| Abstract|| |
One hundred and eight patients with histopathologically confirmed acute cholecystitis underwent laparoscopic or attempted laparoscopic cholecystectomy in the Security Forces Hospital, from October 1991 to April 1996 were retrospectively reviewed. All the patients had routine laboratory works including abdominal ultrasonography. Females represented 75% and 57% had previous admission. Diabetes mellitus was found in 43.5%. Laparoscopic cholecystectomy was successfully completed in 71.2%. The main reasons for conversion in 31 patients were adhesions and unclear anatomy in 87%. The mean operative time was 96 minutes. Laparoscopic cholecystectomy for acute cholecystitis can be a safe and effective alternative to open cholecystectomy provided a safe dissection of the ductal and vascular anatomy with liberal attitude towards conversion is adopted. Patients presenting with leukocytosis >15,000/mm3, mass or diabetes are the most likely to be converted to open surgery.
|How to cite this article:|
Al Qasabi QO. Laparoscopic cholecystectomy for acute cholecystitis. Saudi J Gastroenterol 1998;4:163-6
Laparoscopic cholecystectomy (LC) has dramatically changed the field of general surgery, yet its role in the surgical treatment of acute cholecystitis has not been defined. During the initial experience, acute cholecystitis was considered to be a contraindication, however, with increasing experience, successful treatment by LC was reported,. One of the major questions is the appropriateness and feasibility of the procedure for removal of the acutely inflamed gallbladder. The factors influencing the conversion rate to open surgery, postoperative morbidity and complications are yet to be evaluated.
This is a review of all the patients admitted to the Security Forces Hospital with acute cholecystitis and treated by laparoscopic or attempted laparoscopic cholecystectomy. Particular attention was given to the safety, possible predictive factors for conversion to open cholecystectomy.
| Patients and Methods|| |
The records of all the patients presented to the surgery department in Security Forces Hospital in Riyadh, Saudi Arabia between October 1991 and April 1996 with symptoms and signs of acute cholecystitis were reviewed. Histopathological confirmation of the diagnosis was done in all cases. The diagnosis was based on more than one of the following factors: right upper quadrant abdominal tenderness, guarding, fever, leukocytosis and ultrasonographic findings showing signs of acute inflammation of the gallbladder. All the patients received preoperative antibiotics in the form of second generation cephalosporin in addition to aminoglycoside occasionally in patients with signs of septicemia. Peroperative pneumatic calf compression cuffs were used in all patients with subcutaneous heparin only in patients with high risk of deep vein thrombosis. All the patients underwent laparoscopic cholecystectomy with the usual four ports. We adopted the use of open access technique for the introduction of the first port without urinary catheterization. Occasional modifications were used to overcome technical difficulties. These are decompression of the gallbladder through percutaneous aspiration under camera vision using a long spinal needle, a Babcock grasping forceps or endo clinch forceps was used to hold the usually friable, edematous and thickened wall gallbladder, a fifth port may be utilized to retract, the liver and endo loops were used sometimes to close the wide cystic duct.
Extra care was taken during dissection of the Calot's triangle with minimal use of electrodiathermy in that area. Intraoperative cholangiogram was not done. Pre and/or postoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed selectively in patients with clinical picture suggestive of common bile duct stones.
Chi-square test was used to assess the statistical significance of factors associated with conversion to open cholecystectomy at 5% level of significance.
| Results|| |
During the 4'/z years period of the study, the total number of patients who had laparoscopic or attempted laparoscopic cholecystectomy was 1281 patients. Out of these, 108 (8.4%) presented with acute cholecystitis. The median age is 51.2 (23-87). Eighty-one patients (75%) were females, 62 (57.4%) had previous hospital admissions. Thirty-three patients, referred from hospitals outside Riyadh, required urgent admission for surgical treatment. Diabetes mellitus was found in 47 patients (43.%).
On presentation, 20 patients (18.5%) had fever. Jaundice was detected in 11 (10.1%) and a palpable mass was felt in 14 patients (12.9%). Leuco cystosis (>15,000/mm 3 ) was found in 17 patients (15.7%) and abnormal liver function in 32 (29.6%) [Table - 1]. Laparoscopic cholecystectomy was successfully completed in 77 (71.2%). Conversion to conventional open surgery was necessary in 31 patients (28.7%). The main reasons for conversion were adhesions and unclear anatomy in 27 (87%), gallbladder perforation or bile leak in three (7.9%) and bleeding in one patient (3.2%).
Analysis of the clinical findings in the 31 converted cases are shown in [Table - 2], while the intraoperative findings are shown in [Table - 3]. The mean operative time was 96 minutes with a range of 45-165 minutes. Histological examination of the gallbladder showed acute inflammation in 98 patients (90.7%), features of empyema in 7 (6.4%); gangrene of gallbladder in 2 (1.85%) and adenocarcinoma (confined to the wall of gallbladder) in one patient (0.9%). Major postoperative complications occurred in two patients; the first one had postoperative CBD stricture and the second had postoperative bile leak. Other complications encountered were chest infection in eight, wound infection in three and umbilical port hernia in one patient. Sixty-seven patients (62%) were discharged from the hospital within 72 hours. The median hospital stay was 6.7 days with a range of 2-17 days.
| Discussion|| |
Laparoscopic cholecystectomy for acute cholecystitis constitutes a challenging procedure for many surgeons. Previous reports mentioned that as many as 20% of patients requiring cholecystectomy present with acute cholecystitis. In this series, 8.4% of patients were operated on the same admission with the diagnosis of acute cholecystitis.
In the presence of acute inflammation, several series have reported conversion rates to open surgery ranging from 9-33% ,,,, . However, in patients with histopathological signs of acute inflammation, open cholecystectomy was required in 37% of the cases. Flowers et al reported a conversion rate of 33% for patients with acute cholecystitis compared to 5% conversion rate for elective laparoscopic cholecystectomy.
In this study, the conversion rate (28.7%) falls within the reported range while the overall conversion rate in our hospital is 6.2%. In an attempt to analyze the converted cases with acute cholecystitis, it was found that 35% were males, patients who presented with deranged liver function tests and/or leukocytosis constituted to form 41.9% and 29% respectively, whereas, diabetes mellitus was found in 29% of converted cases. Statistical analysis of the above findings indicated that only leukocytosis, mass and diabetes mellitus were significant [Table - 2]. Other reports have suggested that elderly age, fever, leukocytosis, deranged liver function tests results were significantly associated with failure to complete the procedure laparoscopically and increased length of operation,. In contrast to these reports, other series demonstrated that the male gender elderly age, and the presence of large gallstones were significant,. Adhesions and unclear anatomy were the main reasons for conversion in this series. Interestingly, these same factors have been reported to be the most common causes of conversion in elective cholecystectomy,,,)
The complication rate is similar to that of elective laparoscopic cholecystectomy. Major complications following elective surgery was reported as (0.9 - 1.6%),. In this report, major complication occurred in two cases (1.8%). One patient, an 82year-old female with empyema of the gallbladder developed postoperative CBD stricture. This was managed successfully by PTC stenting and dilatation. Another patient had postoperative bile leak which was treated successfully by postoperative ERCP and endoscopic papillotomy. Other complications reported in the literature included chest infection, wound infection  and umbilical port hernia. The overall complication rate was 13%.
In this study, the median operating time was 96 minutes for laparoscopic procedures and 104 minutes for attempted laparoscopic converted to open surgery. The reported range of operating time was 50-153 minutes for laparoscopic procedure and 105-196 minute for converted cases,,,,,,,
In conclusion, we found similar to others, that laparoscopic cholecystectomy for acute cholecystitis can be a safe and effective alternative to open cholecystectomy,,. However, stress should be placed on ensuring a safe dissection of the ductal and vascular anatomy with liberal attitude towards conversion to open cholecystectomy. Patients presenting with leukocytosis >15,000/mm 3 or mass and/or diabetes are the most likely to be converted to open surgery.
| References|| |
|1.||Peters JH, Miller J, Nichols KE, Ollila D, Avrodopolous D. Laparoscopic cholecystectomy in patients admitted with acute biliary symptoms. Am J Surg 1993;166:300-3. [PUBMED] |
|2.||Cox MR, Wilson TG, Luck AJ, Jeans PL, Padbury RTA, Toouli J. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Ann Surg 1993;218:630-4. |
|3.||Schirmer BD, Edge SB, Dix J, PA C, Hyser MJ, Hanks JB, Jones RS. Laparoscopic cholecystectomy treatment of choice for sysmptomatic cholelithiasis. Ann Surg 1991;213:665-77. |
|4.||Rattner DW, Ferguson C, Warshaw AL. Factors associated with successful laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1993;217:233-6. [PUBMED] [FULLTEXT]|
|5.||Sharp KW. Acute cholecystitis. Surg Clin North Am 1988;68:269-79. [PUBMED] |
|6.||Zucker KA, Flowers JL, Baily RW, et al. Laparoscopic management of acute cholecystitis. Am J Surg 1993;165:508-14. |
|7.||Koo KP, Thirlby RC. Laparoscopic cholecystectomy in acute cholecystitis. What is the optimal timing for operation? Arch Surg;1996:131:540-4. |
|8.||Lo CM, Liu CL, Lai ECS, Fan ST, Wong J. Early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis. Ann Surg 1996;223:37-42. |
|9.||Flowers JL, Bailey RW, Scovilli WA, Zucker KA. The Baltimore experience with laparoscopic management of acute cholecystitis. Am J Surg 1991;161:388-92. |
|10.||Al-Qasabi Q, Mofti A, Suleiman SI, et al. Analyzis of 1105 laparoscopic cholecystectomies. Saudi Medical Journal 1997;18:499-501. |
|11.||Lo CM, Fan ST, Liu CL, Lai ECS, Wong J. Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis. Am J Surg 1997;173:513-7. |
|12.||Taylor EW, Guirguis LM, Johna SP. Laparoscopic cholecystectomy in histologically confirmed acute cholecystitis. J Laparoendosc Surg 1996;6:227-32. |
|13.||Cuschieri A, Dubois F, Mouiel J et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;161:385-7. |
Qassim O Al Qasabi
Department of Surgery, King Khalid University Hospital, P.O. Box 7805, Riyadh 11472
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3]