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PubMedDate not supplied

Laparoscopic cholecystectomy may disseminate gallbladder carcinoma.

Laparoscopic cancer surgery has been reported to facilitate tumor dissemination. In our experience with 158 laparoscopic cholecystectomies, we encountered 2 cases (1.3%) of unsuspected gallbladder cancer. We report these 2 cases to illustrate the disadvantages of laparoscopic tumor resection. In Case 1, a 60-year-old woman with symptomatic cholecystolithiasis underwent a laparoscopic cholecystectomy revealing an unsuspected gallbladder cancer (pT2). Five months later, localized peritoneal carcinomatosis developed in the right subphrenic space, and she died from disseminated disease 19 months postoperatively. Laparoscopic manipulation may have caused the unusual, localized seeding. In Case 2, laparoscopic cholecystectomy was initiated for a polypoid lesion of the gallbladder in a 69-year-old man. When laparoscopy revealed a concomitant cancer (pT3), resection was converted to an open radical cholecystectomy. He remains alive without evidence of disease 31 months postoperatively. Conversion to open surgery may have contributed to the favorable outcome. The contrast between the 2 cases suggests that laparoscopic cholecystectomy should be converted to open surgery whenever malignancy is suspected. Surgeons should note that laparoscopic resection may disseminate cancer.

Adenocarcinoma↗
PubMedDate not supplied

[Laparoscopic cholecystectomy during pregnancy].

BACKGROUND: We evaluated the advantages and risks of laparoscopic cholecystectomy during pregnancy in symptomatic patients. MATERIAL AND METHODS: Three gravid women at an estimated 14 to 26 weeks gestational age underwent laparoscopic cholecystectomy for symptomatic cholelithiasis or biliary pancreatitis. One patient was obese. The operation was successfully completed under tocolytic medication. DISCUSSION: Although rare, gallbladder disease is the second most common abdominal condition during pregnancy requiring operation, being second only to appendicitis. Medical management is the most common approach to treatment, and the surgical intervention is reserved for patients who fail to respond to conservative methods or who have choledocholithiasis, biliary obstruction or pancreatitis. The laparoscopic approach is controversial, and some authors still agree that pregnancy is a contra indication to laparoscopic cholecystectomy. We report our experience with three laparoscopic cholecystectomies performed without complication during pregnancy. On the basis of our experience and a review of the literature, we believe that the laparoscopic cholecystectomy, undertaken preferentially during the second trimester, is a valid alternative to classic management in terms of risks for the foetus and comfort for the mother.

Adolescent↗
PubMedDate not supplied

[Morbidity after video-laparoscopic cholecystectomy in cholelithiasis associated with liver cirrhosis. A case-control study].

At present laparoscopic cholecystectomy represents the treatment of choice for symptomatic cholelithiasis. Authors performed a retrospective case-control study to evaluate whether cirrhosis associated with cholelithiasis increases the risk for morbidity of laparoscopic cholecystectomy. Twenty-one patients with cholelithiasis and cirrhosis (Child-Pugh class A or B) (group A) and 21 controls with cholelithiasis without cirrhosis (group B) entered the study. Controls were paired with cases for age, sex, and indication for cholecystectomy (simple cholelithiasis, acute cholecystitis). The two groups were compared for rate of conversion to open cholecystectomy (19% group A vs 9.5% group B; p = 0.31), morbidity (29.5% group A vs 5.3% group B; p = 0.17), median length of surgery (80 m in the two groups), and median time of postoperative hospitalization (5 days group A vs 3 days group B; p = 0.21). No difference among variables resulted to be statistically significant. Besides, neither common bile duct injuries nor intra or postoperative hemorrhages occurred in patients with cirrhosis. Authors conclude that the laparoscopic cholecystectomy can be considered a safe and effective surgical procedure also for patients with cholelithiasis associated with cirrhosis with a good residual hepatic function.

Aged↗
PubMed1998

Incidence of port site recurrence after laparoscopic cholecystectomy for preoperatively unsuspected gallbladder carcinoma.

BACKGROUND: We sought to determine the incidence of recurrence of carcinoma at the port site and the outcome of patients with such recurrences after exploratory laparoscopy/laparoscopic cholecystectomy for unsuspected gallbladder carcinoma and analyzed aspects of the laparoscopic procedure associated with recurrences at the port site. METHODS: Thirty-seven patients with preoperatively unknown adenocarcinoma of the gallbladder were analyzed. The patients were part of a large prospective study of the Swiss Association of Laparoscopic and Thoracoscopic Surgery including 10,925 patients undergoing laparoscopic cholecystectomy. RESULTS: Preoperatively undiagnosed adenocarcinoma of the gallbladder is rarely encountered in patients undergoing laparoscopic cholecystectomy (0.34%). The incidence of recurrence of carcinoma at the port site in these patients is 14% (5 of 37) and is similar whether the primary tumor is confined to the gallbladder (T1/T2) or locally advanced (T3/T4). The recurrences at the port site were diagnosed within 6 to 16 months (median 10 months) after the operation. Patients with an intraoperative perforation of the gallbladder had a higher incidence of recurrences at the port site (40%) than had patients without perforation (9%; P = .13). All patients with recurrences at the port site had distant metastases and all died of the disease 12 to 35 months (median 19 months) after cholecystectomy; all patients with such recurrences and stage T1/T2 tumors subsequently had peritoneal metastases. CONCLUSIONS: Patients with a preoperatively undiagnosed adenocarcinoma of the gallbladder undergoing laparoscopy or laparoscopic cholecystectomy have a high incidence of recurrences at the port site, and the incidence increases when a gallbladder perforation occurs during the operation. All patients with such recurrences died of the disease. The diagnosis of an isolated recurrence at the port site may therefore be an indicator of disseminated disease in most cases.

Adenocarcinoma↗
PubMedDate not supplied

Abscess formation following spilled gallstones during laparoscopic cholecystectomy.

OBJECTIVE: Our purpose was to report the occurrence of abscess following spilled gallstones during laparoscopic cholecystectomy as experienced at Good Samaritan Hospital, and to compare it to the experience of other institutions in order to identify the incidence, characteristics and possible risk factors for the development of this complication. METHODS: Four case reports of abscess following spilled gallstones during laparoscopic cholecystectomy are presented. The English literature was reviewed, and characteristics of the case reports found in the literature were compared. RESULTS: In four years at this institution, four reports of abscess formation following laparoscopic cholecystectomy have been identified. Two occurred in elderly females and were located in the right flank in both. Two were in middle-aged men, both diabetic. One abscess was in the right flank and one in the right pleural space. Twenty-three cases were found in the literature. The average age was 65 years; there were 12 men and 11 women. The locations of abscess formation were trocar sites (most common), right subphrenic space, right flank or retroperitoneum, and pelvis. The average time to presentation was 4-5 months (range 4 days-12 months). CONCLUSIONS: Abscess formation following spilled gallstones during laparoscopic cholecystectomy occurs infrequently, but can be debilitating and require more than one procedure. The older population appears to be at greater risk. Future prospective studies of patients who undergo laparoscopic cholecystectomy are needed to more accurately determine the incidence of this complication and to identify the population at risk.

Abdominal Abscess↗
PubMed1992

Obesity: an indication rather than contraindication to laparoscopic cholecystectomy.

Obesity was originally designated as a contraindication to laparoscopic cholecystectomy; however, as experience in the procedure develops, it is evolving into an indication. Out of the first 325 consecutive patients undergoing laparoscopic cholecystectomy, 91 were determined to be either obese or morbidly obese. Group I (normal body habitus), consisted of 228 patients, group II (obese) 67 patients, and group III (morbidly obese) 24 patients. Six patients were excluded because of inadequate follow-up data. The groups were fairly well matched for age and seemed to differ only in height and weight. Operative time was similar in groups I and II, while it was approximately 23% longer for group III. The outcome of surgery was compared with respect to conversion to open cholecystectomy, postoperative complications, mortality, length of postoperative stay, and return to normal activity. None of the differences were statistically significant with the exception of the slightly longer length of time for laparoscopic cholecystectomy in the morbidly obese. Laparoscopic cholecystectomy is a safe and effective treatment for obese patients and even for morbidly obese patients, and should be the procedure of choice for these patients, avoiding complications of prolonged bedrest and wound complications, so common in these patients.

Journal Article↗
PubMed1995

Simultaneous Cholecystectomy: to be or not to be.

BACKGROUND: the argument concerning the justification for doing cholecystectomy at the same time as a gastric limiting procedure for morbid obesity continues to be a lively one. This study is an attempt to resolve this issue by reviewing the data of a single surgeon over the 10 year period from January 1983 through April of 1993. METHODS: the first 3 years of the study (386 patients) involved primary gastroplasty with or without cholecystectomy. In 1986, the author began doing Roux-Y gastric bypass which has included 673 consecutive patients. At the same time, our criteria for simultaneous cholecystectomy changed from not only cholelithiasis and cholesterolosis of the gallbladder, but also to a strong family history of biliary tract disease which necessitated surgery and clinical evidence of chronic cholecystitis at surgery, i.e. thickening of the gallbladder wall and more than the usual amount of adhesions. FINDINGS: in the 1983-1986 group, 13% needed a second operation for symptomatic binary tract disease sometime between 1 and 9 years after surgery. In the latter group from 1986 to 1993, 9% have necessitated cholecystectomy, usually several years following the original Roux-Y gastric bypass. CONCLUSIONS: we conclude that simultaneous cholecystectomy be based on the above criteria rather than being done routinely.

Journal Article↗
PubMedDate not supplied

Cystic duct remnant and the 'post-cholecystectomy syndrome'.

Post-cholecystectomy syndrome refers to a wide spectrum of conditions that pose a challenging diagnostic dilemma. Cystic duct remnant, defined as a residual duct greater than 1 cm in length, may, in the presence of stones, cause post-cholecystectomy syndrome. In this report, 4 patients with post-cholecystectomy syndrome due to cystic duct remnant are described. All underwent laparoscopic cholecystectomy and one was converted to open. The patients presented with pain 10 months to 9 years post-cholecystectomy and investigations demonstrated cystic duct remnant. All patients underwent successful resection with resolution of symptoms. In this era of laparoscopic surgery, where surgery favors a long cystic duct remnant, we should be aware of cystic duct stones as a possible cause of postcholecystectomy syndrome. This report highlights magnetic resonance cholangiopancreatography as the optimal method for evaluating the biliary tract in these cases.

Adult↗
PubMed1993

Ventilatory and blood gas changes during laparoscopic and open cholecystectomy.

As part of a randomized trial, ventilatory and arterial blood gas changes were assessed during open (n = 30) and laparoscopic (n = 30) cholecystectomy. Measurements were made during anaesthesia before the start of surgery and at the time of removal of the gallbladder. Despite an increase in minute ventilation from a mean(s.d.) of 5.7(1.4) to 6.1(1.2) litres, mean(s.d.) arterial carbon dioxide tension (PaCO2) rose from 5.3(0.9) to 6.0(0.9) kPa during laparoscopic cholecystectomy. End-tidal carbon dioxide tension (PE'CO2) had poor precision in predicting PaCO2 (95 per cent interval of agreement -0.61 to 1.93 kPa). Mean(s.d.) peak airway pressure increased from 17(4) to 23(4) cmH2O. The mean PaCO2--PE'CO2 value did not change significantly, although there was significant within-patient variation. Arterial oxygen levels did not change significantly. By comparison, no clinically significant changes in ventilation or blood gas values occurred during open cholecystectomy. In conclusion, laparoscopic cholecystectomy requires a substantial but variable increase in minute ventilation to compensate for carbon dioxide absorption from the peritoneum.

Adult↗
PubMed1996

Assessment of splanchnic tissue oxygenation by gastric tonometry in patients undergoing laparoscopic and open cholecystectomy.

This experimental study compared the effects of laparoscopic (n = 31) and open (n = 32) cholecystectomy on gastric intramucosal pH (pHi). For this purpose, pHi was measured tonometrically before induction of anaesthesia, at 30-min intervals during surgery, and 1, 2 and 4 h after operation in otherwise healthy patients undergoing elective cholecystectomy. Additionally, perioperative arterial pH (pHa), arterial carbon dioxide tension (PaCO2), intramucosal carbon dioxide tension, arterial bicarbonate concentration, end-tidal carbon dioxide pressure (PECO2), levels of serum lactate, lactate dehydrogenase (LDH) and gamma-glutamyl transferase (GGT), haematocrit and arterial blood pressure were recorded. In the two groups no significantly different changes occurred in pHi, pHa, serum lactate concentration or haematocrit at any of the observation times. PECO2 and PaCO2 were significantly raised during the laparoscopic procedure, whereas levels of LDH and GGT and arterial blood pressure rose during and after open cholecystectomy. In spite of the increased intra-abdominal pressure and the peritoneal carbon dioxide absorption related to the creation of a pneumoperitoneum, no decrease in pHi was detectable during laparoscopic cholecystectomy.

Adult↗
PubMed2005

Randomized clinical trial of open versus laparoscopic cholecystectomy in the treatment of acute cholecystitis.

BACKGROUND: The aim of this prospective trial was to determine whether surgical approach (open versus laparoscopic) had an impact on morbidity and postoperative recovery after cholecystectomy for acute cholecystitis. METHODS: Seventy patients who met the criteria for acute cholecystitis were randomized to open or laparoscopic cholecystectomy. The type of operation was unknown to the patient and all hospital staff involved in the postoperative care. RESULTS: The two groups were similar with respect to demographic and clinical characteristics. There were no significant differences in rate of postoperative complications, pain score at discharge and sick leave. In eight patients a laparoscopic procedure was converted to open cholecystectomy. Median operating time was 90 (range 30-155) and 80 (range 50-170) min in the laparoscopic and open groups respectively (P = 0.040). The direct medical costs were equivalent in the two groups. Although median postoperative hospital stay was 2 days in each group, it was significantly shorter in the laparoscopic group (P = 0.011). CONCLUSION: Cholecystectomy for acute cholecystitis can be performed by either laparoscopic or open techniques without any major clinically relevant differences in postoperative outcome. Both techniques offer low morbidity and rapid postoperative recovery.

Adult↗
PubMedDate not supplied

Failed or difficult laparoscopic cholecystectomy: can preoperative ultrasonography identify potential problems?

A prospective study was performed to assess the role of preoperative ultrasonography in predicting failed or difficult laparoscopic cholecystectomy. Fifty patients underwent detailed preoperative ultrasound examinations. The number and size of calculi, evidence of acute or chronic cholecystitis, gallbladder morphology, and the presence or absence of aberrant anatomy were documented. A comparison was made of the surgical outcome and the ultrasound findings in each patient. Six patients were converted to open cholecystectomy because of inflammatory changes in the gallbladder. The preoperative ultrasound studies in 5 of these patients demonstrated evidence of cholecystitis and cholelithiasis. Gallbladder wall thickening and contraction were also seen. Five gallbladder resections had intraoperative difficulties; preoperative ultrasonography demonstrated a thickened gallbladder wall in 2. Of 31 uneventful cases, 7 had evidence of gallbladder wall thickening and/or contraction. There were no ultrasound features that identified between the unsuccessful, difficult, or uneventful laparoscopic cholecystectomies. We conclude that detailed preoperative ultrasound evaluation of the gallbladder in patients destined for laparoscopic cholecystectomy is of little value in screening for difficult or unsuitable cases.

Adult↗
PubMed1996

Is male gender a risk factor for conversion of laparoscopic into open cholecystectomy?

BACKGROUND: Based on a clinical observation that the conversion rate of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) is higher in males, we decided to review our records and to verify whether a significant difference in conversion rates exists between sexes. METHODS: A retrospective study on conversion rates of elective laparoscopic cholecystectomy (LC) into open cholecystectomy (LC) in relation to gender was carried out in 329 patients: 267 females and 62 males. RESULTS: Our data revealed that the probability of conversion is fivefold greater in males than females, 21% vs 4.5%, respectively (p = 0.0001). We attribute this striking difference to significantly more adhesions p = 0.0002) and anatomical difficulties (p = 0.003) in males during LC, leading to conversion. CONCLUSIONS: We conclude that conversion of LC to OC is more prevalent among males and is probably attributable to a greater incidence of anatomical difficulties.

Cholecystectomy↗
PubMedDate not supplied

The impact of laparoscopic cholecystectomy on the operative experience of surgical residents.

The impact of laparoscopic cholecystectomy (LC) on the operative experience of surgical residents was assessed in a series of 787 cholecystectomies. During an initial 18-month period, residents participated in LC as operating surgeon and as first assistant or camera operator in 33% and 97% of cases, respectively. Operative time, cholangiography rate, conversion rate, and complications were not adversely affected by resident operators. Residents performed 87% of concurrent planned open cholecystectomies (OC). In comparison to the 6 months preceding LC: (1) The mean number of resident OCs decreased significantly while the total number of resident cholecystectomies was unchanged; (2) the proportion of OCs performed by PGY5 residents significantly increased at the expense of junior resident cases. LC can be safely integrated into surgical resident training by standard methods as for open procedures. Although resident operative experience has been redistributed, initial experience does not suggest that qualification in open biliary surgery has been compromised.

Cholangiography↗
PubMed1994

Preceptored introduction of laparoscopic techniques for cholecystectomy into a large university-affiliated medical center.

Faced with the task of introducing laparoscopic techniques for cholecystectomy into the practice of a large department composed of individuals with varied backgrounds and experience, our surgical staff decided to grant provisional provileges to five surgeons, two from the full-time faculty and three from the community, who had completed a formal course in laparoscopic cholecystectomy. These five surgeons agreed to assist one another through 10 cases a piece before performing any procedures on their own or serving as preceptors for additional surgeons. Other surgeons could obtain credentials for this procedure by satisfying the same course criteria and receiving assistance from one of the five original surgeons during their first 10 cases. In the 14 months after September 1990, 250 laparoscopic cholecystectomies were performed by 19 different attending surgeons at our hospital. One death from hemorrhage (0.4%) and two bile duct injuries (0.8%) occurred in these patients. One of the bile duct injuries occurred after conversion to open cholecystectomy, as did the hemorrhage, which was from a vessel within the parenchyma of the gallbladder bed which rebled even after temporary control through open ligature technique. The second bile duct injury, the result of injudicious application of hemoclips for hemostasis, was minor in degree and the only injury to occur in a procedure conducted exclusively through the laparoscope. This experience demonstrates that laparoscopic techniques can be safely introduced into an environment involving multiple surgeons by adherence to a careful protocol of preceptored assistance.

Academic Medical Centers↗
PubMed1994

Laparoscopic cholecystectomy. Do preoperative factors predict the need to convert to open?

We reviewed our experience with the last 587 laparoscopic cholecystectomies performed between May 1990 and January 1993 to correlate preoperative findings that may predict the conversion of a laparoscopic cholecystectomy to that of an open procedure. The prediction of a need to convert to an open cholecystectomy would allow the surgeon to discuss the higher risk of conversion with the patient and also allow for an earlier intraoperative decision to convert if difficulty was encountered. In addition to routine demographic data, ultrasound reports were available for 526 patients and the following information was recorded: presence of stones, thickened gallbladder wall, common bile duct dilatation, gallbladder sludge, and cystic duct impaction. Overall, a two times higher rate of conversion was found for male patients and patients with a body mass index > 27.2 kg/m2. Additionally, a thickened gallbladder wall on preoperative ultrasound was correlated with a six times higher conversion rate to open cholecystectomy. As expected, the positive intraoperative cholangiogram was associated with a higher incidence of conversion. Additionally, finding a dilated common bile duct on ultrasound was found to be associated with a nearly seven times higher rate of positive intraoperative cholangiogram. No statistical significance was found between conversion and age, previous abdominal operations, the presence of stones, common bile duct dilatation, gallbladder sludge, cystic duct impaction, or a distended gallbladder. Thus, these predictive findings allow the surgeon to preoperatively discuss the higher risk of conversion and allow for an earlier judgment decision to convert if intraoperative difficulty is encountered.

Acute Disease↗
PubMed1995

Patient-controlled analgesia after laparoscopic and open cholecystectomy.

Laparoscopic cholecystectomy (LC) offers advantages over open cholecystectomy (OC) of more rapid patient recovery. The comparative amount of pain that patients must endure after each of these procedures is not clear. We retrospectively analysed the use of patient-controlled analgesia (PCA) of an unselected sample of patients having either LC or OC procedures to quantitate morphine use, as well as pain and sedation scores in the postoperative period. The hospital charts, anaesthetic records and the PCA records of 40 patients having either LC (n = 19) or OC (n = 21) were analysed retrospectively. The use of PCA morphine was standardized and consisted of a loading dose of 5 mg, bolus doses of 1.5 mg and a lockout period of five minutes. By the morning of postoperative day one, OC patients had used 38.0 +/- 11.7 (mean +/- SD) mg compared with 23.7 +/- 15.3 mg in LC patients (P < 0.05). The rates of PCA morphine use in the first two postoperative hours were 4.66 +/- 2.6 mg.hr-1 and 7.04 +/- 2.7 mg.hr-1 for LC and OC patients, respectively (P < 0.05). The rates of morphine use averaged over the day of surgery were 1.28 +/- 0.8 mg.hr-1 and 2.33 +/- 0.8 mg.hr-1 for LC and OC patients (P < 0.05). Despite higher PCA morphine use in OC patients, their pain scores were higher while their sedation scores were comparable. These data suggest that laparoscopic cholecystectomy is associated with less pain than open cholecystectomy in the day after surgery.

Adult↗
PubMed1997

Laparoscopic cholecystectomy for acute cholecystitis: prospective trial.

This prospective study determines the indications for and the optimal timing of laparoscopic cholecystectomy (LC) following the onset of acute cholecystitis. It also evaluates preoperative and operative factors associated with conversion from laparoscopic cholecystectomy to open cholecystectomy in the presence of acute cholecystitis. Having been established as the procedure of choice for elective cholelithiasis, LC is now also used for management of acute cholecystitis. Under these circumstances the procedure may be difficult and challenging. Certain favorable and unfavorable conditions may be present that influence the conversion and complication rates. Information about these conditions may be helpful for elucidating the optimal circumstances for LC or when the procedure is best avoided. We performed LC on an emergency basis as soon as the diagnosis was made on all patients presenting with acute cholecystitis from January 1994 to December 1995. All preoperative, operative, and postoperative data were collected on standardized forms. Of the 137 patients registered, 130 were eligible for the audit. Seven patients found by laparoscopic intraoperative cholangiography to have choledocholithiasis were converted for common bile duct exploration and were excluded from the study. Altogether 83 patients (72%) underwent successful LC and 37 (28%) needed conversion to open cholecystectomy. The conversion rate of acute gangrenous cholecystitis (49%) was significantly higher than that for uncomplicated acute cholecystitis (4.5%) (p < 0.00001) and for hydrops (28.5%) and empyema of the gallbladder (28.5%) (p = 0.004). The difference in conversion between the group with acute necrotizing (gangrenous) cholecystitis and the two groups with hydrops and empyema of the gallbladder was not statistically significant (p = 0.07). The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 9.0%, 9.5%, 14.0%, and 20.0%, respectively (p = NS). Patients with an operative delay of 96 hours or less from the onset of acute cholecystitis had a conversion rate of 23%, whereas a delay of more than 96 hours was associated with a conversion rate of 47% (p = 0.022). The complication rate was 8.5% in the laparoscopic group and 27% in the converted group (p = 0.013). Patients over 65 years of age, with a history of biliary disease, a nonpalpable gallbladder, WBC count over 13,000/cc, and acute gangrenous cholecystitis were independently associated with a high LC conversion rate; male patients, finding large bile stones, serum bilirubin over 0.8 mg/dl, and WBC count over 13,000/cc were independently associated with a high complication rate following laparoscopic surgery with or without conversion. Generally, LC can be performed safely for acute cholecystitis, with acceptably low conversion and complication rates. Different forms of cholecystitis carry various conversion and complication rates in selected cases. LC for acute cholecystitis should be performed within 96 hours of the onset of disease. Predictors of conversion and complications may be helpful when planning the laparoscopic approach to acute cholecystitis.

Acute Disease↗