Aim: The aim of this study was to compare plate positions in Lapidus arthrodesis in terms of displacement and plate stress.

Material and Methods: In this study, the Lapidus arthrodesis was performed in a computerised environment using a finite element foot model with differentially positioned plates. The arthrodesis (Lapidus arthrodesis) was applied to the first metatarsocuneiform joint with 2 proximal 2 distal 3.5 mm screws using a 4-hole plate in three different directions: medial, dorsal and plantar.

Results: Displacement in the arthrodesis area and stress on the fixation material, the plate, were evaluated. After loading, the plantar plate arthrodesis model produced more total displacement (1, 97121 mm) and stress (2242 MPa) than other arthrodesis models. On the other hand, the dorsal plate arthrodesis model has less total displacement (1, 20479 mm) and stress (1253 MPa) than other arthrodesis models. In the volar, dorsal and medial finite element models, it was concluded that the least displacement and plate stress were in the dorsal plate application.

Discussion: In the finite element study, complications can be seen more frequently in Lapidus arthrodesis performed with plantar and medial plates compared to Lapidus arthrodesis performed with dorsal plates. Therefore, Lapidus arthrodesis performed with a dorsal plate may be more stable.

Keywords: Arthrodesis, Finite Element Analysis, Foot

Introduction

Lapidus arthrodesis is a widely preferred and established procedure for the correction of various foot surgical problems, as this surgical technique allows the alignment of the first toe in all three axes. Lapidus arthrodesis is recommended as a first step in the treatment of hallux limitus, hallux valgus, hallux varus, hindfoot deformity, hypermobility of the first toe and metatarsal adductus [1].
Although the Lapidus arthrodesis was first advocated by Albrecht in 1911, it was Lapidus who popularized the method [2, 3]. The described arthrodesis treatment has survived to this day under the name Lapidus [4].
The Lapidus procedure is a form of surgical arthrodesis performed on the first tarsometatarsal joint. Although the results of Lapidus arthrodesis are very good, non-union or malunion is seen in 5-15% of patients. To minimize the risk of complications in Lapidus arthrodesis, the arthrodesis should be as stable as possible [5]. This shows the importance of stability for the arthrodesis.
Lapidus arthrodesis is one of the surgical options for the treatment of hallux valgus [1–3]. Lapidus arthrodesis used for the treatment of hallux valgus may be associated with various complications such as non-union, malunion and implant failure [6].While Myerson et al. [7] indicated that the incidence of non-union in tarsometatarsal arthrodesis was 4.5%, Sangeorzan et al. [8] emphasized that this rate was up to 13%. In a meta-analysis on lapidus arthrodesis [9], non-union was reported in 5.4% of patients after arthrodesis and false union in 6.1%.
Although there are different fixation methods in Lapidus arthrodesis, plate fixation is particularly recommended to minimize the risk of non-union, allow early weight bearing and rapid return to reference range of motion [10, 11]. However, there is no complete consensus on the correct location of the plate, and it is emphasized that there is a need for studies on the location and design of the plate system and the effectiveness of the results of plate detection for the treatment of hallux valgus [1, 12–14].
The aim of this study was to determine the stability of the arthrodesis and the plate stress after loading in a computer environment of 3 different Lapidus arthrodesis fixed with volar, dorsal, and medial 4-hole plates and compression screw modelled with finite elements. It is therefore desirable to demonstrate the importance of plate location in complications such as non-union, malunion and implant failure that may occur in Lapidus surgery.

Material and Methods

In this study, the stress in the plate and the displacement in the arthrodesis were evaluated using finite element analysis according to the volar, dorsal and medial locations of the plate used for Lapidus arthrodesis.
The effect of the plate placed in different positions used in the foot first toe tarsometatarsal arthrodesis (Lapidus arthrodesis) created by finite element modelling on the stability in the arthrodesis and the tension in the plate used was analysed using Ansys Workbench software.
The relationship between plate fixation, which is one of the fixation methods, and such complications was demonstrated using modelling. For this purpose, a three-dimensional (3D) finite element bone model was constructed.
To create a 3D foot first tarsometatarsal joint arthrodesis model, CT images of the right ankle in 90° flexion were digitized to create solid bone models. These models were segmented into cortical and cancellous bone in the tibia, fibula, and foot bone models.
To analyse the arthrodesis of the first tarsometatarsal joint of the foot, the articular surface of the first tarsometatarsal joint of the foot was removed and a bony interface connection was created. The arthrodesis line of the first metatarsophalangeal joint was horizontal with respect to the joint plane and its direction was parallel to the x-axis of the global coordinates. The models were assembled in Ansys/SpaceClaim software according to the surgical procedure with the solid part of the implants. Volar, dorsal, and medial 4-hole plate and screw (PS) fixation methods were used (Figure 1).
A method called plate and screw fixation has been used in tarsometatarsal joint arthrodesis of the first toe. According to this surgical procedure, the incision is made at the level of the tarsometatarsal joint of the first toe and the chondral surface of the joint is removed and fixed [10, 11].
In the finite element model we prepared, as described in this surgical technique, 3 different models of volar, medial, and dorsal 4-hole plates were placed for fixation of the first metatarsophalangeal and medial cuneiform joint arthrodesis. The plates (Parcus Medical, Sarasota, FL, USA) were secured with 2 screws distal to the arthrodesis line and 2 screws proximal to the medial cuneiform of the first metatarsal. The plate used to connect the first finger tarsometatarsal joint arthrodesis is made of titanium alloy material. Linear elastic isotropic material models were used for the plate, bone and joint. The resulting solid models were converted into finite element models using Ansys Workbench software. The material parameters used for the plate and bone are given in Table 1 [15].
The finite element models are constrained so that they cannot make any translations or rotations from the lower boundary of the model. Loads were applied to the upper boundary of the model, the tibia, with a force of 600 N applied vertically downwards [16, 17].
The boundary conditions and loads were used. To simulate the real state of the fibula and tibia in the tissue, horizontal movement from the top of the model was prevented. The elements used for the connection are fixed to the foot, similar to the real conditions. Considering the arthrodesis interface as a frictional contact, the coefficient of friction was set at 0.2.
In order to obtain the best results in the finite element analysis, mesh optimization was performed, and the best mesh density was determined. With the best mesh density, the finite element models of the 3D models were also analysed using Ansys Workbench 2020R2 Finite Element software under the given loads. Then, the foot, fixed with a plate screw under load, was fixed in 3 different ways for arthrodesis in the first toe Lapidus arthrodesis modelling (Figure 1).
Two criteria were chosen to present the results of the numerical analysis (FEA – Finite Element Analysis). One is the von Mises stress criterion on the metal component of the fixation methods. The von Mises stress criterion determines where a given material will yield. The other criterion is the displacement and rotation of the arthrodesis space. The displacement and rotation measured after the application of physical stress is defined as the movement between the components. In particular, interfragmentary movement in the axial direction plays an important role in the stability of the arthrodesis, and this movement prevents bone healing and causes non-union [18].
Points A and B were placed on the arthrodesis surface at the maximum and minimum effective points, respectively. The relative distance measurements of these points were calculated in three axes (X-mediolateral direction, Y-anteroposterior, Z-superoinferior).

Ethical Approval

Our study is not a clinical trial. This finite element study was conducted in a computer environment and a clinical ethics committee decision is not required.

Results

The material parameters used for Lapidus arthrodesis models are given in Table 1. As shown in Figure 1, in Lapidus arthrodesis models, which were fixed with plate screws in 3 different ways under load, first the displacement in the arthrodesis line and then the stress on the plate were evaluated. It was determined that the post-loading displacements of the plantar plate in the x, y and z directions were 0.58 mm, 0.71272 mm and 0.67849 mm, respectively. The total displacement of the plantar plate was 1.97121 mm.
Displacements of the dorsal plate in x, y and z directions were 0.40327 mm, 0.126 mm, and 0.67552 mm, respectively. The total displacement of the dorsal plate was also 1.20479 mm.
For the medial plate, the displacements in x, y and z directions were 0.4577, 0.7486 and 0.57177 mm, respectively (Table 2) (Figure 2, 3).
The maximum stress values in the plates after the analyses are such that for the plantar plate it is 2242 MPa, for the dorsal plate 1253 MPa and for the medial plate 2238 MPa (Table 3). If we compare them, we can see that the minimum stress is on the dorsal plate.
The dorsal plate was the most suitable combination in terms of displacement and minimum stress when three different plate placements were compared. On the other hand, the largest total displacement and stress were found on the plantar plate (Figure 3).
In terms of inter-particle displacement, the lowest displacement was found in the dorsal plate fixation method and the highest displacement was found in the medial plate fixation method.

Discussion

According to our study results, the reason why the dorsal plate placement is more suitable than others is that the dorsal plate is more effective than the plantar and medial plates. This is because the stress distribution on the dorsal plate under load is more homogeneous than others. It causes the load to spread and causes the stresses on the dorsal plate to decrease. Others carry the load mainly with the center of the plate, but the dorsal plate carries the load with the whole body.
Our results are similar to those reported in a previous biomechanical study. In this study by Ray et al, [19] it was emphasized that the use of a plate increased the stability of the first metatarsocuneiform arthrodesis. In addition, fixation of the arthrodesis with 2 proximal and 2 distal 3.5 mm screws using a 4-hole dorsal plate was recommended to protect the fusion site from loading. The dorsal plate is more effective than the plantar and medial plates. These results are consistent with our work in the computer environment using the FEA technique.
On the other hand, a biomechanical study suggests the superiority of the plantar plate position in detection. Plantar and medial plate positions are superior to displacement in arthrodesis. In particular, arthrodesis performed with the plate positioned medially is superior in terms of less displacement and resistance to loading forces. Dorsal plate placement was not superior for any of the outcomes measured. It was emphasized that plantar and medial plates offer biomechanical advantages. It is emphasized that clinical trials with similarly matched constructs are needed to show whether these findings translate into improved clinical outcomes [20]. When these results are evaluated, they differ from the results of our study. In our study, the dorsal plate was found to be superior to the plantar and medial plates in terms of loading and displacement. These results need to be evaluated in long-term clinical trials.
Another study compared plate fixation for arthrodesis with intramedullary fixation. In this study, Roth et al. [13] presented metatarsocuneiform (MTC) fusion (Lapidus arthrodesis) as a treatment option for hallux valgus. They emphasized that plantar plate fixation creates a stronger and more rigid structure than IM fixation. They concluded that plate fixation provides a more stable fixation and reduces the risk of non-union and the duration of weight-bearing disability. They state that plate fixation is appropriate in Lapidus arthrodesis [13]. However, there is no suggestion in the article for different placements of the plate.
A review of the efficacy of the Lapidus plate system in 2022 states that there are insufficient studies on the efficacy of different types of Lapidus plate systems in foot surgery. In addition, it is emphasised that there is a need to increase knowledge about the fixation level, system type and placement of the plate in Lapidus surgery [1].
In a study of dorsal-medial locking plate and screw fixation in Lapidus arthrodesis, the dorsal-medial plate showed better preservation of intermetatarsal angle (IMA) correction compared to screw fixation at mid-term follow-up [21].
A study evaluating the soft tissue effect of Lapidus arthrodesis found that Lapidus arthrodesis with a plantar plate resulted in high patient satisfaction and significant deformity improvement at mid-term follow-up. On the other hand, it was reported that more than half of the patients had tendinopathy symptoms on postoperative magnetic resonance imaging (MRI). It is emphasised that these findings should be taken into account when choosing the method of fixation and implant placement in Lapidus arthrodesis [22].
Another study also highlights that the superficial peroneal nerve (SPN) is at risk of iatrogenic injury due to incisions made along the medial column, including the medial branch of the medial dorsal cutaneous nerve (MDCN) branch, dorsal longitudinal incision for Lapidus fusion. The study concluded that the surgeon must be careful to avoid nerve injuries during dissection [23].
A study of 3-plane first tarsometatarsal arthrodesis using a combination of dorsal and medial plates reported statistically significant improvements in radiographic correction, low deformity recurrence and early return to activity with low complication rates up to 24 months post-operatively. In addition, statistical improvements in patients’ health-related quality of life are reported up to 24 months [24]. Although the fixation results of double plate application are good, it has disadvantages such as additional incision, soft tissue dissection and cost.
In a study comparing the biomechanical stability of Lapidus arthrodesis performed with the plantar Lapidus plate in patients with severe symptomatic hallux valgus with proximal chevron osteotomy performed with plate fixation, it is emphasised that the angular correction potential and clinical value of modified Lapidus arthrodesis performed with the plantar plate is better than chevron osteotomy [25].
In a study on the use of different types of the Lapidus Plate System, it is stated that “the use of screwed or screwless plates, proper levelling and system placement are related to existing foot discomfort” [1]. It is emphasized that there is a need for studies on the level of fixation and placement in foot surgery and studies to increase knowledge of the plate system and plate outcomes in foot surgery. For this purpose, in our study, we addressed this controversial issue from a different perspective with a finite element study.

Conclusions

Although the Lapidus arthrodesis is a recommended surgical technique for the treatment of hallux valgus, various studies show a symptomatic non-union rate of up to 12% and an overall failure rate of up to 20%. In our study, in finite element modeling of dorsal, medial and plantar plate screw fixation, it was determined that the dorsal plate fixation method provided better stability in Lapidus arthrodesis than other plate locations. We believe that these rates may be further reduced with new studies on the design and placement of the proposed plate system in Lapidus arthrodesis. For this purpose, we tried to show the most appropriate plate location in Lapidus arthrodesis in terms of arthrodesis displacement and plate loading using finite element modelling.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and Human Rights Statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.

Funding: None

Conflict of Interest

The authors declare that there is no conflict of interest.

References

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Hacı Ali Olçar, Alaettin Özer, Halil Burak Mutu, Tolgahan Kuru, Göker Yurdakul, Davut Aydın, Murat Korkmaz. The biomechanical analysis of first metatarsocuneiform arthrodesis using the finite element method: A comparison of plate osteosynthesis in different positions. Ann Clin Anal Med 2024;15(4):255-259

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Aim: The study aims to assess the rate of port-site infection after laparoscopic cholecystectomy.

Material and Methods: This descriptive study was conducted in the Department of Surgery at Prince Abdulaziz Bin Musaad Hospital in Arar, Saudi Arabia, over a 12-month period. Patients with symptomatic cholelithiasis undergoing laparoscopic cholecystectomy were included to assess the rate of port-site infection. SPSS version 20 was used to analyze data on diagnosis, port site infection, and demography.

Results: 270 patients with an average age of 38.06 underwent laparoscopic cholecystectomy, including 192 females and 78 males. Thirteen cases (4.81%) of port-site infection were found; most of them involved females (12). Acute cholecystitis cases (10/13) showed higher rates of infection (p = 0.038). The umbilical port was the port site that was most frequently infected (p = 0.002). High BMIs greater than 30 kg/m2 were associated with 9 out of the 13 port site infections (69.2%), while 4 (30.7%) were associated with BMIs < 30 kg/m2. (p=0.01)

Discussion: The rate of port-site infection is 4.8% after laparoscopic cholecystectomy. Surgery in the acute phase and a high body mass index are associated with an increased rate of infection at the umbilical port site.

Keywords: Laparoscopic Cholecystectomy (LC), Port-Site Infection (PSI), Cholecystitis

Introduction

Modern surgical care has changed dramatically with the advent of laparoscopic surgery (LS). It has gained popularity among both surgeons and patients due to the reduced pain, speedy recovery, improved cosmesis, and decreased complications related to wounds [1].
Laparoscopic cholecystectomy is now considered the standard of care for symptomatic gallstones. This minimally invasive technique removes the gallbladder through relatively small abdominal incisions. Since 1987, when the first laparoscopic cholecystectomy was reported by Philips Mouret, this method has been successfully used for a wide range of abdominal, urological, and gynecological procedures [2].
Although laparoscopic cholecystectomy is generally believed to be a safe and effective procedure as compared to a traditional open cholecystectomy, one of its potential complications is port-site infection. It is described as an infection that occurs at the entry site of the laparoscopic instruments used during surgery. Port-site infection is not unusual after laparoscopic cholecystectomy. A systemic review of studies on perioperative antibiotic use in patients undergoing laparoscopic cholecystectomy revealed an infection rate of 2.4-5.2% [3]. Obesity, diabetes, advanced age, prolonged operative time, common bile duct stones, and conversion to open cholecystectomy are risk factors for port site infection (PSI) following LC [4].
According to Mukesh and colleagues’ research, a wound infection rate of 3.71 was identified; in 1.71% of those cases, it was only superficial, and in the remaining 2%, it was deep [5]. The umbilical port was the most frequently affected port, as revealed by a meta-analysis comprising 19 studies. This is most likely due to many local microbes inhabiting the umbilicus [6].
Port-site infection is a disappointing complication that outweighs the advantages of minimally invasive surgery. It increases the patient’s morbidity as well as damages the surgeon’s reputation. Our aim is to assess the rate of infection at the port site after laparoscopic cholecystectomies in our setup.

Aims

To assess the rate of port-site infection after laparoscopic cholecystectomy.

Material and Methods

This prospective study was conducted over a 12-month period in the Department of Surgery at Prince Abdulaziz Bin Musaad Hospital in Arar, Saudi Arabia. On admission, a complete history and physical examination, as well as the body mass index (BMI), were documented. To confirm the diagnosis, abdominal ultrasonography was performed. All male and female patients undergoing laparoscopic cholecystectomy for symptomatic gallstones were included. Patients with obstructive jaundice, pancreatitis, malignancy, and co-morbid conditions like cardiac or respiratory diseases, diabetes mellitus, and immunosuppression were excluded. After fulfilling the inclusion and exclusion criteria, 270 patients were included in the study. For participation in the study, written and informed consent was obtained.
All patients received an intravenous broad-spectrum antibiotic prior to anesthesia induction. Under general anesthesia, a qualified consultant laparoscopic surgeon performed a laparoscopic cholecystectomy. The pneumoperitoneum was created using the closed technique. The gall bladder was removed via an epigastric port using retrieval bags. After removing the cannula, the port sites were washed with normal saline. Antibiotics were given to the patients for 48 hours. On the 1st day after operation, most patients were discharged. The third, seventh, and tenth postoperative days were used to monitor the patients for port-site infection and later, if necessary. After taking a swab and changing their dressing every other day, patients with port-site infections were advised to take antibiotics. Data regarding demography, diagnosis, and port site infection was entered on a proforma.

Statistical analysis

The analysis of all the data was done with SPSS version 20. The data was presented as percentages and numbers. To tabulate the data, frequency distribution was utilized. The significance level was evaluated at 5%. To determine the significance of the relationship between related variables, a Chi square test was used, and P ≤ 0.05 was considered significant.

Ethical Approval

This study was approved by the Local committee of Bioethics (HAP-09-A-043) at Northern Border University (Date: 2022-11-17, No:15/44/H)

Results

This study included 270 cases of laparoscopic cholecystectomy over a period of 12 months. Males were 78 (28.9%) and females were 192 (71.1%). Participants were between the ages of 17 and 79, and the mean age was 38.06. The range of the body mass index was between 17.78 and 57.78. Most patients were obese (41.8%) and overweight (40%), whereas 17.8% were of normal weight as shown in Table.1. Thirteen patients out of a total of 270 patients (4.8%) developed port site infection (PSI) as depicted in Figure 1. Out of these 13 infected cases, 12 involved umbilical ports, while epigastric ports were involved in only one case (p = 0.002), which shows a significant relationship between umbilical ports and infection after laparoscopic cholecystectomy. Regarding gender, 12 out of 192 female patients developed PSI (6.25%), and one out of 78 male patients developed PSI (1.2%). The operative diagnosis was chronic cholecystitis in 138 cases and acute cholecystitis in 132 cases. The infection rate was higher in patients with acute cholecystitis (10), accounting for 76.92% of infected cases (p = 0.03), which is statistically significant as shown in Table.2.
When BMI is considered, 41.8% of people had a BMI of more than 30 kg/m2. Nine out of the 13 port site infections were linked to high BMIs exceeding 30 kg/m2, while four were linked to BMIs under 30 kg/m2, which shows a significant relationship (p = 0.01) between high BMI and port site infection as shown in Table.2.

Discussion

Surgery has been completely transformed by laparoscopy, and laparoscopic cholecystectomy is now considered the standard of care for symptomatic gallstones [7]. Although the procedure has several benefits over open cholecystectomy, there are some risks involved, such as port-site infection. Increased pain and longer hospital stays are linked to port-site infections, which may reduce the cost-effectiveness of this procedure.
In our study, 270 patients were included with age range of 17- 79 years with mean age 38.6. 71.1% of them were female, making up the majority. A study by Sultan in Iraq produced similar results verifying that majority (84%) of gallstone patients were female [8]. The body mass index was in the range of 17.78 to 57.78 in our study. Only 17.8% of the patients were of normal weight, with the majority being overweight (40%) and obese (41.8%).
The infection rate at the port site varies across different research studies, ranging from 2.4% to 6.7% after laparoscopic cholecystectomy [9,10]. In our study, the infection was present in 13 out of 270 cases, with a rate of 4.8%. This is comparable to a rate of 4.5% reported by Al-Naser (Iraq) [11]. A high infection rate (6%) was reported in Pakistan by Javeria et al. [12].
In a case-control study by Sajid comparing open and laparoscopic cholecystectomy, the reported port-site infection rate was around 1.6% in the laparoscopic group [13]. An infection rate of 2.2% was shown by Ganpathi et al. in another study that compared glove closure versus stitch closure of 5-mm ports in laparoscopic cholecystectomy [14]. In a Siddiqui and Tai randomized controlled trial comparing various skin closure techniques for laparoscopic ports, 1.5% of port site infections were reported [15].
The most frequently infected port site was the umbilical port, which was infected in 12 cases (92.3%) in our study. Epigastric port sites were infected in one case (7.7%) only. These results are like the study of Ravindranath GG et al. where umbilical port was the most infected port site (52.4%) [16]. Although an epigastric port was used for the retrieval of gall bladders in our study, the rate of infection was minimal, which could be attributed to the use of an endoglove for gallbladder extraction.
The operative diagnosis in our study was chronic cholecystitis in 132 cases and acute cholecystitis in 138 patients. The rate of infection at the port site was higher in cases of acute cholecystitis (9), accounting for 69.2% of the port site infection rates, which is statistically significant (p = 0.038). A study conducted at the DHQ hospital in Mirpur yielded similar results, indicating a port-site infection rate of 7.1%. Most port-site infections were linked to acute cases, with a 65:35 ratios between acute and chronic cases [17]. Similarly, 60% of port-site infections were seen in cases of acute cholecystitis, according to a study conducted by Naeem (2012) [18]. This may be caused by the gallbladder becoming edematous and having thick walls, or by bile or stones spilling out [19].
In terms of gender, PSI occurred in 12 of 13 (6.25%) female patients and one of 78 (1.2%) males. Females made up 12 of the 13 PSI cases, accounting for 92.3%. Similar results were observed in a study by Ahmed [20], which included 65.17% female patients and 34.83% male patients, with PSI being more common in female patients (7 out of 9 patients).
When we consider BMI, 40% of the patients were overweight and 41.8% were obese. Four of the 13 port site infections were found in overweight patients, while nine were found in obese patients. This shows a significant relationship between obesity and port-site infection (p = 0.01). Similar outcomes were observed in Arvind’s study, where patients with high BMIs (>30 kg/m2) experienced difficulties during the extraction of their gall bladders, causing bile and stones to leak out. There was a correlation between high BMI and port-site infection, as evidenced by the fact that three patients with low BMIs and ten with high BMIs experienced infection [21].

Conclusion

The rate of port-site infection is 4.8% after laparoscopic cholecystectomy. Surgery in the acute phase and a high body mass index are associated with an increased rate of infection at the umbilical port site.

Recommendation

Surgery in the acute phase and a high body mass index increase the risk of infection at the umbilical port site. Although the risk of infection at the port site is low after laparoscopic cholecystectomy, it can be avoided by carefully selecting cases and adhering to basic laparoscopic techniques.

Acknowledgment

The authors extend their appreciation to the Deanship of Scientific Research at Northern Border University, Arar, Saudi Arabia for funding the research work through the project number “MEDA-2022-11-1548”.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and Human Rights Statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.

Funding: Funded by the Deanship of Scientific Research at Northern Border University, Arar, Saudi Arabia. (MEDA-2022-11-1548)

Conflict of Interest

The authors declare that there is no conflict of interest.

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Yasir Mehmood, Muhammad Ayub, Suliman Ali Elsheekh. Port-site infection following laparoscopic cholecystectomy. Ann Clin Anal Med 2024;15(4):266-269

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