting (15 patients) and Sphincterotomy alone (5 patients). Bile leaks stopped in all patients at a median of 4 days (range 2-14 days) after endoscopic interventions. Drains were removed at a median duration of time of 6 days (range 5-16 days) after endoscopic procedures. Stents were removed at a 6-8 weeks’ interval. Three (3/6) who had low-grade cystic duct bile leaks, who underwent Sphincterotomy alone, had mean 3.6±0.88SEM days for complete cessation of bile leakage from the drains. Other three patients (3/6) who underwent Sphincterotomy and stent placement had mean of 3.0±0.57SEM days cessation of bile leakage (P=0.52, t-test). All high-grade bile leak (3/10) patients were offered Sphincterotomy and stent placement and had mean 6.8±0.5SEM days for complete cessation of bile leakage from the drains. CONCLUSIONS: Iatrogenic bile duct injuries occur commonly in the common bile duct. Residual stones are found in one-third of cases. No significant difference in healing was seen between the patients who had low-grade bile leaks due to cystic duct injuries and whom were offered either Sphincterotomy alone and Sphincterotomy and stenting.Item Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?(Springer International, 2009) Liyanage, C.A.H.; Sadakari, Y.; Kitada, H.; Ienaga, J.; Tanabe, R.; Takahata, S.; Nabae, T.; Tanaka, M.BACKGROUND: Prevention of iatrogenic injuries is of paramount importance in difficult laparoscopic cholecystectomies (LC). The objective of this study was to analyze the effectiveness of cholangiography using a pre-inserted endoscopic naso-biliary drain (ENBD) for navigation during difficult cholecystectomies. METHODS:The study design was a retrospective case analysis. In 508 patients who underwent LC in a tertiary referral university hospital from 1996 through 2007, difficult cholecystectomy was anticipated in 26 patients due to possibly aberrant biliary anatomy (four patients), unclear cystic duct anatomy during magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (three patients), and acute cholecystitis (19 patients). An ENBD was inserted during ERCP prior to LC for cholangiography (ENBDC) to facilitate safe dissection during LC. Prevalence of biliary complications was assessed as the main outcome measurement. RESULTS: The majority (68 percent) of the patients who underwent ENBDC had complicated cholecystitis. Advanced technical expertise was not required for insertion of an ENBD. In retrospect, ENBDC was useful in prevention of a possible catastrophe in 69 percent of cases. Open conversion was necessary in five patients and biliary complications occurred in five patients only in the non-ENBD group. There were no procedure-related complications. One limitation of the study was that it was not randomized and there was no comparison with patients without ENBDC. CONCLUSIONS: ENBDC is a useful and safe tool in the prevention of iatrogenic bile duct injuries in LC.