 Abstract | | | Objective: To assess the feasibility and safety of laparoscopic cholecystectomy in acute cholecystitis. Subjects and Methods: Between June 1993 and December 1996, 424 consecutive patients underwent laparoscopic cholecystectomy; 45 (10.6%) had acute cholecystitis confirmed by ultrasound. Results: All 45 patients were opened within 72 hours of admission. Conversion to open cholecystectomy was necessary in three patients (6.7%). The mean operating time was 126 minutes (range: 40-300 minutes). There was no mortality or common bile duct injury in this series. The postoperative stay averaged 3.9 days (range: I to 11 days). There was no delayed morbidity after a mean follow-up of 2 years. Conclusion: Laparoscopic cholecystectomy is feasible and safe in patients with acute cholecystitis, provided it is performed by experienced surgeons. Although the procedure is somewhat lengthy, it is associated with low conversion rate, no serious morbidity and zero mortality. How to cite this article:
Al-Mulhim AA. Laparoscopic cholecystectomy is feasible and safe in acute cholecystitis. Saudi J Gastroenterol 1999;5:56-60 |
Laparoscopic cholecystectomy (LC) has rapidly emerged as the standard treatment for symptomatic gallstones [1],[2],[3] . It is less traumatic than open cholecystectomy resulting in fewer postoperative complainst, rapid recovery, shorter hopsital stay, and minimal cosmetic disfigurement [2],[3],[4],[5],[6] . Initially, acute cholecystitis (AC) was considered a contraindication to LC [1],[7],[8] . This is due to the belief that the inflammation, edema and sometimes necrosis associated with AC distort the anatomy, making identification and dissection of the ductal and vascular structures difficult and thereby increasing the incidence of complications [9] . Approximately 20% of patients requiring cholecystectomy present with AC [10],[11] and therefore may not be offered LC. However, with increased experience and refinement of the instruments, more surgeons are performing LC in patients with AC [12],[13],[14],[15],[16],[17],[18],[19],[20] . This study was undertaken to assess the feasibility and safety of LC in patients with AC.
| Patients and methods | |  |
Since June 1993 LC has been the standard treatment for symptomatic gallstones at King Fahd Hospital of the University. All preoperative, operative and postoperative data were prospectively recorded. Up to December 1996, LC has been attempted in 424 consecutive cases with symptomatic gallstones. Within this cohort of patients, 45 (10.6%) were admitted as emergency with a diagnosis of AC and served as the study population. The diagnosis of AC was based on: (1) systemic manifestations of acute inflammation (right hypochondrium pain, positive Murphy's sign, fever >37.5°C, and leukocytosis >l0xl0 9 /L; (2) sonography suggesting AC (distended gallbladder, "doublewalled" gallbladder, thickened gallbladder wall, positive gallstones, positive Murphy's sonography and peircholecystic fluid collection) [21],[22],[23] ; (3) laparoscopic findings of AC and (4) pathologic confirmation' of acute inflammation. All the aabove criteria had to be satisfied for inclusion in the study. Patients with incidental findings consistent with AC during elective LC were excluded. On admission, all patients received intravenous fluids, and antibiotics. Endoscopic retrograde cholangio-pancreatography (ERCP) was used selectively to diagnose and remove common bile duct (CBD) stones. Preoperative ERCP was based on history or presence of jaundice, ascending cholangitis, pancreatitis, abnormal liver function or suspicion of duct stones on ultrasonography. All eligible patients were offered LC within 1-5 days of admission. Laparoscopic cholecystectomy was performed using the standard four-port technique [24] with some modifications. A closed technique was used in all cases to create pneumoperitoneum and to introduce the subumbilical trocar. In patients with previous abdominal surgery, the left upper quadrant was used as the initial insufflation site when necessary. A side-viewing laparoscope (30°) was used in all cases. This is more versatile than the forwardviewing scope (0°) because it permits inspection of the structures from different angles. Aspiration of the distended gallbladder to allow easier grasping was routine. The gallbladder was freed from adhesions using blunt and sharp dissection. The structures at Calot's triangle were clearly identified. The cystic duct, usually thickened, was controlled with titanium clips in most cases or a pre-tied laparoscopic loop if required. Intraoperative cholangiogram was not performed in any patient. The gallbladder was dissected from the liver bed using monopolar electrocautery or the suctionirrigation instrument. A subhepatic drain was inserted when necessary.
| Results | | |
Laparoscopic cholecystectomy was performed within 72 hours in all patients. There were 23 women and 22 men; the average age was 42.8 years (range, 26 to 81 years). All patients had systemic manifestations of AC and all had cholelithiasis [Table - 1]. Preoperative ERCP was attempted in six patients (13%) with suspected CBD stones. Two of them underwent endoscopic sphincterotomy and successful stone extraction; no CBD stones were visualized in three patients. In the sixth, who had obstructive jaundice, it was not possible to cannulate the edematous ampulla. This patient had complete recovery after LC and remained well for four years of follow up. Two other patients required postoperative ERCP. One underwent sphincterotomy with removal of retained stones. The other had bile leak from the cystic duct, which was dealt with at laparotomy. Five patients (11 %)had undergone previous lower abdominal operations: appendectomy in two; cesarean section in two; appendectomy and cesarean section in the reaminder. An alternate initial insufflation site in the left upper quadrant was used in two of them. The open technique was utilized in none, nor was conversion to open cholecystectomy (OC) required in any. Of the 45 patients, three (6.7%) required conversion to OC for the following reasons: significant adhesions and failure to grasp the "thickwalled" gallbladder in the first, bleeding from the liver bed in the second and obscured ductal anatomy in the third. A closed suction drain was inserted in 29 patients (64%). This was removed in most cases within 24 to 48 hours. The frequency of other modificiations employed is shown in [Table - 2].
Overall, the operating time averaged 126 minutes (range: 40 to 300 minutes); mean postoperative hospital stay (laparoscopy and conversion) was 3.9 days (range: 1 to 11 days).
In this series, there was no CBD injury, wound infection, or mortality. Six patients (13%) developed complications. One had bile leak demonstrated by ERCP. Laparotomy with closure of the cystic duct stump resulted in rapid and complete recovery. Another developed immediate postoperative jaundice due to unsuspected CBD stones, which were subsequently removed endoscopically. Atelectasis and chest infection, in two patients each, were treated conservatively. None of the 45 patients required blood transfusion during or after surgery.
| Discussion | | |
Acute cholecystitis is present in approximately 20% of patients undergoing cholecystectomy [10],[11] . Before the introduction of LC, we were in favor of early cholecystectomy for patients with AC. This practice was based on studies that documented the safety and cost-effectiveness of early cholecystectomy compared with conservative treatment followed by "interval" cholecystectomy [25],[26],[27] . During the early experience with LC, AC was regarded as a contraindication [1],[7],[8] . However, with increased experience and improvement in instruments, more and more patients with AC have undergone LC successfully [12],[13],[28] . Encouraged by these results, we attempted LC in all patients who were admitted to our hospital with AC. Only patients who were emergency admissions and with clinical, laboratory, sonographic, operative and pathologic criteria of AC were included in this study. Patients with findings consistent with AC discovered at elective LC were excluded.
In this series, out of 424 consecutive patients who underwent LC, 45 (10.6%) had AC. This is similar to the 7-13% reported by other investigators [13],[15],[20], but less than the 23-26% in other series [12],[14],[16],[18]. Our low percentage may reflect the strict criteria we used to diagnose AC. The rate of conversion to open cholecystectomy in this series was 6.7%, which compares favorably with the 2.2-8.6% reported for elective LC [2],[5],[29] . However, this is less than the conversion rate of 11.4-35% reported in most studies on LC for AC [Table - 3]. Despite the fact that conversion should not be cosidered a "failure" of LC but rather a sound decision to prevent serious complications, it is associated with increased cost and loss of the advantages of LC. Although, the risk factors for conversion to open cholecystectomy have been evaluated [13] , Zucker et al [15] have concluded that "the surgeon's experience is perhaps the most important factor that determines whether patients with AC can undergo successful LC". All LCs in this series were performed by surgeons with experience in both open and laparoscopic cholecystectomy. Our operation time averaged 120 minutes for successful LC, similar to that reported by others [15],[19] . It is, however, longer than that reported for open cholecystectomy in the setting of AC [19] . The operation time is expected to become progressively shorter with increasing experience in LC for AC.
Open cholecystectomy in patients with AC carries a morbidity rate of 10-36% [18],[30],[31] . The overall morbidity in this series was 13%. Bile leak from the cystic duct stump was recognised in one patient (2%) who initially underwent LC. Urgent laparotomy and closure of the cystic duct stump were uneventful. Bile leak is the most common technical complication of LC occuring in 0.2-2.0% of patientst [32],[33] . Of great importance was the lack of serious complications, in particular, bile duct injury in this series. Also, no deaths occcured. In addition, there were no delayed complications after a follow up which averaged 24 months (range: 7 to 48 months). In this series, the mean postoperative stay for all patients (laparoscopic and conversion) was 3.9 days, similar to that reported by others [13],[15],[20] but shorter than the 6-15.8 days after open cholecystectomy for AC [27],[34],[35] .
| Conclusion | | |
This study shows that LC can be safely offered to patients with AC provided it is performed by experienced surgeons. Although, the procedure is somewhat lengthy, the outcome is rewarding with low conversion rate, no serious morbidity and zero mortality.
| References | | |
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Correspondence Address:
Abdulmohsen Abdullah Al-Mulhim
Department of Surgery, King Fahd Hospital of the University, P.O. Box 1917, Al Khobar 31952
Saudi Arabia
PMID: 19864744
[Table - 1], [Table - 2], [Table - 3] |
