Thesis

COMPARATIVE EVALUATION OF
C-REACTIVE PROTEIN AND TOTAL LEUCOCYTE COUNT
IN
CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY AND
SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY
THESIS
SUBMITTED TO
THE HIMACHAL PRADESH UNIVERSITY, SHIMLA
FOR THE DEGREE OF

M.S. (GENERAL SURGERY)
2011-2014
SUBMITTED BY:
DR. MUKESH KUMAR
DEPARTMENT OF SURGERY
INDIRA GANDHI MEDICAL COLLEGE
SHIMLA (H.P.) -171001.

CERTIFICATE OF SUPERVISORS
This is to certify that the work incorporated in this thesis entitled “Comparative
Evaluation of C-Reactive Protein and Total Leucocyte Count in
Laparoscopic Cholecystectomy and Single Incision Laparoscopic
Cholecystectomy’’ has been carried out by Dr.Mukesh Kumar under our direct
supervision and guidance in the department of Surgery, Indira Gandhi Medical
College, Shimla. The data incorporated in this thesis is genuine and work has
been carried out by the candidate himself.
……………………….
_____________________
Dr. R.S.JHOBTA
Associate Professor
Department of Surgery
I.G. Medical College ,shimla
(SUPERVISOR)
............................. SUPERVISOR .......…………………..
Dr.D.K.VERMA Dr. SAROJ JASWAL

Professor Prof.and Head
Department of Surgery Department of Biochemistry
IGMC,Shimla IGMC,Shimla
(CO-SUPERVISOR ) (CO-SUPERVISOR)
AKNOWLEDGEMENTS
It is my proud privilege and pleasure to acknowledge with deep sense of

gratitude and devotion, the keen personal interest , affectionate encouragement
and invaluable guidance rendered to me by my ingenious and revered teacher
and supervisor Dr. R.S.Jhobta, Assoc. Professor, Department of Surgery,
IGMC, Shimla. His scholastic approach, sympathetic attitude and constructive
criticism have gone a long way in the completion of this thesis.
Words cannot express my veracious thanks and deep gratitude to my

esteemed and learned guide and co supervisors Dr. D.K.Verma, Professor,
Department of Surgery, and Dr.Saroj Jaswal Prof. and Head Department of
Biochemistry, IGMC, Shimla, for the keen interest, invaluable suggestions
rendered to me from time to time during the completion of this project.
I take this opportunity to thank with deep sense of regard and

gratitude Dr. K.S. Jaswal, Professor and Head, Department of Surgery, IGMC,
Shimla, for his keen interest, sincere advice and continuous inspiration given to
me during the course of this study.
I am also very thankful to Dr. Anil Malhotra , Professor, Department

of Surgery, IGMC, Shimla, for his sincere advice and inspiration given to me
during the completion of this thesis.
I am deeply indebted to Dr. Arun Gupta, Professor, Department of

Surgery, IGMC, Shimla, for his constant source of inspiration during the
course of this study.
I shall be failing in my duty if I do not express my deep gratitude to Dr.Ashok
Kaundal, Assistant Professor, Department of Surgery, for his incessant
encouragement and excellent guidance throughout the course of the study.
I would also like to thank Dr. U. K. Chandel, Dr. Bhavesh Devkaran,

Dr. Puneet Mahajan, Associate Professors and Dr. Sanjeev Gupta , Dr. Dhruv
Sharma ,Dr. Ved Sharma, Dr. Jagdish Gupta , Dr.Gopal, Dr.Prikshit and
Dr.Arun Chauhan Assistant Professors Department of Surgery for their much
needed help, advice and guidance.
Words cannot adequately express the deep sense of gratitude I owe to

Dr. Rajan Sood, Dr . Abdhesh and Dr.Rajesh Chopra ,Registrars, Department
of Surgery.
I would like to thank my seniors Dr. vikas, Dr. Shirish, Dr. Rahul
Mrigpuri, Dr. Rajesh Sharma, Dr. Alok Panday and Dr. Uma Sharma for
their help during the making of this thesis.
I would also like to thank my colleagues Dr. Amit, Dr. Abhishek

Thakur, Dr. Gian Chand, Dr. Rajesh Chauhan, Dr. Navneet, Dr. Varun and
Dr. Raj Kumar and my juniors Dr. Subhash, Dr.Sanjay, Dr. Kapil Negi, Dr.
Pawan, Dr. Namit, Dr. Bhavya Thakur, Dr. Rohit Dadwal, Dr. Surender, Dr.
Dinesh, Dr. Karan and Dr. Kulbhushan for their help in the making of this
thesis.
I bow my head to my father Sh.Chunni Lal and mother Smt. Begi Devi
in respect and affection who always inspired me to work hard and boosted my
morale. I thank my wife Dr. Neha Gangwar from core of my heart who have
stood by me all the time, helped me and provided me with support in so many
ways. I thank my younger brother Mr.Virender who gave me courage to face
most distressful situations whenever I happen to experience them. I could not
have done my thesis without their inspiration and help.
Last but not the least I want to thank all my patients who have given me
such an opportunity to learn. I thank them with all my heart and express my
heartfelt gratitude.
…………………….
Dr. Mukesh Kumar
TABLE OF CONTENTS
SR.NO. DESCRIPITION PAGE NO.
1. Introduction 1-2
2. Review of Literature 3-18
3. Aims and Objectives 21
4. Material and Methods 22-23
5. Obervations 33-34
6. Discussion 40-44
7. Summary 50-54
8. Conclusion 54-56
9. Bibliography 57-59
10. Annexure 60-65
a) Proforma I-III
b) Informed Consent IV
c) Key to Master Chart VI
d) Master Chart VII
ABBREVIATIONS
SILC = single incision laparoscopic cholecystectomy
cLC =conventional laparoscopic cholecystectomy
DOS = duration of surgery
Min = minute
CRP =C-reactive protein
TLC =total leucocyte count
LOS =length of stay
LESS =laparo-endoscopic single site surgery
S.NO. =serial number
BMI =body mass index

INTRODUCTION
Over the last 20 years, conventional laparoscopic cholecystectomy (cLC) as less

invasive method, has replaced open cholecystectomy in the treatment of patients
with symptomatic gallstone disease. In recent years, a search for even more
minimally invasive approaches has led to innovative techniques of single
incision laparoscopic surgery (SILS) and natural orifice transluminal
endoscopic surgery (NOTES). While substantial drawbacks of NOTES
technique including technical challenges and scarcity of instrumentation, have
limited its adoption so far1 the SILS has met more favorable acceptance in
surgical community. Its feasibility and safety have been proved in a number of
surgical procedures including cholecystectomy 2, 3.
Compared to conventional LC which is performed via three
or four abdominal ports, the single incision laparoscopic cholecystectomy
(SILC) is performed using only one infra umbilical entry into the abdominal
cavity. The first SILS procedures were done with several ports placed next to
each other through a single skin incision but with multiple fascial perforations 4,
5
. Recent development of multichannel port devices allows entry into the
abdominal cavity through a single fascial incision. Diminishing the number of
ports to only one seems attractive due to its potential to reduce wound related
complications, to decrease postoperative pain and to improve cosmetic
outcome.
Surgery, “controlled deliberate injury”, for purpose of therapy,
induces a series of biochemical and hormonal responses in the body, that
include alteration in the expression of acute phase reactants C–reactive protein
(CRP) and total leucocyte count (TLC). In general, the magnitude of changes in
CRP is apparently taken as proportional to the extent of overall surgical insult 7 .
Recent evidence indicates that trauma induced stress hormone responses are
insufficient to explain the broad spectrum of post injury defects, particularly in
relation to immune system. Stress of injury leads to production of cytokines and
acute phase proteins, which initiates increase in the levels of “Stress” hormones,
loss of muscle proteins, greater vascular permeability and changes in white
blood cell count. Some of these responses are homeostatic defense mechanism
but others such as catabolic state are thought to be deleterious. Magnitude of
metabolic response to surgical trauma, is proportional to degree of injury and
reduction of excess trauma by “Laparoscopic Techniques” might therefore
diminish the response.
Generation of acute-phase proteins is well recognized
response to tissue injury. CRP is a key marker of acute phase protein and
provides dependable screening test, for acute phase reactants6. Post operative
rise in CRP and TLC have been reported by many researchers, whereas other
workers have found no significant difference in CRP levels between
conventional LC(cLC) and SILC7.
Since the introduction of conventional laparoscopic
cholecystectomy (cLC) and SILC in our institution,we have been seeing how
easily and rapidly patients recover from surgery. An effort was made in the
present study to comparatively evaluate the pattern and magnitude of metabolic
response to injury by assessing role of CRP and TLC as stress markers in
conventional laparoscopic cholecystectomy and SILC.
REVIEW OF LITERATURE
Most of the progress in the diagnosis and treatment of biliary tract diseases
has been made in the last 150 years. However, gallstones and their sequelae,
which cause most of the clinical problems are not a malady of just the modern
times. The earliest reported gallstones date back to 21 st Egyptian dynasty
(1085-945 B.C.) having been discovered in the gallbladder of the mummy of a
priestess of Amen. Persian, Abu Bakr Mohd. Ibn Zakairya Razi described gall
stones in an ox in the year 900 BC8,9. According to Gordon-Taylor, the first
clinical description of gall stone disease was recorded in 4 th century BC8,10.
Greek physician Alexander Trallianus described the concretions within bile
ducts in 5th century which was nothing but the gall stones8.
In 1341, Gentile da Aligno demonstrated human gall

stones as one of the findings at autopsy during the public dissection 8 Andreas
Vesalius gave the accurate description of human gall stones concluding that
they represented a disease and described some of their complications 8. In
1546, Vesalius demonstrated eighteen calculi in the gall bladder of famous
advocate who died after brief illness8,11,12. Marcelles Donatus undertook a
systemic collection of data on human gall stones in 1586 and observed that
gall stones may appear in vomitus or stool8,10. Thomas Syndenham of
England has been erroneously credited with discovery of gall stone disease.
He considered biliary colic as a symptom of hysteria8,13.
CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY
The laparoscopy had its beginning in the early eighteenth century. Bozzini in
1805, viewed the urinary bladder for stones and neoplasms using a reflecting
mirror, candle and a double lumen uretheral cannula14,15.

Endoscopic methods remained crude for most of the 19th century. Stein of
Frankfurt developed an instrument called “photo endoscope”, consisting of a
reflecting mirror, a light source and a urethral cannula. A versatile endoscope
was developed by Desormeauxin in 186514,16. He incorporated a kerosene
lamp, a chimney vent and a mirror in the endoscope to visualize the urinary
bladder, cervix and uterus.
The endoscopy became practical in the year 1890 when

Germans improved the optical system14. Three years after, Edison invented the
light bulb, DeRoche invented the incandescent cystoscope14. Nitz in 1887
developed an operating cystoscope that had a prizmatic lens system and a
channel through which urethral probes could be inserted.
20 years later after the cholecystectomy was performed by

Langenbuch in Berlin in 1882; Kelling pioneered diagnostic laparoscopy in
dogs using a cystoscope17,18. Jacobeus of Stockholm is credited with the first
laparoscopy in humans in 191117,19.
The early pioneers introduced their trocars and cystoscopes

directly into the peritoneal cavity prior to the insufflation. Goetz in 1918 and
later on Veress in 1938, developed an insufflation needle for the safe
introduction of gas in the abdominal cavity17,,20. By the 1930’s, CO2 was in use
for pneumoperitoneum and spring loaded needle designed by Veress for
therapeutic pneumothorax was modified for safe introduction of gas into
abdomen20.
Fevers in 1933 was first to recommend CO2 as insufflation gas

to create pneumoperitoneum. He had his experience with 50 cases in which he
used gas from air, oxygen and carbon dioxide16. Kurt and Semm in 1950
created a device for controlled CO2 insufflation with an adjustable pressure
limit. Prior to this air was introduced into abdominal cavity by means of a
syringe17.
The best gas for insufflation at present is carbon dioxide

(CO2). It is 200 times as diffusible as O2 and threrfore more rapidly cleared by
lungs. Lindemann showed that cardiac arrythmias and haemodynamic
disturbances occurred with direct intravascular CO2 insufflation at a rate of
greater than 150 ml/min21,22.
In 1966, Hopkins incorporated rod shaped lenses as light

transmitters. This markedly improved the resolution and contrast 17. In this
system the role of glass and air are reversed in such a manner that optical
system consist of air lenses and long glass spaces. Gynaecologists in Europe
began to use laparoscopy regularly for diagnosis and tubal diathermy in the
1960’s. In 1978, Frimberg in Europe performed laparosopic cholecystectomy
in pigs.
Philipe Mauret drawing an experience with gynaecological

operations and appendicectomy is credited with having performed first
laparoscopic cholecystectomy in humans in 1987 incidently in the same
sitting while he was performing a laparoscopic gynaecological procedure on a
patient23.
Hans Frost, with German manufacturing company WISAP,

made “Galloscope,” a unique instrument complete with optics, instrument
channels, a light conductor, and valves that could maintain pneumoperitoneum
when the instrument was in place.
Mühe introduced the Galloscope on September 12, 1985 during

a planned cholecystectomy. He obtained pneumoperitoneum with a Veress
needle and introduced the Galloscope at the patient's umbilicus. He introduced a
Weck-Reynolds pistol grip hemoclip applier and scissors either through
channels in the Galloscope or through small portholes in her lower abdomen in
order to dissect the gallbladder. Then, in the course of roughly 2 hours, Dr.
Mühe performed cLC24,25.
He postulated that introducing the scope at the costal margin

would eliminate the need for pneumoperitoneum and optic guidance. Initially,
Mühe removed the pneumoperitoneum from the procedure and developed what
he referred to as “gasless LC.” Of the 94 LCs in Mühe's initial series, the first 6
were done in a “traditional” laparoscopic fashion with pneumoperitoneum and
working ports and the remaining 88 were performed by LC without
pneumoperitoneum and/or without optical guidance.25,26,27.
Mühe first presented his experience at the Congress of the

German Surgical Society (GSS) in April 1986. His presentation was met with
skepticism and ridicule. Mühe's procedure was described as “Mickey Mouse
surgery” while others remarked “small brain - small incision.”24
CRP (C REACTIVE PROTIEN)
C-reactive protein was originally discovered by Tillett and

Francis in 1930 as a substance in the serum of patients with acute inflammation
that reacted with the C polysaccharide of pneumococcus . Initially it was
thought that CRP might be a pathogenic secretion as it was elevated in people
with a variety of illnesses including cancer. Discovery of hepatic synthesis and
secretion of CRP closed that debate. It is thought to bind to phosphocholine,
thus initiating recognition and phagocytosis of damaged cells.
CRP (Acute phase reactant) is an unspecific marker of
inflammation regardless of the inflammatory stimuli.28,29. Despite this fact CRP
determination is a well established laboratory test for the diagnosis and
monitoring of different inflammatory processes such as discrimination between
bacterial and viral infections,29,30 identifications of postoperative complications,
diagnosis and grading of other inflammatory diseases, determination of
therapeutic approaches and monitoring the effect of treatment.
CRP is used mainly as a marker of inflammation. Apart from
liver failure, there are a few known factors that interfere with CRP production.
Measuring of CRP levels can help to assess disease progression and treatment
outcome.31.
In healthy young volunteer blood donors the median
concentration of CRP is 0.8 mg/lt but following an acute phase stimulus value
may increase to more than 500 mg/lt . Plasma CRP is produced only by
hepatocytes although other sites of local CRP synthesis and possibly secretion
have been suggested. De novo hepatic synthesis starts very rapidly after a single
stimulus, serum concentration rising above 5 mg/lt by about 6 hrs and peaking
around 48 hrs. The plasma half life of CRP is about 19 hrs and is constant under
all conditions of health and disease so that the sole determinant of circulating
CRP concentration is the synthesis rate, which thus directly reflects the intensity
of the pathological process stimulating CRP production. When the stimulus for
increased production completely ceases, the circulating CRP concentration falls
rapidly. Subjects in the general population tend to have stable CRP
concentration characteristics for each individual, apart from occasional spikes
presumably related to minor or subclinical infection, inflammation or trauma.
The magnitude of the metabolic response to surgical trauma is proportional to
the degree of injury.31,32.
Avery et al characterized CRP as a protein which required
Calcium ions for it to react with polysaccharide C and introduced the term acute
phase to refer to serum from acutely ill patients suffering from infectious
disease and containing CRP.
Semi quantitative assays of CRP were used for many years to
provide an objective index of the acute phase response and of the disease
activity in rheumatological and other conditions. Within the past few years there
has been a resurgence of interest in the chemical structure and functions of
CRP.
Injury or inflammation of the human body results in increased
concentrations of certain serum proteins, known as acute-phase reactant proteins
(APRP). The main influence on the concentration of APRP during the
postoperative period depends on the degree of tissue damage and the
inflammatory reaction associated with the repair and regeneration processes
33
which act to restore the integrity of the injured tissue . There is a direct
positive correlation between the concentrations of APRP, especially C-reactive
protein (CRP) and the severity of inflammation 34,35. CRP is a major component
of the acute-phase response36. CRP is very consistent in response and is
therefore the most satisfactory single screening test for an "acute phase"
34 37
reactant . CRP is a component of normal serum which rises more
38,39
dramatically than any other protein after surgical trauma . CRP begins to
rise 4-12 h postoperatively, reaches the peak level after 24-72 h and returns to
normal after 2 weeks 38,40,41,42.
CRP in cLC
Amount of visceral trauma, manipulation and dissection is often

not taken into account during different surgical techniques and emphasis is laid
mainly on parietal tissue trauma. Although it may significantly influence
surgical stress, LC is mainly considered to be a safer procedure than OC in
terms of metabolic, hormonal and immunological changes.
Several investigators have examined how laparoscopic surgery
affects the acute phase response by measuring CRP. CRP has been found to be
reduced in laparoscopic procedures compared to more radical laparotomy. The
alteration of CRP was noted to be 20 folds after OC, but only 5 folds after LC.
Many investigators have therefore tried to find the ways of reducing the
metabolic response to surgeries43.
TLC (Total Leucocyte Count)
There are normally 4,000-11,000 WBC/ lt of human blood. Of

these, the granulocytes (polymorphonuclear leucocytes) are the most numerous.
Young granulocytes have horse shoe shaped nuclei that become multilobed as
the cell grows older. Most of these contain neutrophillic granules (neutrophils)
but a few contains granules that stain with acidic dyes (eosinophils) and some
have basophillic granules (basophils). Other two cell types found normally in
peripheral blood are lymphocytes, which have large round nuclei with scanty
cytoplasm and monocytes which have abundant agranular cytoplasm with
kidney shaped nuclei. Acting together, these cells provide the body with
powerful defense against tumors and viral, bacterial and parasitic infections.
TLC in cLC
Immunosuppression is an established consequence of surgical

stress and injury. This has been defined not only in terms of cytokine but
perhaps more importantly in the cellular components of the systemic immune
response. Several recent studies have examined how laparoscopic surgery
affects various cellular components of the immune system44,45.
Laparoscopic surgery may attenuate the cellular
immunosuppression created by the stress of surgery. A number of studies have
evaluated this in terms of TLC. Some have demonstrated a significant increase
in overall peripheral leucocyte numbers in open cholecystectomy but not in
patients with LC.46.
SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY (SILC)
Single-port laparoscopy is not new. It had been around for more
than 30 years. The gynaecologists were doing tubal ligation with a single-
puncture laparoscope since the late 70s.47,48 .This technique works well for
gynaecological surgery as the uterus can be manipulated from below.
First laparoscopic cholecystectomy by single incision was

performed by Navarra et al49 in1997 with the removal of gall bladder through a
single periumbilical skin incision .He originally described a technique using
transabdominal sutures to suspend the gallbladder during single incision
laparoscopic cholecystectomy.
Romanelli et al50 performed the SILC with the newer devices

called triport system.They were among the first surgeons to perform lap
cholecystectomy through these devices .They also compared cholecystectomy
through these devices .
Bresadola et al51 in1999 compared the transumbilical technique

of laparoscopic cholecystectomy (2port) with standard laparoscopic
cholecystectomy on 40 patients.He concluded that once the learning curve has
been completed, transumbilical cholecystectomy is possible without some of
difficulties associated with standard laparoscopic cholecystectomy.
Piskun G and Rajpal S.52 in year 1999 studied transumbilical

laparoscopic cholecystectomy (2 port) utilizing no incision outside the
umbilicus. They also used two transabdominal stay suture to avoid abdominal
incision. They concluded that this method result in better cosmesis and may
reduce post operative wound complication.
53
Cuesta et al in year 2007 studied the single incision
transumbilical laparoscopic cholecystectomy on 10 female patients with mean
age of 36yrs and mean body mass index (BMI) 23 using two umbilical ports. He
used 1mm kirschner wire through subcostal line to pull the gall bladder during
dissection. He concluded that in a specific group of patient SILC improve the
cosmetic results and reduce operative trauma.
Romanelli et al50 performed the SILC with the newer devices

called triport system. They were among the first surgeons to perform lap
cholecystectomy through these devices .They also compared their results with
conventional laparoscopic cholecystectomy with special emphasis on post
operative pain in SILC.
Rao et al54 also performed SILC using newer tri-port system

called R-port on 20 patients in 2007.He concluded that SILC is cosmetically
better than the conventional laparoscopic cholecystectomy.
Hodgett et al55 compared the LESS (laparo-endoscopic single

site ) surgey with conventional laparoscopic surgery on various aspects like
operation time ,blood loss, intraoperative complications etc. on 29 patients in
year 2008.They concluded that LESS surgey can be done within same time
period as taken by conventional laparoscopic cholecystectomy with better
cosmetic results.
Li Ping CAO et al56 carried out SILC on 36 cases with

conventional laparoscopic instruments from 2008 to 2010 and compared it with
conventional laparoscopic cholecystectomy. They concluded that SILC with
common laparoscopic instruments was safe and feasible .It may need more time
to complete the operation in early period .It is an ideal alternative to LC.
Scott R Philipp et al57 performed SILC on 29 patients and

compared it with 21 patients who underwent traditional LC.They concluded that
SILC using conventional laparoscpic instruments is an effective alternative to
standard 4 port LC in selected patients. Development of a standardized
technique and additional experience is needed for more consistent success.
Noam Shussman et al58 perfomed SILC using modified technique

in 31patients.They used endo retractors to retract the gall bladder .They
concluded that single incision LC is a technically challenging surgical approach.
Increased operative times are expected at the beginning of each surgeon’s
learning curve. To overcome the technical obstacles and to perform single port
cholecystectomy with safety similar to that for standard LC, dedicated tools for
this surgical approach are needed. With such tools, SILS is a safe and feasible
approach for cholecystectomy.
Deepraj Bhandarkar et al59 attempted SILC in 110 patients

between 2009-2010 and completed in 105.They used conventional laparoscopic
instruments for this. They described step wise details of how to perform SILC.
They concluded that SILC has a relatively short learning curve and is
reproducible.SILC has some benefits over LC but still more studies will be
needed to accept it as a replacement of LC.
Homero Rivas et al60 had performed SlLC i n large series o f

patients .They concluded that Single-incision laparoscopic cholecystectomy
is safe feasible and quite reproducible i n experienced hands. The outcomes
seem comparable with those f o r conventional laparoscopic technique with
similar minimal morbidity and no mortality in their series. The operating times
are reasonable and can be lessened to times comparable with those for the
conventional laparoscopic approach especially when basic concepts regarding
the challenges of this technique are better understood and solutions being
implemented.
A. Karashmalakov e t al61 had performed S I L C in 52 patients

at Trakia University Hospital, Stara Zagora, Bulgaria. They concluded that
SILC can safely replace the LC .Main advantage of SILC over LC was the
cosmesis, leaving almost invisible scar within the umbilicus.
62
Brittney L. Culp et al had done a comparative study between
SILC and conventional LC .They concluded that post operative hospital stay is
significantly less in the patients who had undergone SILC as compared to
conventional LC, while operative time is more due to technical difficulties in
SILC.
Acute-phase proteins and inflammatory cytokines mediate measurable

responses to surgical trauma, which are proportional to the extent of tissue
injury and correlate with post-operative outcome.
McGregor et al in 2011 concluded that there are no statistically

significant differences found between SILC and cLC for interleukin-6 and C-
reactive protein levels, length of stay( LOS) and duration of surgery(DOS).
There was also no correlation between systemic stress response and operative
parameters7. There were no intra-operative complications.
SILC appears to be a safe and feasible technique with potential

advantages of cosmesis, reduced incisional pain and well-being recommending
its use. Data indicates no difference in systemic stress and morbidity between
SILC and cLC .
AIMS AND OBJECTIVES

1. To measure the levels of C-Reactive protein and Total Leucocyte Count
in patients undergoing conventional laparoscopic cholecystectomy(cLC)
and Single incision laparoscopic cholecystectomy(SILC) .
2 To study the role of and do the comparative evaluation of the levels of C-

Reactive Protein and Total Leucocyte Count in patients of conventional
laparoscopic cholecystectomy and Single incision laparoscopic
cholecystectomy.
MATERIAL AND METHODS
The present prospective study included ultrasonographically

proved 50 patients of symptomatic cholelithiasis and were posted for elective
cholecystectomy. These patients were admitted in Surgical Wards of Indira
Gandhi Medical College, Shimla .SILC were performed on 25 (50% of
patients) and cLC were conducted in rest of 25 (50%) patients. The patients
were selected randomly. Relevant history, clinical examination and
investigations were recorded as per performa attached (annexure 1). The
consent of all these patients were taken as per consent form (annexure 2). All
the patients were subjected to same general anesthesia, antibiotics,
perioperative analgesics and intravenous fluids. SILC was done by infra
umblical incision and cLC was done by three /four Trocar Technique.
INCLUSION CRITERIA :
All patients with ultrasonographically proved symptomatic

cholelithiasis , fit for general anaesthesia were included in the study.
Patients having following conditions have been excluded from the study.
1. Acute Cholecystitis /Pancreatitis.

2 Choledocholithiasis
3 Jaundice / Hypoproteinemia/Malignancy
4 History of Allergy , Taking Steroids and Chemotherapy
5 Patients on Oral Contraceptive Pills/Pregnancy
6 Patients requiring peri-operative blood transfusion.
7 Conversion of cLC to OC.
8 Intra operative injury to adjacent organs/structures.
9 Patients developing peri-operative complications.
Serial measurements of TLC and CRP were done by sampling blood

which was collected as mentioned below:-
1. Baseline Sample- Pre-operatively after overnight fasting.

2. At the time of completion of surgery with in 6 Hours.
3. 1st Post Operative day.
4. 2nd post operative day.
Data collected was analyzed statistically by using paired ‘t’ test.
C-REACTIVE PROTEIN ESTIMATION
3 ml of clotted blood sample was taken. The concentration of CRP was

measured by NYCOCARD CRP SINGLE TEST KIT AND USING
NYCOCARD READER II (AXIS– SHIELD, Norway ).
MATERIAL
TD (Test Device) : Plastic device containing a membrane
coated with monoclonal anti-CRP antibodies.
R-1 (Dilution Liquid) : (0.4 ml)
Borate buffer (pH 9.0) and detergents.
R2 (conjugate) : (1 x 3.5 ml)
Solution containing monoclonal anti-CRP
antibodies with ultra small gold particles.
R3 (Working Solution) : ( 1 x 3.0 ml)
Phosphate buffered NaCl solution
(pH 7.4) and detergents
C+ (Control Positive) : (1 x 05 ml)
Serum of human origin with added purified
CRP
Capillary tubes : 5 ml end to end glass capillaries
Pipette (5 ml) and pipette tips

Capillary tube holder
Nycocard Reader II
Test Procedure
1. 5 L capillary was filled with patient sample or C+ (Control Positive), and
the capillary was dropped into the tube with R1(Dilution Liquid). The tube
was closed and mixed well for 10 seconds.
2. 50 L diluted sample or dilute C+ (Control Positive) was applied to the TD

(Test Device). The sample was allowed to soak into the membrane (approx.
30 second).
3. One drop R/2 Conjugate was allowed to the TD (Test Device). The reagent
was allowed to soak into the membrane (approx. 30 seconds).
4. R3 (Washing Solution) was allowed to the TD (Test Device). The reagent

was allowed to soak into the membrane (approx. 20 second).
5. The result was read within 45 minutes using the NycoCard READER II
following the READER II user instruction manual.
TOTAL LEUCOCYTE COUNT ESTIMATION
TLC was measured by AUTOMATED HEMATOLOGY CELL COUNTER

(MELET SCHLOESING LABORATORIES OSNY-FRANCE)
 A collecting tube with anticoagulant EDTA K3 (violet or blue cap) was
filled upto 2/3rd with the blood sample.
 Blood and anticoagulant were mixed thoroughly by inverting the tube 10
times .
 Appropriate bank was selected i.e. male adult /female adult/child .After
selecting appropriate bank that particular bank was saved.
 The MS9 was ready to run the sample.
Following procedures were followed.
o Cap was taken off the tube
o The tube was placed in the holder by choosing the correct adaptor
for the volume of the sample tube(red, blue, white or green)
o The analysis was started automatically by pressing << ALT>>C.
o The tube was taken out after the end of the analysis.
o The result was automatically displayed once the counting was
done.
First of all, the patient was asked to pass urine before entering
operation theatre. With patient in supine position, general anesthesia was given.
Cleaning and draping was done in the standard fashion. The patient was placed
in reverse Trendelenberg position of 30 degree while rotating the table to left by
15 degree. This maneuver allowed the duodenum and colon to fall away from
the liver edge.
The operating surgeon stood to the patient's left, the camera

operator to the surgeon's left and the assistant on the patient's right. The video
monitor was placed on the patient's right at the level of the shoulder, to give an
unobstructed view for the surgeon and camera assistant.
The Veress needle was inserted through a stab incision in the

infra-umbilical region, almost perpendicular to the abdominal wall with a slight
angle towards the pelvis. Saline drop test was done for checking correct
placement of Veress needle. (Saline drops were injected into peritoneal cavity.
When no aspirate was returned, it checked the correct placement of Veress
needle)
Pneumoperitoneum was created using this Veress needle through

which CO2 was insufflated into peritoneal cavity to a pressure of 13mm of
Hg.10mm incision was made for 10mm trocar at the site of stab incision in the
infra-umbilical region. The trocar was inserted towards the pelvis at an angle of
about 80 degree to the anterior abdominal wall.
Laparoscope was introduced through the umbilical port and a

complete examination of abdominal cavity was performed. The second trocar
was placed under direct laparoscopic vision in the midline between the xiphoid
and the umbilicus through a 10mm incision, ensuring that its entry into
abdominal cavity was on the right side of the falciform ligament. Also the trocar
was directed towards the gall bladder, so that there was no need to reposition it
continuously throughout the procedure.
Two 5mm ports were placed, one in the subcostal region, in the
midclavicular line for the atraumatic grasper for the left hand of the surgeon
and another at the level of umbilicus along anterior axillary line for the
assistant’s rachet ( with lock ) grasper, by 5mm stab incisions.
With the laparoscope through the umbilical port, a rachet grasper was
introduced through the lateral 5mm trocar to grasp the fundus of the gall
bladder. The assistant applied traction upward and backward to establish
optimal exposure.
Another atraumatic grasper was introduced through the midclavicular

port. When the anatomy was evident, the grasper was used to catch Hartmann’s
pouch and apply the necessary traction.
Working with both hands , the surgeon took the grasper that holded
Hartmann’s pouch in his or her left hand and applied upward and lateral traction
to identify the structures in the cholecystoduodenal ligament and the common
bile duct.
A 5 or 10mm instrument, generally an atraumatic Maryland curved

dissector was introduced through the subxiphoid port with the right hand and
blunt dissection was started in the cholecystoduodenal ligament, which was
simple when there was no intense acute or chronic inflammation. This
dissection allowed identification of the cystic duct, bile duct and cystic artery.
Once the junctions of the cystic duct to the gallbladder and to the
bile duct were identified and the right peritoneal attachment of the gallbladder
dissected out, traction was applied to Hartmann’s pouch to the right side of the
patient and slightly upwards to enable dissection of the left peritoneal
attachment. At this point care was taken to avoid injury to the small arteries that
accompany the cystic lymph node located near the cystic artery bifurcation.
In case of haemorrhage, the Monopolar Electrocautry or harmonic

scalpel was used.
Once all the structures were clearly identified then the cystic duct
and artery were divided. To perform this, two staples were placed in the cystic
duct, using clip applicator, one proximal to the main duct and the other as
close as possible to the gallbladder to prevent spillage.
Two staples were placed distally and one proximally on the cystic
artery and both structures were divided with metzenbaum scissors. To dissect
and release the gallbladder from the rest of the hepatic bed, a hook or spatula
connected to the monopolar Electrocautry device was used, with the irrigation
and aspiration at the same time. Dissection was performed ensuring careful
haemostasis while the graspers in the fundus and Hartman’s pouch were used to
give a good exposure.
Before removing the gallbladder completely, a careful examination

of the hepatic bed was performed to verify haemostasis and the bleeding points
were cauterized. Drains were left as a routine in most of the cases, introduced
by most lateral 5mm port.
The gall bladder was extracted by subxiphoid port by claw forceps.

All incisions of 10mm were sutured with vicryl (port closure 35mm) to avoid
herniations and post operative complications.
SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY:
Equipment and Instruments:
We used conventional laparoscopic instruments and equipment for performing

SILC. We used 5mm laparoscope for performing the procedure. A sharp image
that allows clear distinction between tissue planes and tissue textures is essential
for safe dissection.
Position of the patient, team and equipment:
The patient was positioned supine on the operating table with the
legs split apart and strapped firmly to the leg boards. Both arms of the patient
were placed on arm boards at an angle less than 90º to the torso.
The surgeon stood on the left side of the patient, with the assistant opposite to
him during the placement of the first port. For rest of the procedure, the surgeon
stood between the legs and the camera person stood to his right (near the left leg
of the patient). The monitor trolley was placed above the patient's right arm.
The diathermy pedal was placed near the surgeon's left foot and all tubes and
cables were fixed such that they do not interfere with the camera person.
Placement of ports:
We had given an infraumbilical curved incision. The umbilicus

was everted and held with two-toothed forceps in a cephalic and caudal position
prior to making an incision of length 2-2.5 cm. This was deepened through the
fat and the flaps were undermined to expose the fascia over a distance of 2-2.5
cm. The left edge of the skin incision was retracted and a fascial stab incision
was made. A Veress needle was introduced through this incision and after
confirmation of its intraperitoneal position; CO2 pneumoperitoneum was
induced and maintained at 12 mm Hg. In the initial cases a 10 mm port was
inserted at the incision line and the two five mm ports were placed 0.5 cm
inferiorly and laterally on either side through the same skin incision. A grasper
introduced through the right lateral port was used for fundal traction. The
dissector introduced through the left lateral port was used to dissect the fine
Calot’s triangle. The instrument port and the telescope port were crossed by a
chopstick method to avoid “sword fighting’’ and clashing of instruments in the
abdomen. At this stage, the patient's position was changed to an anti-
Trendelenberg one with a left-sided tilt which helped in the better exposure of
the Calot’s triangle. Later we used only two ports one five mm port for five mm
camera and another was ten mm working port through which laparoscope,
needle holder, grasper and extractor were introduced at the various steps of
SILC procedure.
Placement of traction sutures :
This was the key step of the SILC i.e. "puppeteer"12 technique, in
which traction sutures were used to hold gall bladder. At the beginning of the
procedure, a grasper or a dissector was used to move the omentum away from
the right upper quadrant so as to obtain a view of the fundus of the gallbladder.
Flimsy omental adhesions, if present, were teased off at this stage. We used a
strand of 1-0 vicryl on a 60-mm straight needle for placing the traction sutures.
The needle was introduced laterally through one of the intercostal spaces above
the level of the costal margin on right side. A laparoscopic needle holder
brought the needle into the peritoneal cavity and placed it on the omentum. The
needle was then regrasped at its midpoint, a bite of the fundus of the gallbladder
was taken and the needle was driven out through the same intercostal space. The
needle was retrieved using an open needle holder and the suture was pulled out
leaving two ends of 5-6 cm. The suture was divided and a haemostat was
applied to both ends close to the skin, resulting in elevation of the gallbladder
fundus. Another traction suture was taken in which the needle was introduced
from the epigastric region just below the xiphi sternum .This needle was passed
through the Hartmann’s pouch with the help of needle holder and then taken out
from lateral abdominal wall. Both ends were held with hemostats. This helped
in lifting the Hartmann’s area and helped in better dissection.
Dissection of the Calot's triangle:
The posterior peritoneum was divided to free the Hartmann's

pouch. This was followed by further dissection of the anterior and posterior
peritoneal leaves overlying the Calot's triangle with the help of a hook and/or a
Maryland dissector. The cystic artery and the cystic duct were skeletonised - the
endpoint of this dissection was obtaining a "critical view".
Control of the cystic artery:
The two windows in the Calot's triangle were dissected more

widely than during an conventional LC so as to safely observe the tips of the
instruments controlling the artery and the duct. We had clipped the cystic artery
with a 10-mm reusable clip applicator. Subsequently, the cystic artery was
divided.
Control of the cystic duct:
If the cystic duct appeared narrow, it was clipped thrice with 10-
mm clips and divided. If the duct appeared wide, we preferred to pass a No. 1
polyglactin suture around it, exteriorize the same and fashioned an
extracorporeal Meltzer’s knot. This knot was then snugged down onto the cystic
duct with the help of a metal knot-pusher. The duct was divided between two
extra corporeally tied ligatures. If there was a suspicion of an impacted stone in
the cystic duct, it was controlled on the gallbladder side, divided partially to
allow the stone to be milked out, and then the stump was ligated using
extracorporeal knotting. A 10-mm port was used for introducing a spoon
forceps for the retrieval of stones from cystic duct or those that may spill from
the gallbladder if it was perforated during dissection. The divided ends of the
cystic artery and duct were carefully inspected to confirm their secure closure.
Dissection of the gallbladder:
Alternating medial and lateral rotation of the gallbladder using

the ends of the suture placed on Hartmann's pouch was done to dissect the
gallbladder from the liver bed using a diathermy hook. Prior to the final
detachment of the gallbladder, meticulous haemostasis in the liver bed was
ensured and the subhepatic space lavaged with saline. The fundal traction suture
was loosened and the gallbladder was freed from the liver.
Specimen extraction:
Gall bladder was then held at neck with the grasper and extracted
through the umbilical 10 mm port.
Closure of the incision:
Careful closure of the fascial incision was done to prevent

formation of port-site hernia. The edges of the fascial incision were identified,
grasped and elevated using fine Kocher's forceps. We closed the rectus sheath
using vicryl no.1 suture. The fascia and the skin were infiltrated with a local
anaesthetic and the skin was closed using sutures.
Postoperative course:
The postoperative care was identical to that of patients undergoing

standard laparoscopic cholecystectomy. Intravenous analgesics and anti-emetics
were administered for the duration of hospital stay. Patients were allowed to
ambulate and take liquids after 6-8 hours of surgery. Findings were recorded as
per Performa attached.
NYCO CARD READER WITH REAGENTS KIT
REAGENTS KIT
AUTOMATED HEMATOLOGY CELL COUNTER
INFRAUMBLICAL INCISION
INSTRUMENTS INSERTION THROUGH INFRAUMBLICAL
INCISION
PUPPETEER TECHNIQUE
DISSECTION OF CALOT’S TRIANGLE
SPECIMEN EXTRACTION
WOUND AFTER SKIN CLOSURE
PATIENT POST OPERATIVELY
OBSERVATIONS
The present study was conducted in the Department of Surgery,

IGMC, Shimla over a period of 1 year from 1st July, 2012 to 30th June, 2013 on
50 patients who were admitted for elective cholecystectomy. These patients
were alternatively divided into two groups of 25 patients each. Group ‘A’
included patients in whom SILC was done and Group ‘B’ included patients who
underwent cLC. Detailed history was taken, thorough clinical examination was
done and appropriate investigations were carried out in each case which were
recorded in the Performa attached. The following observations were made:
1:- AGE DISTRIBUTION IN SINGLE INCISION AND

CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY GROUP:-
The age of patients in the present study ranged from 15 to 58 years. In SILC
group, the age ranged from 15 to 58 years and the mean age was 30.88±9.248
(standard deviation ) years, whereas in cLC group, the age ranged from 15 to 54
years and the mean age was 35.20±9.923 (standard deviation) years. Patients
were grouped as : below 30 years,30-45 years and more than 45 years .Majority
of patients were in between 30-45 years and were 56% and 68% in SILC and
cLC groups respectively . The youngest patient in SILC group was 15years of
age, whereas in cLC group, youngest patient was of 16 years (see master
charts). The p value for age of patients between SILC and cLC groups was
0.095 . (Table 1a,1b and figure 1a,1b ) .
Table no 1a :- GROUP STATISTICS (AGE)
Std. Std. Error
Group N Mean Deviation Mean
Age SILC 25 30.88 9.248 0.850
cLC 25 35.32 9.923 0.980
FIGURE 1a :-
40
35
30
25 no.of pts
mean
20
std .deviation
15 std error of mean
10
0
SILC c LC
Table no 1b :- Age Distribution
Age SILC Clc

(years) No. of patients %age No. of patients %age
(n=25) (n=25)
<30 10 40 5 20
30-45 14 56 17 68
>45 1 4 3 12
pvalue= .095, (p >0.05 - insignificant).
FIGURE 1b :-
70
60
50
40
<30
30
30-45
20
>45
10
0
No. of %age No. of %age
patients patients
SILC cLC
2:- SEX DISTRIBUTION:-
Out of 50 patients, 43 patients (86%) were female and 7 patients (14%)

were male. In the SILC group 24 patients (96%) were female and only 1 patient
(4%) was male, whereas in the cLC 19 patients (76%) were females and 6
patients (24%) were males. (Table 2, Figure 2)
Table no 2 :- Sex Distribution
SILC Clc
Sex
(n=25) %age (n=25) %age
Male 1 4 6 24
Female 24 96 19 76
p value= 1.00 ( p >0.05- insignificant )
FIGURE 2:-
100
90
80
70
60
50 Male
40 Female
30
20
10
0
(n=25) %age (n=25) %age
SILC cLC
3:-BASAL METABOLIC INDEX (BMI) :-
The BMI ranged from 18 to 3O kg/m2 with mean BMI of 21.08 whereas
it was 21.04 and 21.88 in the SILC and cLC groups respectively. The p value
is0.20 which is statistically insignificant. (Table 3, figure 3)
Table no 3 :- BASAL METABOLIC INDEX (BMI) :-

SILC c LC
2
BMI(Kg/M ) No. of patients %age No. of patients %age
(n=25) (n=25)
18-20 16 64 2 8
21-23 9 36 15 60
24-26 0 0 6 24
27-29 0 0 1 4
30-32 0 0 1 4
MEAN 21.04 21.88
p value= .20 ( p >0.05- insignificant )
FIGURE 3:-
16
14
12
10
8
SILC
6
c LC
4
2
0
4:- COMPARISON OF DURATION OF SURGERY (DOS):-
Only one (4%) patient of SILC group was operated during the time
interval of 20-39 minutes while in cLC group 13(52%) were operated during the
similar time interval. During 40-59 minutes of time interval 16(64%) patients in
SILC group had undergone surgery while in cLC group 12(48%) patients were
operated in this time interval. In 60-79 minutes of time duration 8 (32%) of the
patients were operated in SILC group while the entire patient in cLC group had
been operated before this time interval. The mean time for the duration of
surgery was 53.32 min in SILC group and in cLC group mean operating time
was 39.40min, with p value 0.001 ,showing that the operating time in the SILC
group was significantly high as compared to the cLC group. (table 4, figure 4)
Table 4:- COMPARISON OF DURATION OF SURGERY (DOS):-
Time SILC GROUP cLC GROUP

(in No. of %Age No. of %Age
minutes) patients patients
(n =25) (n =25)
20-39 1 4 13 52
40-59 16 64 12 48
60-79 8 32 0 0
MEAN 53.32 35.20
p value= <.001 (p <0.05- significant).

FIGURE 4 :-
70
60
50
40
30
20-39
20
40-59
10
0 60-79
No. of
%Age
patients No. of
%Age
patients
SILC GROUP
cLC GROUP
5:- COMPARASION OF TLC ( BASE LINE)
The pre operative TLC of these patients ranged from 4.78 m/mm3 to 9.56
m/mm3. In the SILC group, pre operative TLC ranged from 4.10 m/mm3 to 8.80
m/mm3 and the mean was 6.286±1.147 m/mm3(standard deviation) . In the cLC
group, pre operative TLC ranged from 4.38 m/mm3 to 9.36 m/mm3 and the
mean was 6.654±1.569 m/mm3(standard deviation). The p value for pre
operative TLC between OC and LC groups was 0.349. (Tables 5. figures 5)
Table 5:- COMPARASION OF TLC ( BASE LINE)
TLC SILC GROUP cLC GROUP

(in m/mm) No. of %Age No. of %Age
patients patients
(n =25) (n =25)
4.00-7.90 24 96 19 76
8.00-11.00 1 4 6 24
>11.00 0 0 0 0
MEAN 6.286 6.654
p value= 0.349, which is insignificant.

FIGURE 5:-
100
90
80
70
60
50
40 4.00-7.90
30 8.00-11.00
20
10 >11.00
0
No. of
%Age
patients No. of
%Age
patients
SILC GROUP
cLC GROUP
6 :- COMPARASION OF TLC (WITH IN 6 HOURS
TLC with in 6 hours ranged from 4.2 m/mm3 to 11.63 m/mm3 .
In the SILC group, mean was 7.106±2.361 m/mm3(standard deviation).
In the cLC group, TLC ranged from 2.2 m/mm3 to 12.00 m/mm3 and
the mean was 9.991±14.547 m/mm3(standard deviation) .The p value for
TLC between SILC and cLC groups was 0.333. (Table 6 and figure 6 ).
Table 6 :- COMPARASION OF TLC (WITH IN 6 HOURS)

patients patients
(n =25) (n =25)
4.00-7.90 19 76 19 76
8.00-11.00 4 16 5 20
>11.00 2 8 1 4
MEAN 7.106 9.991
p value =0.333 ,which is insignificant.
FIGURE 6:-
80
70
60
50
40 4.00-7.90
8.00-11.00
30
>11.00
20
10
0
No. of %Age No. of %Age
patients patients
SILC GROUP cLC GROUP
7 :- COMPARASION OF TLC (WITH IN 24 HOURS)
TLC on 1st post operative day (24 hours after surgery) of these patients ranged
from 4.4 m/mm3 to 12.2 m/mm3. In the SILC group, mean was 7.554±3.196
m/mm3(standard deviation) .In the cLC group, the mean was 7.122±2.351
m/mm3(standard deviation) . Number of patients were 25 in each group
.Majority of patients had TLC between 4.00 -7.90m/mm3 . .i.e. 56 % and 64% in
SILC and cLC group respectively .The p value for TLC on 1st post operative
day between SILC and cLC groups was 0.589.(Table 7 and figure 7 ).

patients patients
(n =25) (n =25)
4.00-7.90 15 56 16 64
8.00-11.00 9 36 8 32
>11.00 2 8 1 4
MEAN 7.554 7.122
p value = 0.589 ,which is insignificant.

Figure 7:-
70
60
50
40
4.00-7.90
30
8.00-11.00
20
>11.00
10
0
patients patients
8 :- COMPARASION OF TLC (WITH IN 48 HOURS)
TLC on 2nd post operative day (48 hours after surgery) of these patients ranged
from 4.3 m/mm3 to 12.8 m/mm3 . In the SILC group, mean was 8.923±2.165
m/mm3(standard deviation). In the cLC group, mean was 7.339±2.776 m/mm3
(standard deviation). Number of patients were 25 in each group .Majority of
patients had TLC between 4.00 -7.90m/mm3 . .i.e. 52 % in cLC group. In SILC
group,majority of patients had TLC between 8.00 -11.00m/mm3 . .i.e. 52 %.The
p value for TLC on 2nd post operative day between SILC and cLC groups was
0.029. (Table 8 figure 8).

(in No. of %Age No. of %Age
m/mm)3 patients patients
(n =25) (n =25)
4.00-7.90 8 32 13 52
8.00-11.00 13 52 11 44
>11.00 4 16 1 4
MEAN 8.923 7.339
p value= 0.029, which is insignificant.
FIGURE 8 :-
60
50
40
30 4.00-7.90
8.00-11.00
20 >11.00
10
0
patients patients
9 :-COMPARASION OF CRP (BASELINE)
The pre operative CRP of these patients ranged from 2 mg% to 5
mg%. In the SILC group, pre operative CRP was < 5 mg% . In the cLC group,
pre operative CRP was also < 5 mg% .The p value for pre operative CRP
between SILC and cLC groups was insignificant.
Table 9 :-COMPARASION OF CRP (BASELINE)
CRP SILC GROUP cLC GROUP

(in mg/dl) No. of %Age No. of %Age
patients patients
(n =25) (n =25)
<5 25 100 25 100
6- 10 0 0 0 0
>10 0 0 0 0
p value in 1.00 , insignificant.

FIGURE 9 :-
100
90
80
70
60
50
40 <5
30
20 .6-10.
10
>10
0
No. of
%Age
patients No. of
%Age
patients
SILC GROUP
cLC GROUP
10 :- COMPARASION OF CRP (WITH IN 6 HOURS)
CRP with in 6 hours ranged from 5 mg% to 48 mg% .In

the SILC group, CRP mean was 22.98±17.55 mg%(standard deviation ).
In the cLC group, CRP mean was 20.58±22.6 mg%(standard deviation).
Number of patients were 25 in each group .Majority of patients had CRP
value below 5 mg% i.e. 80 % and 60% in SILC and cLC group
respectively. The p value for CRP between SILC and cLC groups was
0.854. (Table 10 and figure 10) .
Table 10 :- COMPARASION OF CRP (WITH IN 6 HOURS)

patients patients
(n =25) (n =25)
<5 20 80 15 60
6- 10 01 4 2 8
11- 20 03 12 2 8
>20 01 4 6 24
MEAN 22.98 20.58
p value =0.854, which is insignificant.

FIGURE 10 :-
80
70
SILC GROUP No. of
60
patients
50 SILC GROUP %Age
40
cLC GROUP No. of
30 patients
20 cLC GROUP %Age
10
0
<5 .6-10 .11-20 >20
CRP on 1st post operative day (24 hours after surgery) of these
patients ranged from 5 mg% to 120 mg% . In the SILC group, CRP mean was
47.10±33.28 mg% (standard deviation ). In the cLC group, CRP mean was
45.40±28.54 mg%(standard deviation ). Number of patients were 25 in each
group .Majority of patients had CRP value more than 20 mg% i.e. 60 % and
76% in SILC and cLC group respectively. The p value for CRP at 1st post
operative day (24 hours after surgery) between SILC and cLC groups was
0.854. (Table 11 and figure 11).

patients patients
(n =25) (n =25)
<5 3 12 2 8
6- 10 2 8 0 0
11- 20 5 20 4 16
>20 15 60 19 76
MEAN 47.10 45.40
p value =0.854 ,which is insignificant.
FIGURE 11 :-
80
70
60 SILC GROUP No. of

patients
50
SILC GROUP %Age
40
cLC GROUP No. of
30 patients
cLC GROUP %Age
20
10
0
<5 06-Oct Nov-20 >20
CRP on 2nd post operative day (48 hours after surgery) of

these patients ranged from 6.2 mg% to 120 mg% . In the SILC group, CRP
mean was 61.98±37.06 mg%. In the cLC group, CRP mean was 65.08±39.6
mg%. Number of patients were 25 in each group .Majority of patients had CRP
value more than 20 mg% in each group i.e. 80 % in both SILC and cLC
group. The p value for CRP at 2nd post operative day between SILC and cLC
groups was 0.781 .(Table 12 and Figure 12).

patients patients
(n =25) (n =25)
<5 1 4 1 4
6- 10 1 4 2 8
11- 20 3 12 2 8
>20 20 80 20 80
MEAN 61.98 65.08
p value = 0.781, which is insignificant.

FIGURE 12 :-
80
70
60
50 No. of patients
%Age
40
No. of patients
30
%Age
20
10
0
<5 06- .10 .11-20 >20
Group Statistics
N Mean Std. Deviation Std. Error Mean
Age SILC 25 30.88 9.2480 0.850
cLC 25 35.20 9.923 0.980
BMI SILC 25 21.04 2.111 .422
cLC 25 21.88 2.505 .501
DOS SILC 25 53.32 8.924 1.785
cLC 25 39.40 7.263 1.453
TLC1 SILC 25 6286.64 1147.485 229.497
cLC 25 6654.72 1569.302 313.860

TLC2 SILC 25 7106.72 2361.017 472.203
cLC 25 9991.56 14547.668 2909.534
TLC3 SILC 25 7554.72 3196.590 639.318
cLC 25 7122.44 2351.837 470.367
TLC4 SILC 25 8923.64 2165.719 433.144
cLC 25 7339.08 2776.619 555.324
25
CRP1 SILC 0.000. 0.000. 0.000.
cLC 25 0.000. 0.000. 0.000.
CRP2 SILC 4 22.98 17.558 8.779
cLC 10 20.58 22.662 7.166
CRP3 SILC 23 47.10 33.285 6.940
cLC 22 45.40 28.545 6.086
CRP4 SILC 24 61.98 37.062 7.565
cLC 24 65.08 39.640 8.091
Independent Samples Test
Levene's Test for Equality of Variances t-test for Equality of Means
F Sig. t Df
Age Equal variances assumed 3.649 .062 -2.757 48

Equal variances not assumed -2.757 45.203
BMI Equal variances assumed .369 .546 -1.282 48
Equal variances not assumed -1.282 46.658
DOS Equal variances assumed .822 .369 6.049 48
Equal variances not assumed 6.049 46.098
TLC1 Equal variances assumed 4.842 .033 -.947 48
Equal variances not assumed -.947 43.958
TLC2 Equal variances assumed 2.502 .120 -.979 48
TLC3 Equal variances assumed .445 .508 .545 48
Equal variances not assumed .545 44.095
TLC4 Equal variances assumed 2.082 .156 2.250 48
Equal variances not assumed 2.250 45.313
CRP2 Equal variances assumed .102 .755 .188 12
CRP3 Equal variances assumed .858 .360 .184 43
CRP4 Equal variances assumed .122 .728 -.280 46
Independent Samples Test
t-test for Equality of Means

Sig. (2-tailed)
Std. Error
p-value Mean Difference Difference
Age Equal variances assumed .008 -8.320 3.018
Equal variances not assumed .008 -8.320 3.018
BMI Equal variances assumed .206 -.840 .655
Equal variances not assumed .206 -.840 .655
DOS Equal variances assumed .000 13.920 2.301
Equal variances not assumed .000 13.920 2.301
TLC1 Equal variances assumed .349 -368.080 388.815
TLC2 Equal variances assumed .333 -2884.840 2947.603
TLC3 Equal variances assumed .589 432.280 793.708
TLC4 Equal variances assumed .029 1584.560 704.271
CRP2 Equal variances assumed .854 2.395 12.720
CRP3 Equal variances assumed .854 1.709 9.263
CRP4 Equal variances assumed .781 -3.104 11.077

DISCUSSION
Laparoscopic cholecystectomy (three or four trocars) is known to be a gold

standard for cholecystectomy63,64. As a result of development of new surgical
technique and highly sophisticated technologies, surgical approach to
gallbladder has tendency to become less invasive by reducing number and size
63,65,66
of operative ports and instruments ; with intention of less postoperative
pain, shorter hospitalization time and better cosmetic results. Single-incision
laparoscopic (SILC) cholecystecomy is a step toward these objectives, because
it cannot be overstated that every incision and trocar placement poses a risk of
bleeding, organ damage and incisional hernia. 66,67.
CRP and TLC are well known systemic stress factors. In order to
understand more about the impact of stress factors like C- reactive protein and
total leucocyte count during the surgery and after the surgery, study was
conducted in IGMC,shimla. In this study 25 patients who underwent cLC were
compared with 25 patients who underwent SILC. The patients in reference to
variables such as age, height, weight or BMI were similar in the two different
groups of cLC and SILC .
The aim of this study was to compare single incision

laparoscopic cholecystectomy with 4 port laparoscopic cholecystectomy in
terms of preoperative and post operative CRP and TLC at different time
intervals and to look for any significant difference between these two groups.
1. AGE DISTRIBUTION IN SINGLE INCISION AND 4PORT

LAPAROSCOPIC CHOLECYSTECTOMY GROUP:-
The age of patients included in the study ranged from 15 years to
58 years. The mean age was 30.8 years in the SILC and 35.40 years in cLC
group respectively,which is statistically insignificant(p value=.095).
Rasic Zaraco et al 201068, in his study conducted to compare SILC
and cLC also has shown no significant age differerence.
2. SEX DISTRIBUTION:-
In the present study 86% of the total patients were females and 14 % were
males (Table 2, Figure 2). There was 1 male (4%) and 24 females (96%) in the
SILC and 6 males (24%) and 19 females (76%) in the cLC group. The study of
H. Rivas et al60 in which 80 women (85%) and 15 men (15%) were included in
SILC group and female to male ratio was 16:3.
The study conducted by Roland Raakow et al69 had included 142 women (65%)
and 78 (35%) men. Of all the above cited studies it has been supported the fact
that gall stones are more common in females.
3. BASAL METABOLIC INDEX (BMI):-
The BMI ranged from 18 to 3O kg/m2 . Mean was 21.04 in the

SILC and 21.88 in the cLC group respectively. The p value was >0.206 which
was statistically insignificant. (table3,figure3).
The BMI in the study of Asakuma et al70 was 22+-2kg/m2 in both

SILC and 4 port LC group.
Study conducted by Dragon schwartz et al71 , in 2010 have shown

no significant difference in BMI in SILC and cLC.
4. COMPARISON OF DURATION OF SURGERY (DOS):-
Only 1 (4%) patient of SILC group was operated during the time
interval of 20-39 min while in 4port LC group 13 (52%) were operated during
the similar time interval. During 40-59 min of time interval 16(64%) patients in
SILC group had undergone surgery while in 4port LC group 12(48%) patients
were operated in this time interval. In 60-79 min of time duration 8(32%) of the
patients were operated in SILC group while all the patient in 4port LC group
had been operated before this time interval. The mean time for the duration of
surgery was 53.32min in SILC group and in 4port LC group mean operating
time was 39.40min, showing that the mean operating time in the SILC group
was significantly high as compare to the 4port LC group. P value= <.oo1 (p
<0.05- significant).
The study conducted by Evangelos C. Tsimoyiannis et al 72 had

found Mean operative time 37.3 ± 9.16 min in 4 port LC and 49.65 ± 9.02min in
SILC. Thus, the results of the present study are similar to that reported above in
the manner that total duration of surgery in SILC group is more than that in the
cLC group.
Zaraco et al 201068, in his study conducted to compare SILC and

cLC also has shown no significant differerence in terms of duration of surgery
.It was 46 min in SILC and 43 min in cLC
5. PRE OPERATIVE TLC
The mean pre operative TLC in the SILC group, the mean was
6.286±1.147 m/mm3 whereas in the cLC group, the mean pre operative TLC
was 6.654±1.569 m/mm3. The result was comparable in both the groups (p =
0.395). which is insignificant .
Wright VJ et al73 also compared systemic stress response in

the form of TLC pre and post operatively and found no significant difference
between SILC and cLC.
6. TLC WITH IN 6 HOURS:-
TLC with in 6 hours ranged from 4.2 m/mm3 to 11.63 m/mm3. In

the SILC group, mean was 7.106±2.361 m/mm3. In the cLC group, TLC ranged
from 2.2 m/mm3 to 12.00 m/mm3 and the mean was 9.991±14.54 m/mm3. The p
value for TLC between SILC and cLC groups was 0.333. (Table 6 and figure
6).
Darzi et al 201174 also compared systemic stress response in the
form of TLC pre and post operatively and found no significant difference
between SILC and cLC.
7.COMPARASION OF TLC (WITH IN 24 HOURS)
TLC on 1st post operative day (24 hours after surgery) of these
patients ranged from 4.4 m/mm3 to 12.2 m/mm3. In the SILC group, mean was
7.554±3.196 m/mm3. In the cLC group, the mean was 7.122±2.351 m/mm3. The
p value for TLC on 1st post operative day between SILC and cLC groups was
0.589. (Table 7 and figure 7 ).
As shown by p value there is no significant difference between both groups.
8. COMPARASION OF TLC (WITH IN 48 HOURS)
TLC on 2nd post operative day (48 hours after surgery) of these
patients ranged from 4.3 m/mm3 to 12.8 m/mm3. In the SILC group, mean was
8.923±2.165 m/mm3. In the cLC group, mean was 7.339±2.776 m/mm3. The p
value for TLC on 2nd post operative day between SILC and cLC groups was
0.029. (Table 8 figure 8).
pvalue= 0.290, which is insignificant.
Same finding was supported by McGregor et al ,2011 in his study7.

9 .COMPARASION OF CRP (BASELINE)
The pre operative CRP of these patients ranged from 2 mg% to 5

mg%. In the SILC group, pre operative CRP was ,< 5 mg% . In the cLC group,
pre operative CRP was also < 5 mg% . As all values were < 5 mg% , so p
value for pre operative CRP between SILC and cLC groups was insignificant.
10. COMPARASION OF CRP (WITH IN 6 HOURS)
CRP with in 6 hours ranged from 5 mg% to 48 mg% .In the

SILC group, CRP mean was 22.9±17.55 mg%. In the cLC group, CRP mean
was 20.58±22.6 mg%. The p value for CRP between SILC and cLC groups was
0.854. (Table 10 and figure 10) .
McGregor et al 20117, measured CRP,TLC and IL-6 after gall
bladder removal in both groups i.e. SILC and cLC and found no significant
difference in both these groups.
11. COMPARASION OF CRP (WITH IN 24 HOURS)
CRP on 1st post operative day (24 hours after surgery) of

these patients ranged from 5 mg% to 120 mg% . In the SILC group, CRP
mean was 47.10±33.23 mg%. In the cLC group, CRP mean was
45.40±28.54 mg%. The p value for CRP at 1st post operative day (24 hours
after surgery) between SILC and cLC groups was 0.854. (Table 11 and
figure 11).
Froghi et al (2011)75 reported that serum IL-6, TNF-α, CRP and

TLC levels were not significantly different in the SILC and 4PLC groups at
baseline and at six , 24 hours and 48 hours after surgery (p>0.05 for all).
12 . COMPARASION OF CRP (WITH IN 48 HOURS)
CRP on 2nd post operative day (48 hours after surgery) of these
patients ranged from 6.2 mg% to 120 mg% . In the SILC group, CRP mean was
61.98±37.06 mg%. In the cLC group, CRP mean was 65.08±39.6 mg%. The p
value for CRP at 2nd post operative day between SILC and cLC groups was
0.781 .(Table 12 and Figure 12).
Two studies compared the surgical stress response in SILC and
4PLC patients by measuring biochemical stress markers including IL-6, TNF-α,
CRP and TLC, six and 24 hours after surgery (Froghi et al 2011; McGregor et
al 2011). Froghi et al (2011) reported that serum IL-6, TNF-α, CRP and TLC
levels were not significantly different in the SILC and 4PLC groups at baseline
and at six and 24 hours after surgery75 .
Similarly, McGregor et al (2011)7 reported that serum IL-6 and
CRP levels were not significantly different in the SILC and 4PLC groups at
baseline and at 6 ,24 and 48 hours after surgery (p>0.05 for all).
SUMMARY
The present study was carried out in the Department of Surgery, IGMC,
Shimla over a period of 12 months from 1st July 2012 to 30th June 2013 on 50
patients who were admitted with clinical diagnosis of symptomatic
cholelithiasis. The following observations were made:-
1):- The age of patients included in the study ranged from 15 years to 58
years with mean age of 39.45years . The mean age was 30.8 years in the
SILC and 35.40 years in cLC group respectively,which is statistically
insignificant(p value=.095).
2):- In the present study 86% of the total patients were females and 14 %
were males. There was 1 male (4%) and 24 females (96%) in the SILC
and 6 males (24%) and 19 females (76%) in the cLC group. The data
shows that cholelithiasis is more common among females.
3):- The BMI ranged from 18 to 3O kg/m2 with mean BMI of 21.44 It was
21.04 in the SILC and 21.88 in the cLC group respectively. The p value is
>0.206 which is statistically insignificant.
4):- The total duration of surgery was more in the SILC group as compared
to cLC group .The mean time for the duration of surgery was 53.40min in
SILC group and in 4port LC group mean operating time was 39.80min,
showing that the mean operating time in the SILC group was significantly
high as compared to the 4port LC group. P value= <.oo1 (p <0.05-
significant).
5):- As expected, the preoperative levels of the TLC and CRP were
comparable in the two groups.
6.):- Mean of TLC with in 6 hours ,in SILC group was 7.106±2.361 m/mm3
whereas in the cLC group, mean was 9.991±14.54 m/mm3. The p value
for TLC between SILC and cLC groups was 0.333.
7):- TLC on 1st post operative day (24 hours after surgery) of these patients
ranged from 4.4 m/mm3 to 12.2 m/mm3. In the SILC group, mean was
7.554±3.196 m/mm3. In the cLC group, the mean was 7.122±2.351
m/mm3. The p value for TLC on 1st post operative day between SILC and
cLC groups was 0.589. As shown by p value there is no significant
difference between both groups.
8):- TLC on 2nd post operative day (48 hours after surgery) of these patients
ranged from 4.3 m/mm3 to 12.8 m/mm3. In the SILC group, mean was
8.923±2.165 m/mm3. In the cLC group, mean was 7.339±2.776 m/mm3.
The p value for TLC on 2nd post operative day between SILC and cLC
groups was 0.029.
9) :- The pre operative CRP in both groups were <5 mg% , so p value for pre
operative CRP between SILC and cLC groups was insignificant.
10):- CRP with in 6 hours ranged from 5 mg% to 48 mg% .In the SILC group,
CRP mean was 22.9±17.55 mg%. In the cLC group, CRP mean was
20.58±22.6 mg%. The p value for CRP between SILC and cLC groups
was 0.854.
11):- CRP on 1st post operative day (24 hours after surgery) of these patients
ranged from 5 mg% to 120 mg% . In the SILC group, CRP mean was
47.19±33.28 mg%. In the cLC group, CRP mean was 45.40±28.54 mg%.
The p value for CRP at 1st post operative day (24 hours after surgery)
between SILC and cLC groups was 0.854.
12):- CRP on 2nd post operative day (48 hours after surgery) of these patients
ranged from 6.2 mg% to 120 mg% . In the SILC group, CRP mean was
61.98±37.06 mg%. In the cLC group, CRP mean was 65.08±39.6 mg%.
The p value for CRP at 2nd post operative day between SILC and cLC
groups was 0.781.
CONCLUSION
Recent developments in laparoscopic surgery have led to single incision

laparoscopic surgery technique, in which instead of several ports placed
throughout the abdomen only one entry site into the abdominal cavity is used.
Moreover, with fewer abdominal incisions it seems justified to expect reduced
wound related complications and less postoperative pain as well as better
patient satisfaction with cosmetic outcome.
In this study 50 patients were taken and they had all variables
similar i.e age, BMI as shown in the study.
As SILC is comparatively newer technique in the world of

minimal asses surgery and it has its learning curve , so SILC took longer
operative time than the cLC . We can say that as the experience increases with
the SILC procedure the operative time will decrease .
Moreover,in this study, SILC was done with conventional

instruments which are used for cLC.
In this study,no significant statistical difference were found in

systemic stress factors i.e. CRP and TLC pre and post operatively in either of
groups (SILC and cLC).
Hence based on the comparative evidence presented in this

study, SILC appears to be as safe , effective and feasible technique and good
alternative to cLC with potential advantages of cosmesis. The costs associated
with SILC and cLC procedures appear similar. Ultimately, the decision as to
whether to perform SILC or traditional/conventional LC will be dependent on
the preferences of individual surgeons and patients.
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PROFORMA
1. Particulars of the Patient.
 C.R No.
:…………………………..............………………
 Name
:……….………………………....….........………
 Age :………………Sex
…………………...…............
 Permanent Address ………………………………………...……….
…………………………………………………………………...…
….
 Date of Admission:
…………………….……………………...…....
 Date of Operation :
............................................................................
 Date of Discharge:
……………………...……….…………………..
 Operation (SILC/cLC):
..........................................................................
 Consultant/Surgeon :...........................................
 Duration of surgery : ........................
2. Chief Complaints: Onset/Duration/Progression
 Abdominal Pain
..................................................................................
............................................................................................................
....
 Dyspepsia
............................................................................................
............................................................................................................
....
 Others
..................................................................................................
............................................................................................................
....
3. Relevant History

............................................................................................................
...
............................................................................................................
....
............................................................................................................
....
4. General Physical Examination

Pallor Y N Icterus Y N Clubbing Y N
e e e e e e
Pedal Oedema s s PR per min s s BP in mmHg s s
____/_____
Y N
e e
s s
5. Systemic Examination
Per Abdomen
Chest Cardiovascular System CNS
6.a Routine Laboratory Investigations
Date Hb RBC ESR Na K Cl PLT
6.b Laboratory Investigations
Blood Sugar Bilirubin Serum Proteins
Fasting Random Total Conjugated Total Albumin
Urea SGOT SGPT

Creatinine Amylase Alkaline Phosphatase
7.Radiological Findings:-
o Chest X-Ray
:………………………………………..................
o Ultra Sonography
:…………………………………………..............
o Others
:…………………………………………..............
8. Parameters :-
Sr. No. TLC (per CRP

mm3) (mg/lt)
1. Pre-operative value (baseline)
2. After the completion of Surgery (with in

6hour)
3. 1st Post-operative Day (with in 24 hours)
4. 2nd Post-operative Day (with in 48 hours)
Remarks:.................................................................................................................
....
................................................................................................................................
......
INFORMED CONSENT
I ------------------------------exercising my free power of choice, hereby give my

consent to be a subject in the comparative study of single incision laparoscopic
Cholecysectomy with conventional laparoscopic Cholecystectomy. I have been
informed to my satisfaction by the attending Surgeon, the purpose of study and
nature of procedure and drugs to be used.
I am also aware of my right to opt out of the study at any time during the course
of the procedure without any reason.
..................................................................
Signature/thumb impression of the patient

KEY TO MASTER CHART
Sr.No. serial number
Min minute
F female
M male
BMI body mass index
TLC1 total leucocyte count (baseline)
TLC2 total leucocyte count(with in 6 hours)
CRP1 c reactive protein (baseline)
CRP2 c reactive protein (with in 6 hours)

MASTER CHART SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY
Sr.No. Name Age Sex BMI Duratio TLC(m/mm3) CRP(mg/dl)

(yrs) (kg/m2) n of
TLC1 TLC2 TLC3 TLC4 CRP1 CRP2 CRP3 CRP4
surgery
(min)
1. Bimla bhanu 45 F 20 60 5730 6200 9000 7800 <5 10 5 30
2. Sumitra 30 F 23 70 6100 6500 6000 7688 <5 <5 <5 11
3. Jagdish 34 M 24 60 6500 8600 8354 9800 <5 <5 13 24
4. Neelam 41 F 19 55 6000 5233 5900 5799 <5 <5 9 <5
5. Hemlata 40 F 22 50 7688 6165 7212 8565 <5 <5 120 89

6. Anita 21 F 24 40 4621 6477 7488 12870 <5 <5 70 120
7. Priyanka 22 F 19 45 4100 6700 8800 4800 <5 <5 9.4 10.6
8. Kanta 27 F 20 45 6200 6879 4700 9000 <5 <5 31.7 10.7
9. Sarla 58 F 22 35 6500 6900 3800 8900 <5 48.9 18.8 60.6
10. Rimpy 25 F 22 50 6200 12000 19500 11677 <5 <5 74 88
11. Seema 35 F 18 70 7499 11890 9800 7900 <5 <5 44 41
12. Parwati 21 F 23 60 6519 7400 8489 10986 <5 <5 119 120
13. Sonia 21 F 18 70 4588 6200 4000 4300 <5 <5 44.6 53.7
14. Nanda 15 F 19 62 7000 6500 6100 6400 <5 <5 85.7 81.8
15. Babli 32 F 19 55 5700 2000 4789 9807 <5 <5.6 76.9 86.5
16. Gulshan 41 F 20 50 4470 7599 4199 11000 <5 <5 14 40
17. Sunaina 28 F 23 48 7989 10879 6879 8766 <5 <5 71.2 47
18. Neelam 28 F 25 45 5600 4000 4577 8978 <5 <5 52.8 53

19. Reenu 21 F 22 50 5758 9800 7699 7566 <5 <5 31.5 116
20. Rekha 30 F 23 50 6588 3342 6578 8765 <5 <5 48 78.6
21. Hemlata 30 F 18 55 6799 8766 8890 9877 <5 <5 <5 6
22. Sunita 32 F 22 50 7599 7400 8766 8466 <5 <5 24.8 40
23. Geeta 34 F 20 58 5788 6600 6588 9806 <5 <5 20 80
24. Menu 30 F 22 50 8897 7896 10980 12343 <5 16 40 120
25. Radha 31 F 19 50 6733 5742 9780 11232 <5 17 60 80
MASTER CHART OF cLC
Sr.No. Name Age Sex BMI Duration TLC(m/mm3) CRP(mg/dl)

(yrs) (kg/m2) of
TLC1 TLC2 TLC3 TLC4 CRP1 CRP2 CRP3 CRP4
surgery
(min)
1. Nirmla 56 F 20 35 8976 7322 8544 6421 <5 9.2 15 40
2. Raj 23 F 22 40 5600 6788 4456 6122 <5 39 5.4 10.7
kumari
3. Priyanka 14 F 23 35 5763 6123 6800 6400 <5 <5 <5 <5
4. Kanta 44 F 24 30 7123 8722 6400 5432 <5 <5 54 85
5. Rajo 40 F 18 40 6987 5934 4987 5876 <5 78 120 120
6. Subhadra 52 F 19 45 7190 9821 7809 8796 <5 6 27 62
7. Kamlesh 28 M 23 50 4699 7699 6498 4000 <5 <5 <5 21.7
8. Satya 34 F 22 30 7655 4000 1233 9876 <5 <5 99 85
9. Mukti 23 F 23 35 8790 4199 2133 1300 <5 <5 43 83
10. Hira ram 24 M 21 40 7688 9100 4709 3899 <5 <5 49.8 120
11. Sushil 34 M 22 45 6788 14888 9822 9800 <5 12.7 66 70
Mehta
12. Usha 32 F 18 55 8890 4800 5300 10438 <5 <5 60.7 120
13. Harnam 42 M 19 40 6588 5643 7009 877 <5 5.6 70 19
14. Sari devi 34 F 22 35 6123 7865 8322 6554 <5 <5 34.7 79
15. Akla 32 F 23 30 7544 78990 6453 8765 <5 <5 12.7 40
16. Bharmi 28 F 24 40 4532 6579 7860 6700 <5 <5 <3 6
17. Kali 32 M 19 40 9346 4800 7986 7900 <5 <5 45.8 120
chand
18. Lata 30 F 18 45 4300 4756 11230 10987 <5 <5 49 80
19. Anita 33 F 19 45 5000 6978 9876 9870 <5 5.6 64 86.8
20. Satya 29 F 24 35 5678 8345 7654 8123 <5 <5 56.8 118
21. Getu 34 F 25 30 5480 6987 9780 10999 <5 ,5 17 30
22. Roshni 26 F 23 50 8450 6540 7800 6577 <5 >5 12 10
23. Surrender 28 M 26 50 4590 8799 8900 9765 <5 23 46.2 65.6
24. Maya 24 F 24 30 7800 6456 8700 9877 <5 16.7 30 10
25. Kavita 32 F 26 35 4788 7655 7800 8123 <5 10 20.6 80.2

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COMPARATIVE EVALUATION OF

C-REACTIVE PROTEIN AND TOTAL LEUCOCYTE COUNT

CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY AND

SINGLE INCISION LAPAROSCOPIC CHOLECYSTECTOMY

THE HIMACHAL PRADESH UNIVERSITY, SHIMLA

FOR THE DEGREE OF

DR. MUKESH KUMAR

INDIRA GANDHI MEDICAL COLLEGE

SHIMLA (H.P.) -171001.

Evaluation of C-Reactive Protein and Total Leucocyte Count in

Laparoscopic Cholecystectomy and Single Incision Laparoscopic

supervision and guidance in the department of Surgery, Indira Gandhi Medical

been carried out by the candidate himself.

I.G. Medical College ,shimla

............................. SUPERVISOR .......…………………..

Dr.D.K.VERMA Dr. SAROJ JASWAL

It is my proud privilege and pleasure to acknowledge with deep sense of

Words cannot express my veracious thanks and deep gratitude to my

I take this opportunity to thank with deep sense of regard and

I am also very thankful to Dr. Anil Malhotra , Professor, Department

I am deeply indebted to Dr. Arun Gupta, Professor, Department of

I would also like to thank Dr. U. K. Chandel, Dr. Bhavesh Devkaran,

Words cannot adequately express the deep sense of gratitude I owe to

I would also like to thank my colleagues Dr. Amit, Dr. Abhishek

SR.NO. DESCRIPITION PAGE NO.

SILC = single incision laparoscopic cholecystectomy

cLC =conventional laparoscopic cholecystectomy

DOS = duration of surgery

CRP =C-reactive protein

TLC =total leucocyte count

LOS =length of stay

LESS =laparo-endoscopic single site surgery

S.NO. =serial number

BMI =body mass index

Over the last 20 years, conventional laparoscopic cholecystectomy (cLC) as less

In 1341, Gentile da Aligno demonstrated human gall

CONVENTIONAL LAPAROSCOPIC CHOLECYSTECTOMY

mirror, candle and a double lumen uretheral cannula14,15.

Frankfurt developed an instrument called “photo endoscope”, consisting of a

reflecting mirror, a light source and a urethral cannula. A versatile endoscope

was developed by Desormeauxin in 186514,16. He incorporated a kerosene

bladder, cervix and uterus.

The endoscopy became practical in the year 1890 when

20 years later after the cholecystectomy was performed by

The early pioneers introduced their trocars and cystoscopes

Fevers in 1933 was first to recommend CO2 as insufflation gas

The best gas for insufflation at present is carbon dioxide

In 1966, Hopkins incorporated rod shaped lenses as light

Philipe Mauret drawing an experience with gynaecological

Hans Frost, with German manufacturing company WISAP,

Mühe introduced the Galloscope on September 12, 1985 during

He postulated that introducing the scope at the costal margin

Mühe first presented his experience at the Congress of the

CRP (C REACTIVE PROTIEN)

C-reactive protein was originally discovered by Tillett and

Amount of visceral trauma, manipulation and dissection is often

TLC (Total Leucocyte Count)

There are normally 4,000-11,000 WBC/ lt of human blood. Of

Immunosuppression is an established consequence of surgical

First laparoscopic cholecystectomy by single incision was

Romanelli et al50 performed the SILC with the newer devices

Bresadola et al51 in1999 compared the transumbilical technique

Piskun G and Rajpal S.52 in year 1999 studied transumbilical