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1 ةعارز* Comprtive Study etween Lproscopic Complete nd Subtotl Cholecystectomy in Gots M.. lkhilni*, M. J. Ees**, S. I. Sleh** nd.. jeel** *Ministry of griculture ** College of Veterinry Medicine\ University of ghdd Summry comprison between lproscopic complete nd subtotl cholecystectomy ws studied to find the deference in treting severe cholecystitis nd to study the fte of the remining prt of the gllbldder in subtotl cholecystectomy. ll experimentl nimls hd induced cholecystitis by clipping the cystic duct for five dys tht ws ppered enough for inducing cholecystitis in gots. 24 dult femle gots were used in this study, which were divided rndomly into two equl groups; complete lproscopic cholecystectomy (group ) nd subtotl lproscopic cholecystectomy with cystic duct clipped only by titnium clips nd leved the cystic rtery without clipping (group ) nd Opertions were performed under generl nesthesi by using thiopentl sodium t dose of 15 mg\ Kg..W. intrvenously to mintin the inhltion nesthesi by endotrchel tube with mixture of hlothne ( %) nd oxygen (2-3%). The intrbdominl pressure with CO 2 ws used successfully t low pressure 8-10 mmhg, which ws enough for good vision nd good mnipultion of lproscopic instruments. The physiologicl ctivities nd clinicl symptoms which include hert rte, respirtory rte, temperture nd return to the food nd wter were recorded t the sme time of blood smples tht took for liver function tests which were including; lkline phosphtes (LP), lnine minotrnsferse (LT), sprtte minotrnsferse (ST), totl serum bilirubin nd C- rective protein were mesured in different intervls; before opertion (zero dy) nd t 1hr, 1 st, 3 rd, 5 th nd 7 th postopertive dy. The liver function tests showed significnt elevtion (P<0.05) in lkline phosphtes (LP) nd in the totl bilirubin vlues in group (P> 0.05) comprison with group nd no significnt difference in lnine minotrnsferse (LT), sprtte minotrnsferse (ST) nd C- rective protein between experimentl groups s well s time intervls. The biopsies were tken t the 3rd, 7 th nd 15 th postopertive dy for histopthologicl of the remining prt of gllbldder in group which showed tht cholecystectomies could be performed successfully with the subtotl technique, lthough the superior heling through little degenertion in the remining prt of the gllbldder nd best in the heling stges. دراسة مقارنة للازالة الكاملة والجزي یة للصفراء بالجراحة المنظاریة في الماعز ماجد عبد الرحمن الكیلاني* محمد جواد عیسى** سروة إبراهیم صالح** وأیاد إبراهیم** ا ةرازو **كلیة الطب البیطري/ جامعة بغداد الخلاصة تم إجراء دراسة مقارنة ةلازلا ل الكاملة للصفراء منظاریا ةلازلا او الجزي یة المنظاریة لها للوصول ىلإ الاختلافات في عملیات ةلازلا ا المنظاریة للصفراء لعلاج حالات الالتهاب الشدیدة التي تصاب بها. كل حیوانات التجربة خضعت لعملیة إحداث التهاب كیس الصفراء من خلال غلق قناة كیس الصفراء باستخدام مشابك التیتانیوم 59

2 منظاریا وا جراء العملیة بالیوم الخامس بعد الغلق. استخدم في الدراسة أربعة وعشرون حیوانا من المعز الا ناث البالغة والتي قسمت عشواي یا لمجموعتین متساویتین أجریت للمجموعة ىلولا ا عملیة ةلازلا ا الكاملة للصفراء منظاریا أما المجموعة الثانیة فا جریت لها عملیة لازإة جزي یة منظاریا مع الا بقاء على شریان الصفراء وربط القناة طقف بمشابك التیتانیوم. أجریت جمیع العملیات الجراحیة تحت التخدیر العام باستخدام ثایوبنتال الصودیوم وبجرعة 15 ملغم لكل كیلوغرام من وزن الجسم للمساعدة في إدخال أنبوب ال رغامي ذو الكفة لا دامة التخدیر الاستنشاقي العام باستعمال مزیج من الهالوثین بنسبة 1.5- %2.5 والا وكسجین بنسبة 2-3 % وكان التخدیر جیدا لا تمام العملیات الجراحیة في كافة حیوانات التجربة مع نسبة غیر معنویة من الاختلاطات. استخدم غاز ثاني اوكسید الكربون بنجاح لنفخ البطن في المعز وتحت ضغط منخفض (8-10 ملم زي بق) حیث كان كافیا ءاطعلا رؤیة جیدة لمنطقة العملیة وللاستخدام الجید تاودلا ل الجراحة المنظاریة أیضا في عملیات ةلازلا ا المنظاریة للصفراء في الحیوانات. جرت متابعة الفعالیات الفسلجیة ضارعلا ا و السریریة والتي تضمنت: سرعة القلب والتنفس ودرجة الحرارة ةدوعلاو ىلإ الطعام والماء في فترات متزامنة مع توقیتات اخذ عینات الدم لقیاس انزیمات الكبد والتي شملت ال C-rective protein, ST, LT, LP ونسبة البلیروبین الكلي ابتداء من یوم العملیة والساعة ىلولا ا بعد العملیة والیوم الا ول والثالث والخامس والسابع بعد العملیة الجراحیة. أخذت عینات من الجزء المتبقي من الصفراء في مجموعة ةلازلا ا المنظاریة الجزي یة يف الا یام: الثالث والسابع والخامس عشر بعد العملیة الجراحیة لا جراء الدراسة النسجیة المرضیة. الفعالیات الفسلجیة والملاحظات السریریة بینت نجاح عملیات ةلازإة الصفراء منظاریا في الماعز من خلال عدم ظهور اختلافات مهمة في هذه الفعالیات قبل وبعد العملیات الجراحیة لحیوانات التجربة. كما ان ةلازلا ا المنظاریة الجزي یة لكیس الصفراء قد تمت بنجاح أیضا مع عدم ظهور اختلاطات معنویة. ترهظأ و نتاي ج فحوصات انزیمات الكبد زیادة في مستوى ال والتي أجریت لحیواناتها ة ةلازإ والبلیروبین الكلي في مجموعة LP منظاریة جزي یة للصفراء مع بقاء التجهیز الدموي بدون ربط مقارنة مع مجموعة. ولم یظهر اختلاف معنوي في مستویات ال ST, LT, -C rective protein التوقیتات المتعددة هلاعأ بین المجموعتین يفو كللا المجموعتین. أما نتاي ج الدراسة النسجیة المرضیة للجزء المتبقي من الصفراء في مجموعتي ةلازلا ا المنظاریة الجزي یة دقف ترهظ أ إمكانیة إجراء الجراحة المنظاریة الجزي یة بنجاح من خلال قلة النخر والسرعة الجیدة في التي ام ألجزء المتبقي مما یبین أهمیة استمرار التجهیز الدموي في مراحل الالتي ام حیث قل التنكس الكلي وقلل من إمكانیة تحوله ىلإ مركز للانتان والاختلاطات الغیر مرغوب بها. Introduction When conventionl lproscopic cholecystectomy is not possible, lproscopic subtotl cholecystectomy is vilble nd cceptble lterntive to conversion to open cholecystectomy. It voids the risk of mjor bile duct injury, nd compred with studies of ptients undergoing conversion to open cholecystectomy, demonstrtes reduce mortlity s well s reduce incidence of wound infections nd incision herni. Lproscopic subtotl cholecystectomy, performed when the cystic duct cnnot be identified sfely, consists of resenting the nterior wll of the gllbldder nd removing ll stones (1). Lproscopic subtotl cholecystectomy introduction cn prevent misidentifiction of the bile duct, whereby injury to the bile duct or other orgns is voided. For these resons, they ttribute the decresed incidences of bile duct injury nd conversions to open surgery t their institution, to the introduction of lproscopic subtotl cholecystectomy (2). lthough the lproscopic subtotl cholecystectomy is commonly performed tody, nd often substitute for the conversion of conventionl 60

3 lproscopic cholecystectomy to open cholecystectomy, but the fte of the remining posterior prt of the gllbldder which is ttched to the liver is still unknown by reserchers; whether is it showed fibrosis or necrosis nd becomes focus of infection, nd no informtion bout its impct on ptient s helth ws found. We were Compred two surgicl techniques in lproscopic cholecystectomy which were completed in the first nd subtotl cholecystectomy in the second to find the deference in the two technique with best postopertive results nd to follow the fte of remining prt of cholecystectomized gllbldder mcroscopiclly, cliniclly nd histopthologiclly t different periods postopertively. Mterils nd Methods Twenty- four helthy dult Indgenus femle gots, ged between 2.5 to 4 yers, nd weight (37 to 45 kg.) were used. The nimls were divided rndomly into two equl groups; nd, ech group subdivided into three subgroups ccording to the period of 3, 7 nd 15 dys postopertively to tke biopsies for histopthologicl exmintion. The nimls were fsted for 36 hours of food nd 12 hours wter preopertively. The treted nimls were put under observtion postopertively. In ll 24 gots, Cholecystitis ws induced experimentlly by lproscopic clipping of cystic duct by titnium clips fter identifiction. t the 5 th dy post inducing cholecystitis the nimls performed lproscopic subtotl cholecystectomy. Lproscopic inspection nd histopthologicl exmintion used s prmeters. Thiopentl sodium t dose of 25 mg/kg.w. intrvenously ws used to fcilitte introducing endotrchel tube for inhltion nesthesi, which is the method of choice for mintining nesthesi for prolonged procedure (3). Pneumoperitoneum with CO 2 (8-10 mmhg) ws performed in ll experimentl nimls. The subtotl cholecystectomy ws begun by clipping the cystic duct nd cystic rtery in group, nd cystic duct in group. Then the gll bldder ws punctured t the fundus with monopolr electrocutery hook nd the suction-irrigtion pprtus ws used to evcute the contents. The gllbldder ws pulled crnilly nd lterlly, Clot`s tringle nd its structure (cystic duct, cystic rtery nd inferior border of the liver) were put under tension. Subtotl cholecystectomy ws performed by leving the posterior wll of the gll bldder which ttched to the liver intct. The incision ws performed djcent to the liver nd crried out round to the posterior wll of the gllbldder both incisions were meeting medilly (Fig.1). ny bleeding t the mrgin borders ws cogulted with electrocutery. The mucos of remnnt prt of gllbldder ws cuterized with sptul to destruct the mucos nd to prevent ny secretions (Fig. 2). Fig.(1) Gll bldder dissection strted from the Fig. (2) mucosl cuteriztion by hook neck upwrd, in subtotl Cholecystectomy Food nd wter were free to record the time of returned to et nd drink post opertion. Penicillin streptomycin in dose I.U., nd 10 mg/kg.w. respectively, ws dministered intrmusculrly for four dys post-opertively. Rectl temperture, respirtory nd hert rte were monitored once dily for seven dys postopertively. Skin sutures were removed ten dys post-opertively. iopsies bout 1 squre cm 2 were tken lproscopiclly t the third, seventh nd fifteenth dy postopertively. The specimens were fixed in 10% neutrl buffered formlin, then routinely processed nd embedded in prffin which were cut t (5-6) microns nd 61

4 stined by hemtoxyline nd eosin stin (4, 5) nd they were exmined under light microscope. The opertion periods were depended on the severity of the cholecystitis nd other complictions occurred during the opertions, such s bleeding nd viscerl injury. The respirtory rte, hert rte nd temperture were recorded long the length of the opertion. The bdominl cvity of experimentl nimls ws inspected lproscopiclly t 3 rd, 7 th nd 15 th dy postopertively ccording to the period of subgroups in groups nd to evlute ny pthologicl chnges nd to tke biopsies for histopthologicl study. Results In inducing cholecystitis the mcroscopic nd microscopic result showed tht five dys period ws enough for inducing cholecystitis becuse of the severity of histopthologicl chnges t the 7 th dy period which ws showed severe necrosis, so the fifth dy period ws depended. The opertion time ws rnged between minutes (men 67 min.); while the rnge of opertive time for completes lproscopic cholecystectomy were minutes (men 35min.). The treted nimls hd returned to et nd drink within short time post recovery from nesthesi nd with norml ctivity, which hd indicted less postopertive pin. No significnt chnges occurred in physiologicl ctivities post opertions; the respirtory rte, hert rte nd temperture were within norml rte. Two nimls (one of ech group) of twenty- four nimls (8.3%) hd shown pin few dys postopertively. This might be due to the dhesion occurred between gllbldder nd djcent omentum nd viscer becuse of the experimentlly induced cholecystitis which required long time during surgery for gllbldder identifiction nd seprtion from the liver bed, tht my led to dmge nd post opertive pin. Pneumoperitoneum with CO 2 ws successfully produced in experimentl gots with miniml complictions such s tht occurred t the beginning of the experiment tht some cses showed pneumo-omentum t the onset of the insuffltion (4 nimls). t the 3 rd postopertive dy, mild dhesions observed between the omentum nd the site of the opertion, while t the 7 th post opertive dy five nimls (one from group nd two from group ) hd showed severe dhesions (12.5%). Mostly the dhesions were circumscribed to the opertion site nd did not occur in other regions in the bdominl cvity. The incidence of dhesions occurred in this study ws low in comprison with the rte of occurrence in open surgery nd this result comes in greement with result of dhesion in lproscopic surgery. These dhesions my be result of the liver bed dmge in dissection of cystic duct, cystic rtery nd omentum which ttched to the inflmed gllbldder. In cses where bleeding or injury to the liver bed occurred, dhesion formtion occurred. In induced cholecystitis the microscopic findings t the fifth dy post clipping showed congested blood vessels, mononucler cells infiltrtion round the vessels, between muscle fibers (Fig.1). The histopthologicl findings were s following ccording to the period of biopsy: t the 3 rd postopertive dy microscopic picture the microscopic sections in group () showed neutrophils infiltrtion in the strom, s well s neutrophils ggregtion in dilted blood vessel (Fig.2). Neutrophils infiltrtion ppered in their lumen, round them, nd round mucosl glnd. There were network of fibrin deposition with neutrophils infiltrtion nd frgmenttion of muscle fibers in nother section (Fig.3). There were congested blood vessels nd network of fibrin in group, this is sign of progress in heling. The histopthologicl exmintion in group () t the 7 th postopertive dy showed trophy of the epithelil mucos which become rounded nd neutrophils infiltrtion in the sub epithelil lyer nd there ws fibrin deposition in the strom (Fig. 4 nd 5). Dilted mucosl glnds with inflmmtory cells infiltrted in the connective tissue which found round glnds. There ws neutrophils ggregtion in necrotized strom. The epithelil lyer become rounded nd lined by cuboids or simple cells with inflmmtory cells infiltrtion in the lmin propri. There ws necrosis of mucosl glnd, grnultion tissue prolifertion nd fibrin deposition. t the 15 th dy the lesions in group () were chrcterized by severe prolifertion of fibrous connective tissue, which ws highly cellulr with mononucler cell infiltrtion. 62

5 The fibrous connective tissue ws surrounding necrotized mucosl glnd. In other section, there ws mture fibrous connective tissue in the strom, chrcterized by regulr fibers direction with less fibroblst cells nd more collgen deposition (Fig.6). The heling ppered in dvnce phses in group t the fifteenth dy postopertively nd this ws evident from the prolifertion of connective tissue, which ws chrcterized by regulr collgen fibers deposition nd less fibroblst cells. These findings show tht the survivl of blood supply to the remining piece of the gllbldder hd helped in shortening the heling time. The results showed significnt (P< 0.05) decline in the men of the vlues of lkline phosphtse (LP) in group for ll time periods, compred with group (Tble, 1). In nother wy the liver injury which occurred during the cystic duct nd rtery dissection my be the cuse of this increse in LP titers. There were no significnt differences in the men vlues of the ST between the different groups nd nd in the different periods (Tble, 2). nd there ws no significnt difference t the level of (P>0.05) in the men vlues of LT between the different groups nd nd in different periods lso (Tble, 3). The results lso showed decline in the vlues of the men of totl bilirubin on the 5 th nd 7 th dy significntly in the level of (P>0.05) compred with other time periods in groups nd (Tble, 4).The results showed no significnt differences (P>0.05) in C-rective protein between different groups of different intervls in the number of negtive nd positive smples (Tble, 5). Tble (1) lkline phosphtes (U/L) (LP) Group Time Zero dy 1 hrs. 1st. dy 3rd. dy 5th. dy 7th. Dy 49.7 ± 4.6 b 46.7 ±5.2 b 52.5 ± 4.2 b 55.3 ± ± ± ± ± ± ± ± ± 8.3 Different smll letters verticlly refers to the existence of significnt differences (P< 0.05). Tble (2) sprtte minotrnsferse (GOT) (ST) (U/L) Group Time Zero dy ±14.0 1hrs. 1 st.dy 3 rd. dy 5 th. dy 7 th.dy ± ± ± ± ± ± ± ± ± ± ±13.28 There re no significnt differences in the men vlue between the different groups nd nd in the different periods. Tble (3) lnine minotrnsferse (LT) (GPT) (U/L) Group Time Zero dy 1hrs. 1 st.dy 3 rd. dy 5 th. dy 7 th.dy 53.4 ± ± ± ± ± ± ± ± ± ± ± ±2.2 There re no significnt differences in the men vlues between the different groups, in the different periods. Tble (4) Totl bilirubin (mg/dl) 63

6 Time Zero dy 1hrs. 1 st.dy 3 rd. dy 5 th. dy 7 th.dy Group ±0.002 c ± ±0.003 b ± ±0.005 b ± ±0.002 b ± ±0.003 b ±0.005 * Different smll letters verticlly refers to the existence of significnt differences P< * Similr smll letters verticlly refers to the bsence of significnt differences P>0.05. * Different cpitl letters horizontlly refers to the existence of significnt differences. Tble (5) C - rective protein ± ±0.002 Group The Time Totl No. Zerody 1hrs. 1 st.dy 3 rd.dy 5 th.dy 7 th.dy There is bsence of significnt differences in the men vlues between the different groups, nd C nd in different periods. Fig.(1) Induced cholecystitis group, 5 dys Pos. clipping shows congested blood vessel with neutrophils in their lumen () nd neutrophils infiltrtion in the subepithelil lyer nd between mucosl glnd ()(H&E 40X). Fig.(4) Group, three dys postopertion show neutrophils ggregtion in dilted blood vessel (). (H&E40X) Fig.(5) Group, three dys p. op. there is fibrin network deposition with neutrophils infiltrtion (), frgmented muscle fibers (). (H&E 40X). Fig.(8) Group, seven dys post op. shows trophy of epithelil mucos which become rounded (), with neutrophils infiltrtion in subepithelil lyer() (H&E 40 X). Fig.(9) Group, seven dys post op. there is neutrophils infiltrtion in subepithelil lyer (), nd fibrin deposition in Strom (). (H&E 20 X). Fig.(11) Group, fifteen dys post op. there is mture fibrous connective tissue in the strom (). (H&E 20X). Discussion Pneumo-omentum t the onset of the insuffltion coincided with reserchers (6); which found tht when Veress needle plced blindly, there is potentil for its misplcement in the subcutneous spce, vsculr spce, viscer, omentum nd mesentery or retroperitonel. These complictions could occur in humn s mentioned by reserchers (7) who found tht the overll incidence of opertive complictions ws 22 from 350 (6.29%), mong them three of pneumo-omentum were relted to 64

7 inpproprite CO 2 insuffltion. The low intr-bdominl pressure used in present study (8-10 mm Hg) ws enough for good mnipultion of the instruments in the bdominl cvity nd llowed good opertion field nd visuliztion. These results were consistent with wht ws reported by some reserches (8), bout the higher intrbdominl pressure which my be incomptible t some degree with the respirtion nd vsculr blood flow. lso using low-pressure pneumoperitoneum (7mmHg) hd been shown to minimize dverse hemodynmic effects on heptic portl blood flow nd heptic function due to the hrmful effects of elevted intrbdominl pressure, it is recommended tht the lowest possible intrbdominl pressure be used, llowing dequte exposure of the opertive field, rther thn stndrd pressure (13-15 mmhg). This ws consistent with findings (9) tht the low-pressure technique could be employed in the mjority of ptients subjected to lproscopic cholecystectomy nd reducing the pressure of the pneumoperitoneum to (7 mmhg) tended to produce lower incidence of postopertive shoulder-tip pin in humn. It my lso prevent mortlity due to CO2 embolism (10). The opertion time greed with reserchers (11) whom remembered tht the medin operting time for lproscopic subtotl cholecystectomy ws 92.5 min. (rnge, min). nd this result consistent with some reserches (12), when they recorded the medin opertion time of lproscopic subtotl cholecystectomy which ws 65.5± 15.2 minute. Similr results of the postopertive pin chieved by reserchers (13), tht viscerl pin is predominnt, especilly during the first hours fter the intervention, despite of lproscopic surgery is ssocited with less postopertive wound pin nd fewer complictions thn open procedures (2). Similr results of increse in LP titers were recorded (14), s consequences heptocytes pthology; cholecystitis should be regrded s n importnt dditionl cuse of rective heptitis. These findings lso gree with reserch (15) tht showed gll stones nd cholecystitis hd bnorml liver histology, nd the most sensitive indictor of cliniclly importnt liver pthology ws rised serum lkline phosphtes vlue, nd liver chnges ssocited with cholecystitis. lso they support the inference tht rective heptitis might be the result of recent episode of common bile duct obstruction in humn. s common disese, cholecystitis should be regrded s n importnt dditionl cuse, so n obstructive pttern with rised lkline phosphtes vlues ws the most frequent bnormlity. Elevtions of ST nd LT ctivities re ssocited with heptocellulr dmge from ny cuse (16). While other (17) reported tht LT enzyme is not present in lrge enough mount in liver cells of horse, ruminnt nd pig. Incresing in totl bilirubin could be result of mny cuses, tht hemolytic disese nd heptobiliry disese re the most common cuses of hyperbilirubinemi (16). ile slts tht re rebsorbed by the enteroheptic circultion increse plsm bilirubin, which under norml levels, is excreted in the urine. However, when bile ducts re dmged, bilirubin ccumultes in blood nd cn be used s n indictor of heptic disese (18). lthough there were difference in bilirubin vlues between ll groups in this study, but these vlues were in the norml rnge. In study on Nubin gots (19); they found tht the vlues of totl bilirubin were o.55 to 1.86 in different experimentl groups which treted with chemotherpy. This explins tht the bilirubin vlues in present study were less thn those of other study (19), which proved tht they were in the norml rnge. This lso supported by others (16) tht test result of 3.1 mg/dl ws significntly elevted over vlues typicl for his experimentl nimls, nd it ws interpreted to represent rel elevtion. The bdominl cvity of experimentl nimls ws inspected lproscopiclly t 3 rd, 7 th nd 15 th dy postopertively to evlute ny pthologicl chnges nd to tke biopsies for histopthologicl study. t the 3 rd postopertive dy, mild dhesions observed between the omentum nd the site of the 65

8 opertion, while t the 7 th post opertive dy three nimls (one from group, nd two from group ) hd showed severe dhesions (12.5%). Mostly the dhesions were circumscribed to the opertion site nd did not occur in other regions in the bdominl cvity. The incidence of dhesions occurred in this study ws low in comprison with the rte of occurrence in open surgery nd this result comes in greement with result of dhesion in lproscopic surgery. These dhesions my be result of the liver bed dmge in dissection of cystic duct, cystic rtery nd omentum which ttched to the inflmed gllbldder. Others (20) hd found the sme result bout dhesions tht the lproscopic cholecystectomy hs reduced rte of dhesion formtion when compred with the open technique. This ws supported by study (21) tht conventionl cholecystectomy hd seven times more dhesions thn lproscopic cholecystectomy, nd fr distnt dhesions developed lso. This observtion is gree with nother study (21) in which they found tht liver bed dhesions developed in six of twenty lproscopic cholecystectomies dogs, in which fr dhesions developed only t the trocr site beyond the xyphoid nd t the 5-mm trocr sites, nd no other fr dhesion ws detected. In the lproscopic cholecystectomy group, dhesions were loclized only to the liver bed. Only two columnr dhesions were found, nd they were loclized in the epigstrium t the site of the opertive trocr. Complictions such s bleeding or injury to the liver substnce during lproscopic cholecystectomy cn enhnce dhesion formtion. This observtion ws consistent with (22,23) nd (23) tht miniml mnipultion of viscerl orgns distnt from the opertive site, reduce the formtion of dhesions t these sites. In the cses where bleeding or injury to the liver bed occurred, dhesion formtion occurred. t the 7 th postopertive dy, two from group ) hd shown sc contined serous fluid in the site of persistent prt of gllbldder; this my be due to secretion from mucos which my be still intct lthough it ws cogulted with electrocutery, so the remining gllbldder must be cogulted completely. This ws lso confirmed by (24) who recorded tht destruction of the residul gllbldder mucos with electro cogultion ws optionl. lso my be s result of bile lek from bile ducts tht in some cses enter from the liver into the gllbldder directly, this observtion ws supported by (25), who found tht bile ductules in sheep nd got sometimes entering the gll bldder from the liver directly through its ttched wll. nd so found (26) tht the biliry lek my be minor one rising from smll, ccessory bile duct nd cliniclly significnt nd tht lesions of the ccessory bile duct re the commonest cuse of postopertive compliction. In study (27) on the lproscopic cholecystectomy in dog, lso found tht lproscopic surgery did not ffect physiologicl prmeters, except tht the body temperture hd temporrily decresed fter opertion nd then returned to norml. The importnce of blood supply to the inflmmtory re is supported by resercher (28), tht the circultory disturbnces could ply role in the pthogenesis of cute clculous cholecystitis. The monocyte mcrophge system nd neutrophils grnulocyte ctivtion re highly importnt in the inflmmtory process. nd the neutrophils grnulocytes represent the erliest immune cell flow to the site of inflmmtion, nd the terminl phse of tissue repir is fibrosis in the liver bed, which ws well demonstrted by the histologicl investigtion (29). The presence of grnultion tissue formtion nd fibrous connective tissue in group t the 7 th dy is supported in study (30), tht in cse of blood supply presence, the expensive tissue defect becomes filled with grnultion tissue, nd in such injuries the repir filled by connective tissue replcement. While the presence of proteineus mteril my be due to interruption of blood supply in group which led to red blood cells hemolysis nd resulting in severe necrosis. References 66

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