With A Pinch Of Salt 

A city surgeon creates a simple device to cut 
down complications after gallstone operation, says Biplab Das

For some people removal of gall bladder stone through laparoscopic surgery sounds like a nightmare. The negative feelings invariably arise out of some anecdotal evidence - a distant relative or a friend's complications following a laparoscopic operation. In most cases, such problems show up as a queasy feeling in the abdomen, and a clinical checkup reveals severe injury on the liver tissues - unwittingly caused by the high electric currents used by the surgery. 

To overcome the complication, Dr. Nirjhar Bhattacharya at the department of surgery, Medical College, has developed a simple device, which delivers a high-pressure jet of normal saline water to the diseased gall bladder before it is surgically removed. This technique brings down the temperature and cuts down the risk of injury to neighbouring healthy organs. The young surgeon has used this technique during gall stone removal in as many as 72 patients in the hospital. He recently presented his findings at a conference of the Association of Surgeons of India at Park Hotel. 

"The concept of using normal or sterile water in open surgery has long been in use," says Bhattacharya. "But its role in laparoscopic operation has hardly been explored." Previously a team of US-based surgeons led by Dr. G. P. Naude had devised a technique, which is not only clumsy but also costly. Naude's technique employs a device called surgical-irrigation machine, which sprays water to an organ by squeezing a bottle of saline water manually. It takes too much time to finish the operation. 

The technique developed by Bhattacharya uses a mechanised device to spray water through a hand-held probe. "It is made of bits and pieces of instruments which are available in all surgery units," Bhattacharya says. 

In conventional laparoscopic cholesystechtomy (surgical removal of gall bladder), high frequency current is passed through a hand-held probe, which is inserted through a small incision on the abdomen. The tip of the probe becomes hot and separates gall bladder from the adjoining tissue and organs. 

The procedure is risky because the hot tip often burns vital organs like the liver and small intestine. What is more, the tip vapourises body fluid, creating a smoky environment, which obscures the vision of a surgeon's operating field. "Delivering high-pressure jet of saline water through a hand-held probe takes care of these problems," says Bhattacharya. As the jet of saline water passes through the same instrument that delivers currents, the hot tip can be cooled off at regular intervals, maintaining the flow of water. At the same time, it produces less vapour. 

The gall bladder remains wrapped in a membrane called peritoneum along with gall bladder duct and an artery. "This forms a tangle which makes it extremely difficult to separate the parts of gall bladder from its surrounding tissue," says Bhattacharya. 

A successful laparoscopic cholesystechtomy requires proper identification of the gall bladder duct and artery. But inflammation and swelling of surrounding tissues, as often seen in patients with severe gall bladder infection, can hinder the identification of these organs. Visualisation can also be obscured by the presence of fatty tissue, particularly in obese patients. 

The jet of saline water loosens the membrane and fatty tissue from gall bladder exposing it. As a result, the duct and artery - to be separated - become clearly visible. It also minimises the blood loss. The stream of water also washes away all blood clots. 

Because there is little use of high currents and the hot tip is continuously bathed with water, the chance of inadvertent injuries to vital organs are reduced. The gall bladder is also separated and removed safely without a rupture, diminishing the possibility of bleeding and spillage of stones. The water jet creates free operating space to dissect the organ. 

However, if a patient turns up late in life for the operation, the surgeon has to use a low-pressure water jet, considering the poor condition of the gall bladder. Also, it cannot be used in patients with ailments like ischaemic heart disease and cardiac myopathy (problem of cardiac muscle). "As the gall bladder is splashed with saline water, it can mix with the bloodstream," says Bhattacharya. "This is harmful for patients with high blood pressure who live on salt-restricted diet." The use of carbon dioxide in this operation also makes it unsuitable for patients with lung diseases like asthma and emphysema. 

"There is always a possibility of a build-up of excess carbon dioxide in the patients' blood," Bhattacharya says. The patients with diseased lungs cannot exhale the excess gas, which is toxic for cells. 

Bhattacharya is yet to explore the role of this operation in gall bladder cancer. "But I think this device can be safely used in hernia operation," he comments.