| Abstract|| |
Laparoscopic cholecystectomy was first performed in Buraydah Central Hospital, Al Qassim in September 1993. Since more than 125 open cholecystectomies were performed annually, there was a need to be able to deliver this type of service to the patients in our hospital. Continued audit is needed to ensure that the results with low complication rates achieved in tertiary centers are reproduced by the surgeons at district level. Our study of 340 laparoscopic cholecystectomies performed between September 21, 1993 and September 20, 1995 describes the results with incidence of complications, conversion to open procedure, mean operation time and the extend of postoperative stay in a district hospital. Our complication rates compare favorably with the results achieved in laparoscopic cholecystectomy in many centers. Data obtained by us suggests that laparoscopic cholecystectomy is safe and effective for the treatment of cholecystitis, and this technique can be introduced safely in
a district general hospital in Saudi Arabia.
|How to cite this article:|
Rather GM, Ravi VK. Audit of laparoscopic cholecystectomies in a district general hospital. Saudi J Gastroenterol 1997;3:15-21
Laparosocpic cholecystectomy has become the approach of choice for gallbladder removal for the vast majority of patients and is already well established in the Kingdom of Saudi Arabia  . It provides a quicker, comfortable recovery with rapid return to work by reducing the trauma of operative access. However, there is an ongoing challenge which involves assessing the safety of laparoscopic cholecystectomy and alerting the surgeons to possible complications. Well controlled comparative studies at district and tertiary level are needed with no bias towards the reporting of favorable results. Now as our series in Buraydah Central Hospital has grown, we were able to review our experience with increased perspective.
Most of the early published series ,,,,, were from major teaching centers specializing in laparoscopic techniques.
Reports from specialized centers with wide experience in laparoscopic surgery are unlikely to represent what occurs in everyday practice ,,,, . Our study represents the true incidence of complications, conversation to open procedure and the extend of postoperative stay in a district general hospital. Our complication rates compare favorably with those from other centers ,,,, . The aim of this audit was to ensure that standards of care were maintained for patients undergoing cholecystectomy following the introduction of this new technique in our hospital.
| Patients and Methods|| |
A retrospective review of 340 patients who underwent laparoscopic cholecystectomy over a twoyear period from September 21, 1993 to September 20 1995, was performed. The series included 268 females and 72 males whose age ranged from 15 to 80 years. Data was collected on a standardized form [Figure - 1] by one of the authors and patients were seen within six weeks postoperatively in outpatient clinics. During this audit period five consultants with vast experience in open surgery performed laparoscopic cholecystectomy.
Gallbladder disease was diagnosed on the basis of history, physical examination, laboratory testing and ultrasonic evaluation. The indications for surgery included chronic calculous cholecystitis (249 cases), acute calculous cholecystitis (71 cases, 12 of which involved gangrene of gallbladder), acalculous cholecystitis (12 cases) and hydrops (8 cases). Patients with acute acalculous cholecystitis were only considered for surgery if the pain and tenderness in the right upper quadrant of abdomen persisted along with leukocytosis with normal upper gastrointestinal endoscopy and acutely inflamed thick walled gallbladder on ultrasonography.
In 42 cases (12.3%) surgery was performed on an emergency basis. Twelve patients underwent umbilical herniorrhaphy and seven cases adhesiolysis along with the procedure.
In each instance, laparoscopic procedure was explained to the patient preoperatively, and informal consent was obtained; the patient was also told that, in the event of intraoperative difficulties, the procedure might be converted to an open cholecystectomy.
| Operative Technique|| |
Preoperative antibiotic coverage was provided with premedication by one of the cephalosporins available. Prophylactic subcutaneous heparin was used in 173 cases (50.9%). The basic operative technique confirmed to the standard pattern involving a four puncture technique in all cases. Diathermy of the gallbladder was performed with monopolar electrosurgical hook in all cases. In none of the cases scissors was used for dissection
Intraoperative cholangiography was not performed in any case. Selective preoperative ERCP was performed in 14 cases because of jaundice, pancreatitis, abnormal liver enzyme levels or a dilated common bile duct on ultrasound. In nine cases in which choledocholithiasis was present it was managed with preoperative ERCP and endoscopic sphincterotomy. Three patients had successful postoperative ERCP and endoscopic sphincterotomy done for common bile duct stones. They had not undergone preoperative ERCP.
| Results|| |
The operating time was calculated from skin incision for introduction of Verees needle to end of skin closure of puncture wounds. An average of 98 minutes (range 35 to 200 minutes) was required for each operation. The median operating time for the first 100 patients was 125 minutes but this had fallen to 110 minutes for the second and 90 minutes for the third 100 patients.
Rate of Conversion to Open Cholecystectomy
Conversion to a standard open cholecystectomy was necessary in 26 cases (7.6%). Reasons for conversion to open technique were: acutely inflamed edematous thick-walled gallbladder was difficult to grasp in 14, in six bleeding from cystic artery, in one cystic duct puncture near the common bile duct and in five poor visualization of the operative field due to technical difficulties with our camera. Conversion rate was higher (12%) for the first 100 cases and 6% each for the second and third 100 patients.
[Table - 1]
| Operative Morbidity|| |
Bile Duct Injury
Two common bile duct injuries occurred in our series. None of them was detected at the time of surgery. Both of these patients had subhepatic redivac drains and there was continuous bile drainage. In the first case, the patient had acute cholecystitis and because of clipped common bile duct had laparotomy and choledochojejunostomy carried out after ERCP in the second week after the primary procedure. Our second patient also had a clipped common bile duct secondary to abnormal cystic duct anatomy that was not recognized during the laparoscopic procedure and the patient continued to drain bile from the drain. After ERCP the patient had laparotomy and choledochojejunostomy on the 10th postoperative day. Both the patients were transferred to hepatobiliary centers with experience in laparoscopic bile duct injuries.
| Post Operative Bleeding|| |
Reoperation was necessary in two patients for postoperative bleeding 12 and 16 hours following the procedure. The hemorrhage stemmed from cystic artery because of slipped clips.
| Bile Leaks|| |
Postoperative bile leakage occurred in six patients (1.8%). All these patients had drains placed at the time of surgery. In five patients it stopped on the third postoperative day and one patient who continued to drain bile had a stone impacted at the lower end of common bile duct which was successfully removed by endoscopic sphincterotomy.
| Visceral Injury|| |
One patient developed symptoms and signs of small bowel obstruction with peritonism on the fourth postoperative day and had laparotomy. He needed resection of six inches of the perforated small bowel caused by diathermy burn injury that was not recognized at the time of laparoscopic procedure.
| Pulmonary Embolism|| |
Two female patients who were above 60 years of age developed pulmonary embolism on the third postoperative day, in the early part of our series and none of them had received prophylactic heparin. Both recovered after anticoagulation.
| Minor Complaints|| |
During the immediate postoperative period 32% of our patients complained of shoulder pain. In most of the patients it was controlled with paracetamol but in some cases it had to be supplemented with nonsteroidal anti-inflammatory agents.
| Umbilical Hernia Formation|| |
Three of our patients (0.9%) presented with umbilical hernias noted at 6, 5 and 4 months respectively after surgery and had successful hernia repairs done.
| Operative Mortality|| |
There was no death in our series of 340 laparoscopic cholecystectomies.
| Hospital Stay|| |
In none of our patients hospital discharge occurred on the day of surgery. Only seven patients were discharged 24 hours after the procedure. The average duration of hospital stay was four days (2 to 14 days).
| Discussion|| |
Although laparoscopic cholecystectomy has become very popular for the treatment of gallbladder stones, the procedure must be able to be performed reliably without increased morbidity and mortality. Perhaps when figures come from specialist hepatobilairy units showing increase in the number of referrals for management of bile duct injury then it will reflect the true scale of the problem. Injury to common bile duct causes the most serious morbidity associated with laparoscopic cholecystectomy. It has been seen recntly that bile duct injuries occurred with both experienced and inexperienced surgeons ,,,, .
Our incidence of bile duct injury (0.6%) during laparoscopic cholecystectomy is equivalent to many published series in the literature ,,,,,,,,,, [Table - 2]. Four bile duct injuries (1.%), out of which one resulted in the death have been described by Troidal et al in a series of 400 patietns  . In a series of 579 patients, Traverso reported 17 (2.8%) common bile duct injuries  . Most single center series of more than 300 laparoscopic cholecystectornies have a bile duct injury rate of 0.3 , .
It has been seen in our study that most of the time bile duct injuries were not detected during the procedure and there was a delay in the detection of these injuries. It is therefore, necessary for good longterm results that the first repair be undertaken by an experienced biliary surgeon in a specialist hepatobilaary unit. It becomes all the more important as laparoscopic bile duct injury tends to be more severe than that which occurs during open cholecystectomy. Many surgeons perform intraoperative cholangiography to facilitate exposure and prevent iatrogenic injury but we did not use it in any of our cases.
All of our six cases who had postoperative bile leakage had subhepatic drains placed at the time of the procedure and it resolved with no complications, in one case it resolved only after ERCP and sphincterotomy for impacted stone at lower end of common bile duct. The majority of these complications in the published series have been dealt with by laparotomy, percutaneous drainage and endoscopic biliary drainage ,,,, . Laparosocpy with peritoneal lavage and placement of subhepatic drain has also been reported  . Our study shows that placement of subhepatic drains is a safe technique in cases with difficult dissection as none of our cases needed second procedure for the drainage of bile as they all had drains. Most of these minor bile leaks will stop if there is no distal obstruction as majority of them mentioned in the literature are either due to failure of clips used to secure the cystic duct or from accessory Ducts of Luschka More Details.
One of our patients in the series sustained small bowel injury with the diathermy hook which remained unrecognized at the time of surgery, and was operated on the fourth postoeprative day with small bowel resection. If immediately recognized it can be repaired by immediate laparotomy as unrecognized injuries at laparoscopy carry high rates of morbidity and mortality.
No case of pulmonary embolism occurred in our series of 173 cases who received prophylactic heparin. Two patients who were not given prophylactic heparin had pulmonary embolism, were above 60 years of age and occurred early in the series.
Operation time was more than two hours in both cases. We found that prophylactic heparin is useful in the prevention of pulmonary embolism especially in the older age group and in those cases where induction of pneumoperitoneum may be prolonged by difficult dissection as in cases of acute cholecystitis and multiple adhesions.
Our average operating time (35-200 minutes) reflects the fact that 12.3% of the operations were carried out for acute cholecystitits on an emergency basis which takes longer time. But the median operating time decreased as the experience increased.
The median operating time for our third 100 patients was only 90 minutes.
The conversion rate of 7.6% in our series was because 12.3% of our patients were operated for acute cholecystitis. The average postoperative stay of our patients (4 days) was longer than reported in most series. This was partly due to social reasons and as most patients believed in staying longer in the hospital after surgery. ,,,,,,,,,,
The procedural complications of laparoscopic cholecystectomy are the same as reported elsewhere. Mortality and morbidity continue to occur in relation to both procedures.
| Conclusion|| |
Laparoscopic cholecystectomy which has been accepted and strongly sought after by our patients has been available here for more than two years and its results are beginning to be clarified. Our series has indicated overwhelming patient satisfaction with the procedure and its clinical outcomes. However, a continuous effort is needed to improve the quality of service delivered to our patients. The increased incidence of bile duct injury than after conventional cholecystectomy remains a source of anxiety and needs to be reduced. Intraoperative injuries like intraperitoneal bleeding, bile duct injuries, bile leaks and visceral injuries need to be recognized and managed early. We must realise that conversion to an open procedure is not a failure but may avoid unneccesary complications. The length of hospital stay needs to be reduced when appropriate. Learning of safe technique is important for the procedure to be performed with lower morbidity. The results of this study confirm that laparoscopic cholecystectomy can be introduced as safely into district general hospitals as in major teaching hospitals in Saudi Arabia.
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Ghulam Mommed Rather
Consultant Surgeon, Law Hospital,Carluke, Lanarkshire ML8 SER, United Kingdom
Source of Support: None, Conflict of Interest: None
[Figure - 1]
[Table - 1], [Table - 2]