Hydro-dissection: An Effective Intra-Operative Technique for Difcult Laparoscopic Cholecystectomies

Hydrodissection, a technique used to treat nerve entrapments, involves injecting an anaesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue. Objectives: To assess the e�cacy of this technique in all patients undergoing di�cult laparoscopic cholecystectomy in terms of operative time, haemorrhage, and intra-operative complications. Methods: A multicenter observational study was conducted at the department of surgery, PAF Faisal Hospital and Anis Bantva Trust Hospital Karachi. A total of 219 patients were included in this study who underwent laparoscopic cholecystectomy for symptomatic gall stones, with age ranging from 18-70 years, with intra-operative Cuschieri classi�cation >1, using a non-probability sampling method. Results: This study included 219 patients from hospital records categorized as per intra-operative di�culty grading of Cuschieri from grade II-IV. The mean age of patients was 40.46 ±12.50 years, with an average duration of symptoms of 16.95 ± 8.73 days. There were 160 (73.1%) males and 59 (26.9%) females. About two-thirds of patients were admitted through the emergency department. The pre-operative and intraoperative diagnosis of patients was symptomatic cholelithiasis 76 (34.7%), acute on chronic cholecystitis (27.9%), chronic cholecystitis 57 (26.0%), empyema and mucocele gallbladder 11 (5%) each, and Gangrenous gallbladder 3 (1.4%) were recorded. Conclusion: This study showed a clear association of intra-operative complicated anatomy during laparoscopic cholecystectomy to its conversion to open cholecystectomy. Techniques of dissection are of signi�cant importance to minimize injuries to vital structures.


I N T R O D U C T I O N
Hydrodissection, a technique used to treat nerve entrapments, involves injecting an anaesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue. Objectives: To assess the e cacy of this technique in all patients undergoing di cult laparoscopic cholecystectomy in terms of operative time, haemorrhage, and intra-operative complications. Methods: A multicenter observational study was conducted at the department of surgery, PAF Faisal Hospital and Anis Bantva Trust Hospital Karachi. A total of 219 patients were included in this study who underwent laparoscopic cholecystectomy for symptomatic gall stones, with age ranging from 18-70 years, with intra-operative Cuschieri classi cation >1, using a non-probability sampling method. Results: This study included 219 patients from hospital records categorized as per intra-operative di culty grading of Cuschieri from grade II-IV. The mean age of patients was 40.46 ±12.50 years, with an average duration of symptoms of 16.95 ± 8.73 days. There were 160 (73.1%) males and 59 (26.9%) females. About two-thirds of patients were admitted through the emergency department. The pre-operative and intraoperative diagnosis of patients was symptomatic cholelithiasis 76 (34.7%), acute on chronic cholecystitis (27.9%), chronic cholecystitis 57 (26.0%), empyema and mucocele gallbladder 11 (5%) each, and Gangrenous gallbladder 3 (1.4%) were recorded. Conclusion: This study showed a clear association of intra-operative complicated anatomy during laparoscopic cholecystectomy to its conversion to open cholecystectomy. Techniques of dissection are of signi cant importance to minimize injuries to vital structures. injection of 50 mL or more of saline between tissue spaces was injected to create an edematous area, allowing delineation of tissue planes to ease excision with fewer chances of bleeding [11]. The data iweres entered and analyzed using Statistical Program of Social Sciences ver. 20.0 (SPSS version 20.0). Mean with standard deviation, frequency, and percentages are calculated for continuous and categorical variables, respectively. Cross-tabulations were formulated. The Chi-square test and Fischer's exact t e s t w e r e r u n t o d e t e r m i n e a n y s i g n i c a n t relationship/association. P-value <0.05 was considered signi cant.

M E T H O D S
stratifying the complicated laparoscopic cholecystectomy based on anatomic and intraoperative ndings [7]. Numerous studies have shown adequate human tissue dissection using water jet streams in various medical and s u r g i c a l p r o c e d u r e s [ 8 , 9 ] . I n L a p a r o s c o p i c cholecystectomies, where anatomy is not clear to dissect, hydro-dissection has shown promising results [10]. In 1998, Naude et al. reported that the hydro dissection technique during laparoscopic cholecystectomy reduces the chances of intraoperative hemorrhage, gallbladder rupture, stone spilling, and operative time [11]. We also believe that hydro dissection can effectively clear the obscure anatomy during laparoscopic cholecystectomy. Previously this technique is used fairly in cases where anatomy is obscure by adhesions and mostly in acute settings. However, no comprehensive data is available to show the superiority of this technique. This technique should be taught from the beginning of surgical training to achieve optimal outcomes of laparoscopic surgical procedures and avoid dreaded complications like bile duct injury. We set out to evaluate the e cacy of this technique in all patients undergoing di cult laparoscopic cholecystectomy in terms of operative time, haemorrhage, and intra-operative complications.
This multicenter observational study was conducted at the department of surgery, PAF Faisal Hospital/ Fazaia Ruth Pfau Medical College, Anis Bantva Trust Hospital, Karachi .The data were collected prospectively from the hospital database after approval from the institutional ethical committee, from 1st September 2021 to 28th February 2022 . Total 219 number of patients were included in this study who underwent laparoscopic cholecystectomy for symptomatic gall stones, with age ranging from 18-70 years, with intra-operative Cuschieri classi cation >1 was included in this study, using a non-probability sampling method. In contrast, those who were Cuscheiri grade I or associated with Common bile duct calculi were excluded. Demographic characteristics such as age, gender, diagnosis, intra-operative di culty as per Cuschieri grading were extracted from the hospital record after approval from the ethical review committee of the hospital. All procedures were performed by quali ed general surgeons in their department. Hydrodissection techniques were used in all cases and outcome variables including operating time, length of hospital stay, conversion to open cholecystectomy, other complications were recorded in the proposed proforma. The water stream under high pressure is called hydro jet in 1000ml saline bag with in atable cuff around to create a pressure of 250 mmHg to 300 mmHg. Hydrodissection is a technique in which . However, none has included di culty grading as in our research and used hydro-dissection as a method of surgical dissection of di cult gallbladder. Hydro-dissection by either injecting saline in between tissue planes or using small jet propulsion techniques to separate adhesions from organs has been used in all open surgeries and laparoscopic surgeries. It is a way of blunt dissection to minimize damage to the organs and bleeding. We used 50 ml -500 ml of warm normal saline in jet propulsion to break adhesions surrounding the Calot's triangle to improve better visualization and safe clipping of the cystic duct and the cystic artery, using a standard suction irrigation port. Following saline jet adhesion-lysis, we remove uid from the peritoneal cavity to prevent complications associated w i t h u i d ove r l o a d a n d s e p s i s . I n t r a -o p e r at i ve complications such as common bile duct (CBD) injury in our study are recorded as 0.9% which is comparably lower than 1.4% in the literature [17]. The most challenging anatomy (Cuschieri grade IV) cases, which usually ended up in open cholecystectomy; however, in our observational study, about 50% of patients were managed laparoscopically. Hence, proving the importance of the hydro-dissection technique as a novel technique to improve surgical outcomes in di cult laparoscopic cholecystectomies by reducing complications and less dissection time. The

D I S C U S S I O N
The mean duration of surgery was 75.82 ± 22.34 minutes. The Intra-operative complication in patients is recorded with bile leakage (10%) of cases, gallbladder injury in (12.3%), and common bile duct injuries (0.9%) of patients. Furthermore, the strati cation of complications as per di culty grading is shown in gure 2.
Laparoscopic procedures usually take longer than open, and intra-abdominal adhesions make it more challenging as anatomy is obscure. Hydro-dissection and hydro jet streams are documented to break adhesions and improvise visualization of anatomical planes to assist tissue dissection. Hydro-dissection has been used for the last 25 years for complex laparoscopic procedures,

Laparoscopic conversion into Open Cholecystectomy
Cuschieri Grading YES NO < 0.00001.

C O N C L U S I O N S
hydro-jet technique is superior to the diathermy, blunt or sharp dissection. Moreover, it becomes di cult to use diathermy hemostasis within tissues saturated with saline. Temperature and volume need to be monitored carefully to avoid hypothermia. Hydrodissection is another form of saline/water tissue dissection where a one off xed amount of saline/adren-aline solution is injected into adherent tissues to create water logging, leading to separation of tissues along bloodless natural planes ( gure 3) [13]. The disadvantages are that there is no pressure or jet and the ow is not continuous. According to a previous investigation the HD techniques feasibility in a porcine study was valid but failed in human study for showing routine e cacy, simple cholecystectomy. The HD group had quicker and cleaner dissections in the operating eld [18]. Other studies suggested that HD technique could be utilized in laparoscopic cholecystectomy. HD used in laparoscopic cholecystectomy of 55 patients were categorized into different groups depending on the determination of surgical di culty level using Cuschieri Scale [19]. The anatomy of all patients were clearly and effectively visualized as demonstrated by their results. Sharp dissection was needed in some patients for complete procedure. According to a previous study conducted on 133 patients underwent laparoscopic cholecystectomy using HD reported that liver cirrhosis could be dissected by retrograde and prograde dissections [20]. Another study found a decrease in occurrence of GB damages, blood loss, and dissection times [21]. In Multi-Stream Saline Jet (MSSJ), we use physiological normal saline that is readily available and inexpensive. It cleanses body systems, di-lutes any blood, encourages hemostasis, and is readily absorbed. Dissection is faster, because one can visualize anatomical bloodless tissue planes more readily. [3] [4] [5] [6] [7] [8]