| Abstract|| |
Objective : Poverty, pressing priorities and tropical diseases prevailed added to the factors that delay the implementation of Laparoscopic Cholecystectomy (LC). The objective of this study was to assess the feasibility and safety of LC in this country (Sudan). Subjects and methods: From June 1995-May 1999, we enrolled 288 patients presented with symptomatic gallstone disease without pre-selection criteria. 242 were females and 46 were males, mean age 48.1 years. Results : LC was successful in 201 (94.81%) patients including 49 patients with acute cholecystitis. The operation was done the same day of admission and 60 (29.35%) were able to leave as a day case. There was no mortality and no common bile duct injury. Conclusion: LC is feasible, safe and cost effective in Sudan.
Keywords: Tropical disease, Cholecystectomy, Laparoscopic, acute cholecystitis, males and females.
|How to cite this article:|
Ibn Ouf MA, Salama AA, Fedail SS. Laparscopic cholecytectoy: A local experience in Sudan. Saudi J Gastroenterol 2001;7:22-5
Background: Born in France in 1987 Laparoscopic Cholecystectomy (LC), faced with skepticism in 1989-1990, became popular and led to a variable revolution in the field of general surgery thereafter  . In several countries it is now the gold standard for gallstone disease  . But in tropical countries LC. implementation faces difficulties, namely financial constraints. Tropical diseases may increase the rate of conversion to classical open cholecystectomy . In Sudan, the first LC was introduced in June 24,1995, in Sudan Surgical Clinic where a prospective data was collected for all patients admitted with symptomatic gallstone disease. The study endeavors to reflect the feasibility and safety of LC in this developing tropical country as judged by the presence of concomitant intraperitoneal tropical disease, rate of conversion and complications
| Patients and Methods|| |
From June 1995 to May 1999, we enrolled 288 consecutive patients presented with symptomatic gallstone disease for L.C. without pre-selection criteria. There were 46 males and 242 females with a mean (S.D.) age 48.1 (14.8), (Range 15- 80) years. Detailed description of L.C and possibility of conversion to open cholecystectomy was explained to every patient. Every patient received 750 mg cefuroxime IV at induction of anesthesia and when indicated subcutaneous 5000 units of heparin. All patients were requested to void immediately before surgery. Neither nasogastric tube nor Folly's urinary catheter was introduced preoperatively  . In 24 patients pharyngeal mask was used instead of the endotrachial tube for delivering the anaesthetic gasses  . Under general anaethesia, with the patient in supine position, the surgeon on the left hand side of the patient and the cameraman on the left hand side of the surgeon, after skin preparation, Veress needle was introduced through a parauumbilical stab, C02 was insuflated. Subsequently this stab was used for insertion of a 10mm trocar for the camera. Another three pores were made, one at the epigastrium for the dissector , the second at the right iliac fossa and the fourth in between the second and the third. The patient was then tittered to the lefthand side in an antitrendlingburg position. Peritoneoscopy (using Olympus single chip video camera) was routinely conducted to exclude concomitant intraperitoneal pathology and to assess the condition of the gallbladder. The funds of the gallbladder was then grasped and pushed upwards. If the gallbladder was tense and difficult to grasp, it was aspirated. The Hartmann's pouch was then grasped and retracted to the left to expose the posterior aspect of the Calotte's triangle and the Rouviere's sulcus of the liver  . The peritoneum covering the posterior aspect of the Calotte's triangle was pealed off to expose the cystic duct. Then the anterior surface of the Calotte's triangle was dissected to clear the cystic duct and artery. Each of these structures was clipped separately and transected in between clips. The G.B was then dissected and removed in the majority of cases through the epigastric wound The severity of the gallbladder pathology, operative time, rate of conversion, and the hospital stay were noted. Cost of LC compared to that of open Cholecystectomy conducted in other hospitals in this country. X 2 and student t test were used for statistical analysis of data.
| Results|| |
The main clinical findings were shown in [Table - 1], the operative findings in [Table - 2] and the pathological status of the gallbladder in [Table - 3]. LC was completed successfully in 201 (94.81) patients. Elective conversion  to open Cholecystectomy was done in nine patients these were a female with carcinoma of the gallbladder proved by histopathology, two females with spontaneous cholecysto-duodenal fistula, four diabetic patients with empyema of the gallbladder, two of them were males and two females with dense adhesions and an unclear anatomy. Delayed exploration was needed in a male and a female because of cystic duct bile leak; the first of them was diagnosed after ERCP. This makes our total conversion rate 5.19%. Ligation of the cystic duct stump was done for the last two patients and they were discharged two days later in good condition. This makes our morbidity rate 0.94%. We didn't encounter any major duct injury or mortality. Severe gallbladder disease (acute cholecystitis, mucocele and empyema of the gallbladder) occurred in 49 (23.1%) patients. Eighteen (48.65%) were males and 31 (17.71%) were female patients. X2 = 13.92 (P<0.001). In this group of patients who had severe gallbladder disease in 6 (12.24%) patients which required conversion to open Cholecystectomy.
The extraction of the gallbladder was difficult in 58 patients requiring wound dilation and/or extension. The mean (SD) operative time was 65.62 (29.27) minutes for females and 72.70 (32.93) for males, t = 1.014 (p<0.5). 60 (29.35%) patients were discharged in the same day. 141 were operated in the afternoon and discharged in the next morning. The mean (SD) postoperative hospital stay was 20.4 (5.84) (range 6-48) hours.
During the period of this study the cost of LC was Ls1200000 ($600) and the cost of open Cholecystectomy in similar institutions in this country was Ls 1800000-2500000 ($900-1250).
| Discussion|| |
Although LC has been recommended for all patients suffering from gallstone disease ,, , it was reported that cases of acute cholecystitis carry higher conversion rate , . Conversion rate may even be higher in countries where tropical diseases like amoebic liver abscesses and abdominal tuberculoses are common  . In this study we have operated successfully eight with nodular liver, four of them proved to be due to schistosomal periportal fibrosis after tru-cut needle biopsy. We also operated successfully a case of sickle cell trait and another with sickle cell disease and both proved by haemochromatography. In fact, we routinely used laparoscopy to diagnose and biopsy suspected cases of abdominal tuberculoses, but we did not see this disease during the routine open cholecystectomy. However, we operated nine cases with upper abdominal adhesions, three of them due to upper abdominal surgery. The rest of them were difficult to explain though at least one was female with adhesions between the liver and the diaphragm i.e. suspected clinically Krutz-Fitz-Hugh syndrome because clamydia titre was not available to prove the case. We did not routinely use preoperative cholangiogram, but we relay on endoscopic retrograde cholangiography for clearance of common bile duct stones.
In this study severe gallbladder disease was encountered in 18 (48.65%) males and 31 (17.71%) females, x 2 =13.92(p< 0.001). We believe that since males are the breadwinners, they present rather late i.e. when the disease is severe enough to interfere with earning of living.
Hutchinson  reported an increased conversion rate among males and Edar  found an increased complication rate in males with or without conversion. However, we needed to convert to open cholecystectomy in four males and seven females. Nevertheless, our conversion rate in the group of patients with severe gallbladder disease was 12.34% which compared favorably well with the reported rates of conversion in acute cholecystitis ,, . We didn't observe any significant difference in the operative time between males and females t=1.014, (p<0.5). Therefore, like others ,,,, we believe all patients suffering from gallstone disease should be offered the lapascopic option.
The impression that LC is not cost effective was not only disapproved , but it was raised as the greatest argument in favor of LC implementation, because of the less medications, short hospital stay, cost effective bed utility and early return to productive life. During the period of this study the cost LC in Sudan is Ls 1.200.000 ($ 600). This cost is less than that of open Cholecystectomy performed in the private sector, which is Ls 2.800.000. In governmental hospitals the OC is subsidized to about one third of its real cost. We feel that financial difficulties could be reduced to a great extent by the medical schemes, which were recently introduced in the country. During the period of this study 452 open cholecystectomies with comparable age and sex distribution were performed by three surgeons (the first author is one of them) at the National Center of Gastrointestinal and Liver Diseases. There were three deaths among these open cholecystectomies (mortality rate 0.66%) and four re-explorations for non-major duct bile leak (morbidity 0.88%). In comparison to no mortality and only 0.94% morbidity in this series of LC, this encourages us in the future to say that LC is safe, well accepted and carries the inspirations of the future for this and other under-developing countries at the dawn of the third millenium.
| Conclusion|| |
In our country LC is acceptable by patients, safe, and successful and cost effective as compared to open Cholecystectomy. Tropical diseases could safely be suspected and LC can be started with careful open technique of peritoneal C02 insuflation. Males being main breadwinners in this country they tend to present late with severe gallstone disease. With the introduction of medical insurance schemes, problems of poverty will not remain as an argument against implementation of LC.
| Acknowledgement|| |
We would like to thank Mr. Ahmed A. Seid Ahmed for processing this manuscript.
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Mohamed A.M Ibn Ouf
Dept. of Surgery, Gastro-intestinal and Liver Diseases Center, Ibn Sena Hospital, P.O. Box 8057, Khartoum
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3]