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Journal of Minimal Access Surgery, Vol. 7, No. 3, July-September, 2011, pp. 200 Letter to the Editor Bleeding complications in laparoscopic cholecystectomy: Incidence, mechanisms, prevention and management Sudhir Kumar Thakur Department of Surgery, Saraswathi Institute of Medical Sciences, Hapur, Ghaziabad, Uttar Pradesh, India
Code Number: ma11049 DOI: 10.4103/0972-9941.83516 Dear Sir, I read with great interest the review article by Kaushik. [1] I congratulate the author for covering this basic topic, which is still unexplored and under-reported. I appreciate the effort of the author for suggesting a basis for classification of bleeding into major and minor groups after laparoscopic cholecystectomy. I would like to add that if we lose the patient because of the bleeding, irrespective of whether any open surgical intervention was done or not, it should be grouped under major category. Though the issue has been discussed very nicely, the author has overlooked the criteria he has followed for the classification of the bleeding into major group in [Table 1]. It should have been clearly mentioned in materials and methods section. There is a need for consensus on this debatable issue. The author has not included the secondary haemorrhage, which could occur 7-14 days after surgery and may be precipitated by factors such as infection, pressure necrosis or malignancy. [2] The standard classification of any bleeding related with surgery whether open or laparoscopic are primary, reactionary and secondary. One should follow the standard norm. It is true that the secondary haemorrhage after any surgery, particularly laparoscopic surgery is extremely rare these days. Nevertheless it does occur. The author should not have followed the working classification of Schafer et al, which he has mentioned. The intra-operative and post-operative bleeding, which have been followed in this article are just primary and reactionary haemorrhage. The author, also, has mentioned about the aortic injury occurring at the time of skin incision, which is unacceptable to me. He has stressed upon the fact that distance between abdominal wall and the great vessels can be as little as 1-2 cm, in thin individuals. I am of the opinion that only in thin, frail and cathexic patient this can be true. This distance increases once the abdominal wall is lifted to insert Veress needle thus increasing the margin of safety. India has truly adopted MAS and is using it extensively and successfully. [3] We have many reputed laparoscopic surgeons, who have performed laparoscopic cholecystectomies in five figures. However, as far as the reporting of bleeding complications of laparoscopic cholecystectomy is concerned, it is quite rare to find it in biomedical journals by the Indian authors. There is no denying the fact that bleeding complications of any surgery are under-reported all over the world due to various reasons as mentioned by the author in his article. Out of 41 references quoted here only Refs. 1 and 11 are by Indian authors. And the author himself is the co-author and author, respectively. In Ref. 11, the author has given the experience of 1233 cases of laparoscopic cholecystectomies focussing on conversion rate from laparoscopic to open surgery. Unfortunately, I could not access the article but from the abstract of this article, I could find that the bleeding was no reason for conversion to open procedure. The article in Ref. 1 has reported complications following 1748 laparoscopic cholecystectomies and in this article three bleeding related complications are mentioned. This is quite commendable and courageous on the part of authors. What surfaces in the journal is not even the tip of an iceberg. Through this letter I request all the stalwarts, in this field in our country, to report the related bleeding and other complications of laparoscopic cholecystectomy truly, so that the younger generation of surgeons can take lesson from it. References
Copyright 2011 - Journal of Minimal Access Surgery |
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