ReMed 2018 Remed 5 - Histoire de la Médecine | Page 7

pain localized in the upper right quadrant with radia-
tion to the right Scapula area. Such pain is called a he-
patic colic. Fever and jaundice maybe associated to it
and are signs of complications. These symptoms aren’t
constantly found and may even lack in some cases 3 .

Gallbladder disease was thought to be caused
by an accumulation of black bile. It was treated by many
“medical remedies” such as taking ox bile, eating grass
and administering ether or other organic solvents in
order to dissolute the calculi. None of these remedies
proved their efficiency. Even the injections of such sol-
vents endoscopically through the sphincter of Oddi or
the use of shock wave therapy (lithotripsy) in associa-
tion with gallstone solubilizing agents (cheno- and/or
ursodeoxycholic acid) proved futile because of the nu-
merous recurrences and multiple complications 3 .
Cholecystectomy: from open to closed by keyholes!
Therefore, cholecystectomy became the gold-standard
in treating Gallbladder disease. It is one of the most
performed surgeries worldwide 1,3,6 .

If by chance we took a surgery textbook such
as Maingot’s abdominal operation, and compared the
chapter on cholelithiasis and cholecystectomy be-
tween two editions: one prior to the 1980s and one
after, the difference found would be staggering.

Before the 1980s, open cholecystectomy was
the standard procedure. Classically, “The operation re-
quired a large incision under the patient’s ribs on the
right side, allowing the anatomy to be displayed and
the gallbladder removed.” 7
Maingot’s 7th edition described it as follow: “After the
[cystic] artery is divided the fatty envelope around the
cystic duct is dissected clear, and the duct is traced
to its junction with the common hepatic duct and the
common bile duct. When there three ducts have been
freed and displayed, an aneurysm needle threaded
with a strand of 0 (m.4) chromic catgut is passed un-
derneath the cystic duct, and this duct is ligatured al-
most flush with the main ducts.” 7

In 2013’s 12th edition, an overall view of the
chapter permits us already the interception of words
such as pneumoperitoneum, trocar, electrocautery,
laparoscope and entrapment sac. The technique is
described as follow: an “American” or a “French” way
refers to the possible position the surgeon might take
vis-à-vis the patient. In the former, the surgeon is left
of the patient and the assistant is right. In the latter,
the surgeon is between the two abducted legs of the
operated-on 8 .
A pneumoperitoneum is created by insufflating CO 2
into the peritoneal cavity to allow future maneuver-
ing. The use of CO 2 is advantageous: not only is it a
noncombustible gas which allows the use of electric
devices, it is also absorbed quickly. The patient is then
placed in a reverse Tredelenburg position with a 15°
inclination to the left. Four incisions of small diameter
are made, called ports: one on the anterior axillary line
between the 12th rib and the iliac crest. The second is
right underneath the ribs on the mid-clavicular line.
Both of these ports are on the right. Through them are
introduced two grasping forceps manipulated by the
assistant. Their main function is to elevate the liver 8 .
The third incision is in the periumbilical region and
is for introducing the laparoscope. It has been used
beforehand to insufflate the CO 2 . The last port is situ-
ated 5cm bellow the xyphoid process in epigastrium’s
midline and is used for inserting dissecting forceps 8 .

The actual procedure differs little from the
open technique. After dissecting and ligating all the
necessary anatomic structures and inspecting for he-
mostasis and bile leakage, the retrieving of the gall-
bladder at the end of the cholecystectomy is done
with “claw” grasping forceps via an entrapment sac.
Everything (sac, forceps and trocar) is then retract-
ed through the umbilical incision and the remaining
instruments are restored. Finally, the four ports are
stitched up and the patient can go home in the six
to twelve following hours 8 . A few days later, he would
have resumed his daily routine.

One can easily guess the benefits such inno-
vation has over its predecessor. First, it has minimized
patient’s hospitalization stay and rendered many an
operation doable in outpatient settings. It has also
permitted an earlier return to full activity therefore
reducing the total costs of the operation. The small-
ness of the incisions made them more esthetically tol-
erable and less debilitating for the operated-on 1, 8 .
Team work and work hours
Notable is the trip which the field of surgery had gone
through. In fact, of the remarkable changes that came
with such an evolution, there is the shift of interest
from the surgeon: once main actor of the operating
theatre, main conveyer of orders and knowledge to
trainees and soul decision-holder, the surgeon is now
part of a team. Decisions are more and more made in a
multidisciplinary fashion. The patient has also a word
to say in the matter and medical care is now said to be
patient-centered 6 .

In the US and UK, surgical trainees no longer
work on call at all time since the 2003 modifications
on shift-hours. The regulation has limited work time
between 90 and 120 hours for most specialties, with a
24-hours-limit to consecutive hours (non-stop) and an
additional 6 hours for education and transfer of care 5 .
Evidently, such program did enhance the quality of a res-
ident’s life. Nonetheless, it remains obvious that the dis-
continuity in medical care through hand-offs and chang-
ing teams is subject to controversy. It is also argued that
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