Editorial Comment on: Andrzej Smereczyński, Teresa Starzyńska, Katarzyna Kołaczyk and Józef Kładny Role of sonography in assessing complications after laparoscopic cholecystectomy.

Abstract

Laparoscopic cholecystectomy (LC) was introduced to the arsenal of surgical techniques in 1987 and has become the gold standard in treating cholecystolithiasis. In spite of undoubted benefits for patients, it is not a complication-free procedure. The type of complications after a classical, i.e. “open” surgery and LC do not differ in a significant way. The difference lies in their prevalence. One of the most common complications is a fluid collection in the gallbladder bed under the liver. To prevent it from developing, a drain is usually placed under the liver. For many years, it was believed that such a practice is correct, but recent reports indicate that leaving the drain after a planned laparoscopic cholecystectomy may do more damage rather than be beneficial. Moreover, it may give a false impression of safety since we are convinced that we remain in control over the situation in case of, for instance, a hemorrhage(1). In fact, when the postoperative bleeding to the peritoneal cavity is intense, a thin Redon drain, which usually remains inserted after the procedure, may become occluded by a thrombus. Decisions are made based on the patient's clinical condition or imaging examinations (including sonography) which can reveal not only a fluid collection under the liver, but also free fluid in the peritoneal cavity. The peritoneum secretes considerable amounts of peritoneal fluid daily. It becomes absorbed completely mainly via the lymphatic channels in the diaphragmatic region. Therefore, detection of a collection of serous fluid should not be alarming. It will absorb with no consequences for the patient. It has been observed that leaving a drain in the gallbladder bed causes increased fluid secretion. Moreover, Fraser et al. claim that such a practice may provoke bile leakage form slight bile ducts in the gallbladder bed(2). If it is a suction drain the risk of bile leakage is significant. Thiebe and Eggert observed that leaving the drain caused fluid to accumulate in the gallbladder bed in 44% of cases compared to 4.1% in the group without the drain(3). Their results were confirmed in ultrasound examinations which revealed that the fluid collection that developed within 24 hours after the surgery appeared considerably more frequently in the group with the drain. When, apart from ultrasound findings, patients also manifest symptoms of peritoneal irritation, the clinical picture becomes slightly different. In such a situation, we deal with bile leakage, either from damaged bile ducts of from the duct of Luschka. This can be managed by an endoscopic intervention or a US-guided puncture and drainage of the fluid collection. If the presence of fluid is concomitant with elevated temperature and general symptoms of inflammation, an abscess may be suspected to have formed under the liver. In such a situation, a surgical intervention is also necessary. To conclude, benefits of leaving a drain in the gallbladder bed after uncomplicated cholecystectomy are not significant. Numerous studies reveal that removing the drain results in fewer pain complaints, better comfort of patients, lower rate of complications and faster discharge from hospital. Furthermore, pain complaints associated with the presence of the drain restrict chest movement at the right side and result in more frequent respiratory infections. The role of sonography in the assessment of fluid collections in the peritoneal cavity following laparoscopic cholecystectomy is not overrated. An ultrasound examination is simple, repeatable, safe and can be a remarkable diagnostic and therapeutic tool in experienced hands. However, ultrasound findings must not be interpreted separately from the clinical picture. Thanks to a skillful combination of these elements, it is possible to avoid numerous unneeded instrumental actions which do not always give an expected therapeutic effect. The remarks and tips presented by Smereczynski et al.(4) regarding the usage of various diagnostic tools in the post-operative period, particularly in diagnosing complications, are of considerable practical value and are useful for every surgeon irrespective of his or her experience.