| Abstract|| |
The objective of this study is to describe the normal, abdominal radiological findings after laparoscopic cholecystectomy that could be confused with a pathological process. Thirty-one patients, who had laparoscopic cholecystectomy were prospectively studied. They underwent supine and erect abdominal X-rays, on the first and second postoperative days. In 19 patients (61 %) no residual free intraperitoneal gas was seen. In 12 patients (39%) small amounts of free gas were noticed 24 hours postoperatively, and in six (19%), some free intraperitoneal gas was seen after 48 hours. Distention of the colon was noticed in 17 (55%), and was mainly in the hepatic flexure area in nine of these patients (29%). Eight patients complained of shoulder pain. This study shows that pneumoperitoneum tends to disappear within 48 hours of laparoscopic cholecystectomy. When present, there is usually no cause for alarm as long as patients show no evidence of clinical disturbance.
|How to cite this article:|
Al Shehri MY. Radiological evaluation of patients after laparoscopic cholecystectomy
. Saudi J Gastroenterol 1999;5:23-6
The first successful laparoscopic cholecystectomy was performed by Mouret in France in 1987, but it was not until the reports by Dubois et al, Reddick and Olsen that laparoscopic cholecystectomy became widely accentable , . Interest in this procedure has spread in the world like an epidemic and laparoscopic cholecystectomy is fast replacing open cholecystectomy in many parts of the world. Because of patients' demand and the eagerness of the surgical community to carry out this procedure, little attention has been paid to the overall effects of laparoscopic cholecystectomy  . The objective of this study is to describe the commonly occurring abdominal radiological findings, after laparoscopic cholecystectomy, with a view of differentiating these from pathological situations like accidental bowel injury.
| Patients and Methods|| |
All the patients presented with symptomatic gallstones to this author in Asir Central Hospital (ACH) between April 1993 and April 1994 were offered laparoscopic cholecystectomy and prospectively studied. Thirty-three patients treated only by this author were entered into the study. There were 26 women and seven men. Age ranged from 20 to 75 years (mean 38.5 years). The indication for surgery was biliary colic in 27 patients. Three patients had acute cholecystitis and the remaining three had mucocele of the gallbladder. Two patients were converted to open cholecystectomy, and therefore, were withdrawn from the study. The diagnosis of gallbladder disease was made by the usual routine preoperative workup. But the confirmation and the diagnosis of mucocele of gallbladder were made intraoperatively and was confirmed by histological examination. Since antibiotics prophylaxis is routinely given in laparoscopic cholecystectomy ,, , this was also done in this series. All patients had gastric decompression with nasogastric tube before surgery. Foley's catheter was used to decompress the urinary bladder in the beginning of the study, but later patients were just instructed to empty their urinary bladders immediately before surgery. Laparoscopic cholecystectomy was perfoilued by a standardized technique. The gallbladder was dissected using electrocautery, and removed through the umbilical port. The abdomen was usually deflated by opening the ports before their removal.The fascia of the umbilical and epigastric ports were routinely closed with vicryl 0 suture and the skin incisions were closed with subcuticular sutures and adhesive tapes. Patients underwent supine and erect radiographic views of the abdomen in the first and second postoperative days. All radiographs were initially examined by the on-call radiologist. At the completion of the study, all the films were reviewed by one radiologist who had no knowledge of the patients. The patients were usually discharged as soon as they felt comfortable and followed in the outpatient clinic in one to two weeks after discharge. Student t-test was used for comparison of means. Chi-square was used for categorial varibles, and z-test for comparison of two proportions. Differences were taken as significant when P < 0.05.
| Results|| |
The mean operating time was 80 minutes (ranging from 40 to 155 minutes) and the average hospital stay was 2.9 (2-6) days. Ten patients had complications. Two patients had wound infection involving the umbilical incision, and transient postoperative fever occurred in two patients. Two patients suffered severe upper abdominal pain in the first postoperative day, for which no cause could be found despite extensive investigatioins, although small amount of biliary leak could not be ruled out. The pain resolved over the next 48 hours with no further complaints. Eight patients (25%) complained of right shoulder pain which was severe enough to require pethidine injections for its control. The mean age of these patients with shoulder pain was 32 ± 10 years in comparison to 40 ± 11.7 years in the other patients without shoulder pain, P=0.15. There was no difference in the operating time, postoperative hospital stay, indication for surgery, or the presence of free gas in the abdomen in the postoperative radiological films, between patients with and without shoulder pain.
Plain films of the abdomen, obtained in the 31 patients used for this prospective study, revealed no residual free intraperitoneal gas in 19 patients (61%) [Figure - 1]. Small amount of free gas was noticed in 12 patients (39%) 24 hours postoperatively, and in six (19%) of them no free gas was seen after 48 hours. Moderate to large amounts of gas were noticed in only one patient 24 hours postoperatively and this persisted to the second postoperative day. There was no difference between patients with and without intraperitoneal gas 48 hours postlaparoscopic cholecystectomy, regarding age, sex distribution, operating time, postoperative stay, or postoperative complications [Table - 1].
Fourteen patients (45%) were considered to have nomial gas distribution in the colon and small intestine. Distention of the colon was noticed in 17 patients (55%), and this was mainly in the hepatic flexure are in nine patients (29%) [Figure - 2]. Minimal small intestinal distention was noticed in only five patients (16%).
| Discussion|| |
Residual intraperitoneal gas after laparoscopy appears to be rapidly absorbed, although no efforts were made to evacuate the intra-abdominal gas, apart from opening the trocar valves at the end of the procedure. Only six patients (19%) had radiological evidence of pneumoperitoneum after 48 hours, and only one of them had moderate to large amount of gas seen after 48 hours. These six patients were followed up clinically for a minimum of one month with no noticeable difference in their outcome from the others.These findings would suggest that significant amount of pneumoperitoneum 48 hours after laparoscopic cholecystectomy without clinical evidence of sepsis is no cause of alarm, and does not require any active surgical intervention.
The radiological findings in this study show that small bowel distention is unusual since only minimal distention was noticed in five patints. Abnormal colonic distention however was frequent in this study and it was mainly in the hepatic flexure area [Figure - 2]. These findings did not correlate with any abnormal clinical course. These patients tolerated their diet early and did not have excessive nausea or vomiting in any way different from the rest of the patients. These findings in the colon could be explained on the basis of partial ileus related either to manipulation during surgery or an effect of the diathermy used during dissection which may be transmitted locally to the nearby colon, since the pneumoperitoneum usually pushes the small intestines away from the operating area. Other possible explanation is an effect of carbon dioxide on the colon  .
Shoulder pain requiring injectable analgesics, occurred in eight patients (25%). The association between laparoscopy and shoulder pain has been reported previously in the literature , . Riedel and Semm reported that 28% of 200 patients who had laparoscopy, had shoulder pain on the day of operation and 54.5% had shoulder pain on the day following the operation day  . They found that 93% of all patients had subphrenic gas on radiological investigation of the chest and that the gas was carbon dioxide by infra-red spectroscopy. Therefore, they suggested that the effect of the volume of the remaining gas on the phrenic nerve is the cause of the shoulder pain.
Wallace et al in a recent publication found that the insufflation pressure significantly affects the post operative pain associated with laparoscopic cholecystectomy  .
| Conclusion|| |
This study shows that after laparoscopic cholecystectomy, pneumoperitoneum tends to disappear within 48 hours. When present there is usually no cause for alarm as long as patients show no evidence of peritonitis.
Intestinal distention tends to occur more frequently in the hepatic flexure of the colon and rarely in the small bowel.
| References|| |
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|3.||Neugebauer E, Troidl H, Spangenberger W, Dietrich A, Leering R, et al. Conventional versus laparoscopic cholecystectomy and the randomised controlled trial. Br J Surg 1991;78:150-4. |
|4.||Smith R, Kolyn D, Pymar H, Sauerbrei E, Pace RE Ultrasonographic and radiologic evaluation of patients after laparoscopic cholecystectomy. CJS 1992;35:55-8. |
|5.||Riedel HH, Semm K. The postlaparoscopic pain syndrome (author's syndrome). Geburtshilfe-Frauenheilkd 1980;40:635-43. [PUBMED] |
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|7.||Wallace DH, Senpell, MG, Baxter JN and O'Dusyen PJ. Randomized trial of different insufflation pressure for laparoscopic cholecystectomy. Br J Surg 1997;84:455-8. |
Mohammad Yahya Al Shehri
Department of Surgery, College of Medicine, P.O. Box 641, Abha
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2]
[Table - 1]