Surg Endosc DOI 10.1007/s00464-015-4235-5
and Other Interventional Techniques
Laparoscopic subtotal cholecystectomy for severe cholecystitis Yuji Shingu1 • Shunichiro Komatsu2 • Shinji Norimizu1 • Yoshiro Taguchi1 Eiji Sakamoto1
•
Received: 22 December 2014 / Accepted: 8 May 2015 Ó Springer Science+Business Media New York 2015
Abstract Background The concept of laparoscopic subtotal cholecystectomy (LSC), without approaching Calot’s triangle to avoid both laparotomy and serious complications, is not widely accepted. In this study, we evaluated the outcomes of LSC for severe cholecystitis when dissection of the cystic duct and cystic artery is hazardous. Methods From January 2004 to December 2013, 110 consecutive patients who underwent LSC without ligation of the cystic duct and vessels were enrolled in this retrospective study. Their clinical records, including operative records and outcomes, had been entered into a prospectively maintained database and were analyzed. Results The mean operating time and blood loss were 121 min and 33.8 ml, respectively. All LSCs were completed without conversion to an open procedure. No injuries to the bile duct or vessels were experienced. Postoperative complications occurred in ten (9.1 %) patients, including subhepatic hematoma in 3, bile leakage in 3, and subhepatic abscess in 1. Patients recovered from complications without requiring re-operation. During follow-up periods (mean 30.7 months), symptomatic biliary stone diseases relapsed in three patients (2.7 %) and were successfully treated by endoscopic management.
& Yuji Shingu [email protected] 1
Department of Digestive Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan
2
Department of Gastroenterological Surgery, Aichi Medical University, Nagakute, Aichi, Japan
Conclusions LSC without an attempt to dissect Calot’s triangle is a safe and feasible procedure that can avoid conversion to laparotomy. Keywords Laparoscopic subtotal cholecystectomy Cholecystitis Calot’s triangle
With advancements in devices and techniques, severe cholecystitis is no longer considered a contraindication for the laparoscopic approach. However, the risk of damage to the bile duct and structures in the hepatic hilum during a standard cholecystectomy is greatest when Calot’s triangle cannot be safely dissected, particularly in the presence of severe inflammation or fibrosis [1, 2], Mirizzi syndrome, or anomalous biliary anatomy [3, 4]. Conventionally, conversion to open cholecystectomy has been recommended in such difficult situations [5], but this may result in increased postoperative pain, delayed mobility, and a prolonged hospital stay [6, 7]. In addition, conversion does not necessarily improve exposure or facilitate cystic duct identification [8], with no guarantee for avoidance of bile duct injury [9]. Laparoscopic subtotal cholecystectomy (LSC) that avoids hazardous dissection at the triangle of Calot has been advocated to be an alternative to the conversion to laparotomy in the cases of severe cholecystitis or liver cirrhosis [9–19], following previous reports of open subtotal cholecystectomy [20, 21]. Acceptable outcomes of LSC have been shown with lower rates of both conversion and major inadvertent injuries, suggesting the safety and feasibility of the technique under severe conditions. However, the sample size in these studies was relatively small and included a substantial number of cases in which ligation or clipping of the cystic duct and artery appeared possible. Furthermore, long-term outcomes after LSC were
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not well described. Thus, efficacy and safety of LSC for severe cholecystitis, which may be associated with an increased risk of postoperative bile leak and local infection, residual gallstones, or incidental gallbladder cancer, were not fully estimated. In this study, we examined more than 100 cases of LSC without cystic duct ligation for severe inflammation or fibrosis of the gallbladder, in which approaching Calot’s triangle would be dangerous. Efficacy and safety of this procedure were assessed, based on the evaluation of shortand long-term outcomes, to verify its role as an alternative to conversion to laparotomy.
Cholecystectomies n=2003
LC n=1964
OC n=39
Simultaneous management n=291
Suspected malignancy
Only LC n=1673
Materials and methods Patients In our institute, the laparoscopic approach was primarily chosen for benign gallbladder disease regardless of combined cholecystitis or previous surgical history with the exception of cases of suspected malignancy. Diagnostic workups, such as blood test, abdominal ultrasonography (US), and abdominal computed tomography (CT), were performed in all patients at the initial consultation. Preoperative cholangiography was also employed to identify the biliary anatomy, including possible anomalies or variations, and location of gallstones. Imaging included drip infusion cholecystocholangiography under CT (DICCT), magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiography. For acute cholecystitis, antibiotic therapy or percutaneous transhepatic gallbladder drainage (PTGBD) was initially performed, followed by interval elective laparoscopic cholecystectomy (LC). During the 10-year period from January 2004 to December 2013, 2003 consecutive patients underwent cholecystectomy at Nagoya Daini Red Cross Hospital, including 1964 laparoscopic and 39 open procedures. Of the 1964 patients in whom laparoscopy was initially attempted, 291 underwent simultaneous management for a coexistent disease. Among the remaining 1673 patients, 1563 patients underwent conventional LC, which included 24 conversions to open, and the rest (110 cases, 5.5 %) underwent LSC without ligation of the cystic duct and vessels. Figure 1 is a flowchart showing the performance of cholecystectomies at our institute. The clinical records of 110 LSC patients, which included clinical factors, findings of imaging studies, operative records, and outcomes, have been entered into a prospectively maintained database and were analyzed for this study. Postoperative follow-up was performed by medical chart review and phone contact, when necessary.
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Conventional LC n=1563
LSC n=110 Patients in whom approaching Calot’s triangle would be hazardous (eligible for study)
Complete LC n=1539
Conversion to open n=24
Complete LSC n=110
Perihepatic adhesion: 14 Suspicion of cancer: 6 Injury of adjacent structures: 4
Fig. 1 Flow diagram of our cholecystectomies performed at our institute. LC laparoscopic cholecystectomy, OC open cholecystectomy, LSC laparoscopic subtotal cholecystectomy
Surgical technique of LSC In this series, the majority of operations were performed with the initial purpose of total removal of the gallbladder and were only converted to the subtotal technique when dense inflammation or fibrosis would resulted in hazardous entry into Calot’s triangle. Under about 8 mmHg CO2 intra-abdominal pressure, a 4-port technique with three 5-mm ports and one 12-mm port was applied, using a 10-mm flexible laparoscope. The fundus-first technique [22, 23], dividing the liver bed from the fundus to the neck downward, was employed when possible. The division was completed ventral to Rouviere’s sulcus to leaving the plane of the common bile duct and Calot’s triangle untouched [24]. An incision was made through the ventral and caudal side of the gallbladder neck or body, followed by removal of the contents, in order to avoid any intra-abdominal spillage, confirming the anatomy of Hartmann’s pouch and the cystic duct orifice from the view of the inner lumen. The removed stones were placed in an endobag. Then, transection and closure at the gallbladder neck were carried out by using an endoscopic linear stapler.
Surg Endosc
When there was a stone impaction in Hartmann’s pouch, including Mirizzi syndrome, or a severely sclerosed change in the gallbladder wall, the site of the stone impaction or gallbladder neck was incised followed by removal of the stones, allowing visualization of the cystic duct orifice from the inner lumen of the gallbladder. Then the incision was continued into the posterior wall under direct vision in a circumferential fashion. The gallbladder contents were evacuated by removing and/or aspirating them. In cases where significant difficulty in dissecting the gallbladder from the liver bed was encountered, the gallbladder’s posterior wall was left attached to the liver and the mucosa was peeled off or ablated using an energy device. The mucosa in the proximal remnant was cauterized as extensively as possible, and the proximal stump of the gallbladder was sutured and closed with absorbable suture material, so as to diminish the inner cavity of the infundibulum rather than to close the stump neatly (Fig. 2). After LSC, the operative field was washed copiously, and a drainage tube was routinely placed in the subhepatic plane.
Results Preoperative features of patients The mean age of the 110 patients (75 men, 35 women) was 66.7 y (range 31–83), and the mean body mass index was 24.2 (range 15.9–44.3). Of 110 patients, 105 (95.5 %) complained of various manifestations, including right upper abdominal pain in 93 (84.5 %), upper abdominal discomfort in two (2 %), back pain in four (3.6 %), and a simultaneous fever ([37.5 °C) in 78 (70.9 %). The US and/or CT showed cholecystitis in 96 patients (87.3 %), and PTGBD was required in 40 patients (36.3 %) in addition to antibiotics therapy. All cholecystitis resolved with expectant management. As the means of preoperative cholangiography, DICCT, and/or MRCP were conducted in
100 patients (90.9 %). ERC was performed for diagnostic and therapeutic purposes in 21 patients (19.1 %) when bile duct diseases were suspected. These imaging studies revealed stone impaction in Hartmann’s pouch in 46 patients (41.8 %), and Mirizzi syndrome was diagnosed in 8 of these 46 patients. An anomalous right hepatic duct was observed in ten patients (9.1 %), of whom eight had combined cholecystitis. Surgical outcomes Operative outcomes of the 110 LSC are shown in Table 1. The mean operating time and blood loss were 121 min and 33.8 ml, respectively. All LSCs were completed without conversion to an open procedure, and neither bile duct injury nor vessel injury was observed. Closure of the remnant stump could be done in all LSCs except one. The median postoperative hospitalization was 4 days. Postoperative complications occurred in ten patients (9.1 %), including subhepatic hematoma in 3, bile leakage in 3, portsite infection in 1, subhepatic abscess in 1, urination difficulty in 1, and arrhythmia in 1. The postoperative imaging studies, such as CT and/or fistulography, in patients with abdominal complications showed that biliary injury and a residual stone were not evident and clarified that three bile leaks occurred from the remnant gallbladder stump. All complications were resolved without re-operation, but biliary stent placement and percutaneous intervention were necessary for 1 of the 3 bile leaks and for one subhepatic abscess, respectively. There was no mortality in this series. Incidental gallbladder carcinoma was found in one elderly patient (0.9 %), for whom additional operation was impossible due to her severe comorbidities. Follow-up evaluation after LSC was performed in all patients by medical chart review in 83 (75.5 %) and/or phone contact in 27 (25.5 %). During follow-up periods (mean 30.7 months, median 29 months, range 3–104 months), only four patients showed any symptoms caused by postoperative complications or biliary stones. Of these,
Fig. 2 Intraoperative photograph of laparoscopic subtotal cholecystectomy. A Impacted stone is removed after transection of the gallbladder neck. B The stump of the gallbladder is sutured and closed with absorbable suture material
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Surg Endosc Table 1 Outcome in patients who underwent LSC
LSC patients (n = 110) Mean operating time (min)
33.8
Conversion to laparotomy (n)
0
Injury of bile duct and/or vessels (n)
0
Median length of postoperative hospitalization (days)
4
Postoperative complication (n)
10 (9.1 %)
Hematoma
3
Bile leakage
3
Port site infection
1
Others
4
Postoperative mortality
0
Incidental gallbladder carcinoma
1
two patients (1.8 %) had fever and right subcostal pain due to common bile duct stone within 3 months after LSC, requiring endoscopic sphincterotomy and removal. One patient complained of right abdominal discomfort and dark urine at 4 years after LSC and had common bile duct stone treated with endoscopic management. The fourth patient had an incisional hernia at the umbilical port site, which was controlled with an elastic corset.
Discussion An early laparoscopic approach for acute cholecystitis has been proposed to be technically feasible and at least equally as safe as the open approach. However, extensive inflammation, adhesions and consequent increased oozing can make laparoscopic dissection of Calot’s triangle and recognition of the biliary anatomy hazardous and difficult. Therefore, conversion to an open approach remains a valid option to secure patient safety under such difficult conditions. Indeed, conversion rates of laparoscopic surgery for acute cholecystitis range from 10 to 20 %, even in the recent reports of early surgery. In as much as conversion does not necessarily improve exposure or facilitate cystic duct identification [8], LSC has been proposed to be a safe and feasible alternative to conversion to open surgery during a difficult laparoscopic cholecystectomy [25]. Our results showed no conversion to laparotomy without any injury of the bile duct or major vessels in more than 100 LSCs limited to patients with severe cholecystitis in which dissection of Calot’s triangle would be hazardous. If the concept of LSC was not available, open surgery would have been required in most of the cases in this study group. Furthermore, the overall complication rate in this study was 9.1 %, which is lower than the reported rate in conversion to an open procedure (10.5–28.0 %) [26–28]. A recent randomized controlled
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121.0
Mean estimated blood loss (ml)
trial for acute cholecystitis also demonstrated higher morbidity rates, 11.8 % in an immediate laparoscopic cholecystectomy group and 34.4 % in a delayed surgery [29]. With regard to drawbacks of the procedure, there is a potentially increased risk of postoperative local infection, related to a combination of contamination by bile or mucus secretion and intraperitoneal gallstone migration. In our series, great care was taken to remove the spilled contents and to wash the operative field copiously, followed by placement of subhepatic peritoneal drainage. Additionally, in the cases in which there was difficulty in removing the posterior wall within the liver bed, we carefully peeled off or ablated the remnant mucosa using an energy device after the gallbladder neck transection. By following these points, the infectious complication rate was extremely low in the present study. In almost all of our patients, the remnant gallbladder was closed by sutures or staples. The closure was not successful in only one patient due to severe wall thickness. Consequently, the incidence of bile leaks and subhepatic collections after LSC was found to be low, whereas the majority of patients had presented with severe cholecystitis. Consistent with the results of a previous review [25], bile leaks from the cystic duct stump did not result in major complications, which were controlled by conservative management. There is a possibility that residual stones in the bile duct or cystic duct could cause cholestasis, thereby promoting stump leakage, whereas such complicated gallstones were not evident in our cases of bile leak. In this study, symptomatic biliary stone diseases occurred in 3 (2.7 %) of the 110 patients during the mean follow-up period of 30.7 months and were successfully treated by endoscopic management. Choledocholithiasis after LSC may be attributed to residual or newly formed stones in the remnant gallbladder or cystic duct. Since the endoscopic transpapillary approach has been established as a standard technique for common bile duct stones [30–32],
Surg Endosc
it seems rational that safety of the surgery should be considered prior to thorough removal of gallstones in severe cholecystitis. Moreover, dissection or cannulation of the cystic duct for intraoperative cholangiography (IOC) should be avoided according to the concept of LSC. Our emphasis has been on precise preoperative imaging to locate gallstones and to delineate the biliary anatomy [33–35] as well as postoperative follow-up examinations (e.g., MRCP), minimizing the dependence on intraoperative observation under severe conditions. The combination with endoscopic transpapillary intervention before or after surgery is a treatment of choice, when gallstones in the bile duct or cystic duct are found by cholangiography. Laparoscopic ultrasound or IOC through the intraluminal orifice of the cystic duct may be promising approaches for intraoperative imaging of the bile duct [36, 37], although the efficacy of these procedures remains to be estimated. There is a small but definite risk of gallbladder cancer being found unexpectedly. Such findings were made in 0.2–0.8 % of patients who underwent laparoscopic cholecystectomy [38, 39]. One patient was incidentally found to have carcinoma in the resected specimen in our series. If the gallbladder wall is cut open in patients with gallbladder cancer, abdominal dissemination and remnant tumors are always observed. The LSC procedure allows an intraoperative leak of gallbladder contents into the abdominal cavity; therefore, the preoperative and intraoperative exclusion of gallbladder cancer is of utmost importance. Our follow-up evaluation concerning symptomatic biliary complications was performed in all patients, and range and median times of the follow-up period were 3–104 and 29 months, respectively. The follow-up period appears sufficient to capture almost all of the late complications associated with residual stones [40–42], but may be too short to detect problems associated with the remnant gallbladder, such as newly formed gallstones or postcholecystectomy syndrome [43]. In conclusion, LSC is a treatment of choice to avert conversion to open surgery, for limited cases in which dissection of Calot’s triangle would be hazardous due to severe inflammation.
Disclosures Drs. Yuji Shingu, Shunichiro Komatsu, Eiji Sakamoto, Shinji Norimizu, and Yoshiro Taguchi have no conflicts of interest or financial ties to disclose.
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and Other Interventional Techniques
Laparoscopic subtotal cholecystectomy for severe cholecystitis Yuji Shingu1 • Shunichiro Komatsu2 • Shinji Norimizu1 • Yoshiro Taguchi1 Eiji Sakamoto1
•
Received: 22 December 2014 / Accepted: 8 May 2015 Ó Springer Science+Business Media New York 2015
Abstract Background The concept of laparoscopic subtotal cholecystectomy (LSC), without approaching Calot’s triangle to avoid both laparotomy and serious complications, is not widely accepted. In this study, we evaluated the outcomes of LSC for severe cholecystitis when dissection of the cystic duct and cystic artery is hazardous. Methods From January 2004 to December 2013, 110 consecutive patients who underwent LSC without ligation of the cystic duct and vessels were enrolled in this retrospective study. Their clinical records, including operative records and outcomes, had been entered into a prospectively maintained database and were analyzed. Results The mean operating time and blood loss were 121 min and 33.8 ml, respectively. All LSCs were completed without conversion to an open procedure. No injuries to the bile duct or vessels were experienced. Postoperative complications occurred in ten (9.1 %) patients, including subhepatic hematoma in 3, bile leakage in 3, and subhepatic abscess in 1. Patients recovered from complications without requiring re-operation. During follow-up periods (mean 30.7 months), symptomatic biliary stone diseases relapsed in three patients (2.7 %) and were successfully treated by endoscopic management.
& Yuji Shingu [email protected] 1
Department of Digestive Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan
2
Department of Gastroenterological Surgery, Aichi Medical University, Nagakute, Aichi, Japan
Conclusions LSC without an attempt to dissect Calot’s triangle is a safe and feasible procedure that can avoid conversion to laparotomy. Keywords Laparoscopic subtotal cholecystectomy Cholecystitis Calot’s triangle
With advancements in devices and techniques, severe cholecystitis is no longer considered a contraindication for the laparoscopic approach. However, the risk of damage to the bile duct and structures in the hepatic hilum during a standard cholecystectomy is greatest when Calot’s triangle cannot be safely dissected, particularly in the presence of severe inflammation or fibrosis [1, 2], Mirizzi syndrome, or anomalous biliary anatomy [3, 4]. Conventionally, conversion to open cholecystectomy has been recommended in such difficult situations [5], but this may result in increased postoperative pain, delayed mobility, and a prolonged hospital stay [6, 7]. In addition, conversion does not necessarily improve exposure or facilitate cystic duct identification [8], with no guarantee for avoidance of bile duct injury [9]. Laparoscopic subtotal cholecystectomy (LSC) that avoids hazardous dissection at the triangle of Calot has been advocated to be an alternative to the conversion to laparotomy in the cases of severe cholecystitis or liver cirrhosis [9–19], following previous reports of open subtotal cholecystectomy [20, 21]. Acceptable outcomes of LSC have been shown with lower rates of both conversion and major inadvertent injuries, suggesting the safety and feasibility of the technique under severe conditions. However, the sample size in these studies was relatively small and included a substantial number of cases in which ligation or clipping of the cystic duct and artery appeared possible. Furthermore, long-term outcomes after LSC were
123
Surg Endosc
not well described. Thus, efficacy and safety of LSC for severe cholecystitis, which may be associated with an increased risk of postoperative bile leak and local infection, residual gallstones, or incidental gallbladder cancer, were not fully estimated. In this study, we examined more than 100 cases of LSC without cystic duct ligation for severe inflammation or fibrosis of the gallbladder, in which approaching Calot’s triangle would be dangerous. Efficacy and safety of this procedure were assessed, based on the evaluation of shortand long-term outcomes, to verify its role as an alternative to conversion to laparotomy.
Cholecystectomies n=2003
LC n=1964
OC n=39
Simultaneous management n=291
Suspected malignancy
Only LC n=1673
Materials and methods Patients In our institute, the laparoscopic approach was primarily chosen for benign gallbladder disease regardless of combined cholecystitis or previous surgical history with the exception of cases of suspected malignancy. Diagnostic workups, such as blood test, abdominal ultrasonography (US), and abdominal computed tomography (CT), were performed in all patients at the initial consultation. Preoperative cholangiography was also employed to identify the biliary anatomy, including possible anomalies or variations, and location of gallstones. Imaging included drip infusion cholecystocholangiography under CT (DICCT), magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiography. For acute cholecystitis, antibiotic therapy or percutaneous transhepatic gallbladder drainage (PTGBD) was initially performed, followed by interval elective laparoscopic cholecystectomy (LC). During the 10-year period from January 2004 to December 2013, 2003 consecutive patients underwent cholecystectomy at Nagoya Daini Red Cross Hospital, including 1964 laparoscopic and 39 open procedures. Of the 1964 patients in whom laparoscopy was initially attempted, 291 underwent simultaneous management for a coexistent disease. Among the remaining 1673 patients, 1563 patients underwent conventional LC, which included 24 conversions to open, and the rest (110 cases, 5.5 %) underwent LSC without ligation of the cystic duct and vessels. Figure 1 is a flowchart showing the performance of cholecystectomies at our institute. The clinical records of 110 LSC patients, which included clinical factors, findings of imaging studies, operative records, and outcomes, have been entered into a prospectively maintained database and were analyzed for this study. Postoperative follow-up was performed by medical chart review and phone contact, when necessary.
123
Conventional LC n=1563
LSC n=110 Patients in whom approaching Calot’s triangle would be hazardous (eligible for study)
Complete LC n=1539
Conversion to open n=24
Complete LSC n=110
Perihepatic adhesion: 14 Suspicion of cancer: 6 Injury of adjacent structures: 4
Fig. 1 Flow diagram of our cholecystectomies performed at our institute. LC laparoscopic cholecystectomy, OC open cholecystectomy, LSC laparoscopic subtotal cholecystectomy
Surgical technique of LSC In this series, the majority of operations were performed with the initial purpose of total removal of the gallbladder and were only converted to the subtotal technique when dense inflammation or fibrosis would resulted in hazardous entry into Calot’s triangle. Under about 8 mmHg CO2 intra-abdominal pressure, a 4-port technique with three 5-mm ports and one 12-mm port was applied, using a 10-mm flexible laparoscope. The fundus-first technique [22, 23], dividing the liver bed from the fundus to the neck downward, was employed when possible. The division was completed ventral to Rouviere’s sulcus to leaving the plane of the common bile duct and Calot’s triangle untouched [24]. An incision was made through the ventral and caudal side of the gallbladder neck or body, followed by removal of the contents, in order to avoid any intra-abdominal spillage, confirming the anatomy of Hartmann’s pouch and the cystic duct orifice from the view of the inner lumen. The removed stones were placed in an endobag. Then, transection and closure at the gallbladder neck were carried out by using an endoscopic linear stapler.
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When there was a stone impaction in Hartmann’s pouch, including Mirizzi syndrome, or a severely sclerosed change in the gallbladder wall, the site of the stone impaction or gallbladder neck was incised followed by removal of the stones, allowing visualization of the cystic duct orifice from the inner lumen of the gallbladder. Then the incision was continued into the posterior wall under direct vision in a circumferential fashion. The gallbladder contents were evacuated by removing and/or aspirating them. In cases where significant difficulty in dissecting the gallbladder from the liver bed was encountered, the gallbladder’s posterior wall was left attached to the liver and the mucosa was peeled off or ablated using an energy device. The mucosa in the proximal remnant was cauterized as extensively as possible, and the proximal stump of the gallbladder was sutured and closed with absorbable suture material, so as to diminish the inner cavity of the infundibulum rather than to close the stump neatly (Fig. 2). After LSC, the operative field was washed copiously, and a drainage tube was routinely placed in the subhepatic plane.
Results Preoperative features of patients The mean age of the 110 patients (75 men, 35 women) was 66.7 y (range 31–83), and the mean body mass index was 24.2 (range 15.9–44.3). Of 110 patients, 105 (95.5 %) complained of various manifestations, including right upper abdominal pain in 93 (84.5 %), upper abdominal discomfort in two (2 %), back pain in four (3.6 %), and a simultaneous fever ([37.5 °C) in 78 (70.9 %). The US and/or CT showed cholecystitis in 96 patients (87.3 %), and PTGBD was required in 40 patients (36.3 %) in addition to antibiotics therapy. All cholecystitis resolved with expectant management. As the means of preoperative cholangiography, DICCT, and/or MRCP were conducted in
100 patients (90.9 %). ERC was performed for diagnostic and therapeutic purposes in 21 patients (19.1 %) when bile duct diseases were suspected. These imaging studies revealed stone impaction in Hartmann’s pouch in 46 patients (41.8 %), and Mirizzi syndrome was diagnosed in 8 of these 46 patients. An anomalous right hepatic duct was observed in ten patients (9.1 %), of whom eight had combined cholecystitis. Surgical outcomes Operative outcomes of the 110 LSC are shown in Table 1. The mean operating time and blood loss were 121 min and 33.8 ml, respectively. All LSCs were completed without conversion to an open procedure, and neither bile duct injury nor vessel injury was observed. Closure of the remnant stump could be done in all LSCs except one. The median postoperative hospitalization was 4 days. Postoperative complications occurred in ten patients (9.1 %), including subhepatic hematoma in 3, bile leakage in 3, portsite infection in 1, subhepatic abscess in 1, urination difficulty in 1, and arrhythmia in 1. The postoperative imaging studies, such as CT and/or fistulography, in patients with abdominal complications showed that biliary injury and a residual stone were not evident and clarified that three bile leaks occurred from the remnant gallbladder stump. All complications were resolved without re-operation, but biliary stent placement and percutaneous intervention were necessary for 1 of the 3 bile leaks and for one subhepatic abscess, respectively. There was no mortality in this series. Incidental gallbladder carcinoma was found in one elderly patient (0.9 %), for whom additional operation was impossible due to her severe comorbidities. Follow-up evaluation after LSC was performed in all patients by medical chart review in 83 (75.5 %) and/or phone contact in 27 (25.5 %). During follow-up periods (mean 30.7 months, median 29 months, range 3–104 months), only four patients showed any symptoms caused by postoperative complications or biliary stones. Of these,
Fig. 2 Intraoperative photograph of laparoscopic subtotal cholecystectomy. A Impacted stone is removed after transection of the gallbladder neck. B The stump of the gallbladder is sutured and closed with absorbable suture material
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Surg Endosc Table 1 Outcome in patients who underwent LSC
LSC patients (n = 110) Mean operating time (min)
33.8
Conversion to laparotomy (n)
0
Injury of bile duct and/or vessels (n)
0
Median length of postoperative hospitalization (days)
4
Postoperative complication (n)
10 (9.1 %)
Hematoma
3
Bile leakage
3
Port site infection
1
Others
4
Postoperative mortality
0
Incidental gallbladder carcinoma
1
two patients (1.8 %) had fever and right subcostal pain due to common bile duct stone within 3 months after LSC, requiring endoscopic sphincterotomy and removal. One patient complained of right abdominal discomfort and dark urine at 4 years after LSC and had common bile duct stone treated with endoscopic management. The fourth patient had an incisional hernia at the umbilical port site, which was controlled with an elastic corset.
Discussion An early laparoscopic approach for acute cholecystitis has been proposed to be technically feasible and at least equally as safe as the open approach. However, extensive inflammation, adhesions and consequent increased oozing can make laparoscopic dissection of Calot’s triangle and recognition of the biliary anatomy hazardous and difficult. Therefore, conversion to an open approach remains a valid option to secure patient safety under such difficult conditions. Indeed, conversion rates of laparoscopic surgery for acute cholecystitis range from 10 to 20 %, even in the recent reports of early surgery. In as much as conversion does not necessarily improve exposure or facilitate cystic duct identification [8], LSC has been proposed to be a safe and feasible alternative to conversion to open surgery during a difficult laparoscopic cholecystectomy [25]. Our results showed no conversion to laparotomy without any injury of the bile duct or major vessels in more than 100 LSCs limited to patients with severe cholecystitis in which dissection of Calot’s triangle would be hazardous. If the concept of LSC was not available, open surgery would have been required in most of the cases in this study group. Furthermore, the overall complication rate in this study was 9.1 %, which is lower than the reported rate in conversion to an open procedure (10.5–28.0 %) [26–28]. A recent randomized controlled
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121.0
Mean estimated blood loss (ml)
trial for acute cholecystitis also demonstrated higher morbidity rates, 11.8 % in an immediate laparoscopic cholecystectomy group and 34.4 % in a delayed surgery [29]. With regard to drawbacks of the procedure, there is a potentially increased risk of postoperative local infection, related to a combination of contamination by bile or mucus secretion and intraperitoneal gallstone migration. In our series, great care was taken to remove the spilled contents and to wash the operative field copiously, followed by placement of subhepatic peritoneal drainage. Additionally, in the cases in which there was difficulty in removing the posterior wall within the liver bed, we carefully peeled off or ablated the remnant mucosa using an energy device after the gallbladder neck transection. By following these points, the infectious complication rate was extremely low in the present study. In almost all of our patients, the remnant gallbladder was closed by sutures or staples. The closure was not successful in only one patient due to severe wall thickness. Consequently, the incidence of bile leaks and subhepatic collections after LSC was found to be low, whereas the majority of patients had presented with severe cholecystitis. Consistent with the results of a previous review [25], bile leaks from the cystic duct stump did not result in major complications, which were controlled by conservative management. There is a possibility that residual stones in the bile duct or cystic duct could cause cholestasis, thereby promoting stump leakage, whereas such complicated gallstones were not evident in our cases of bile leak. In this study, symptomatic biliary stone diseases occurred in 3 (2.7 %) of the 110 patients during the mean follow-up period of 30.7 months and were successfully treated by endoscopic management. Choledocholithiasis after LSC may be attributed to residual or newly formed stones in the remnant gallbladder or cystic duct. Since the endoscopic transpapillary approach has been established as a standard technique for common bile duct stones [30–32],
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it seems rational that safety of the surgery should be considered prior to thorough removal of gallstones in severe cholecystitis. Moreover, dissection or cannulation of the cystic duct for intraoperative cholangiography (IOC) should be avoided according to the concept of LSC. Our emphasis has been on precise preoperative imaging to locate gallstones and to delineate the biliary anatomy [33–35] as well as postoperative follow-up examinations (e.g., MRCP), minimizing the dependence on intraoperative observation under severe conditions. The combination with endoscopic transpapillary intervention before or after surgery is a treatment of choice, when gallstones in the bile duct or cystic duct are found by cholangiography. Laparoscopic ultrasound or IOC through the intraluminal orifice of the cystic duct may be promising approaches for intraoperative imaging of the bile duct [36, 37], although the efficacy of these procedures remains to be estimated. There is a small but definite risk of gallbladder cancer being found unexpectedly. Such findings were made in 0.2–0.8 % of patients who underwent laparoscopic cholecystectomy [38, 39]. One patient was incidentally found to have carcinoma in the resected specimen in our series. If the gallbladder wall is cut open in patients with gallbladder cancer, abdominal dissemination and remnant tumors are always observed. The LSC procedure allows an intraoperative leak of gallbladder contents into the abdominal cavity; therefore, the preoperative and intraoperative exclusion of gallbladder cancer is of utmost importance. Our follow-up evaluation concerning symptomatic biliary complications was performed in all patients, and range and median times of the follow-up period were 3–104 and 29 months, respectively. The follow-up period appears sufficient to capture almost all of the late complications associated with residual stones [40–42], but may be too short to detect problems associated with the remnant gallbladder, such as newly formed gallstones or postcholecystectomy syndrome [43]. In conclusion, LSC is a treatment of choice to avert conversion to open surgery, for limited cases in which dissection of Calot’s triangle would be hazardous due to severe inflammation.
Disclosures Drs. Yuji Shingu, Shunichiro Komatsu, Eiji Sakamoto, Shinji Norimizu, and Yoshiro Taguchi have no conflicts of interest or financial ties to disclose.
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