Difficult Gallbladder Research Articles

Laparoscopic partial cholecystectomy for the difficult gallbladder: a systematic review

In the setting of difficult dissection of Calot's triangle during laparoscopic cholecystectomy, conversion is commonly advocated. An alternative approach aimed at preventing bile duct injury is laparoscopic partial cholecystectomy (LPC). The safety and efficacy of this procedure are unclear. A systematic review of the literature was performed independently by three researchers. The outcomes were conversion rate, hospital length of stay (LOS), bile duct injury, bile leak, symptomatic gallstones in the remnant gallbladder, need for reoperation, postoperative endoscopic retrograde cholangiopancreaticography (ERCP), percutaneous intervention, and mortality. The review included 15 publications, which reported on 625 patients. Four different operative techniques could be distinguished. Conversion to open (partial) cholecystectomy was performed in 10.4 % of the cases. The median LOS was 4.5 days (range, 0-48 days). The most common complication was postoperative bile leak, which occurred in 66 patients (10.6 %). One case of bile duct injury occurred. During the follow-up period, 2.2 % of the patients experienced recurrent symptoms of gallstones. Eight patients (2.7 %) underwent reoperation. Postoperative ERCP was performed for 26 (7.5 %) of 349 patients. A percutaneous intervention was performed for 5 (1.4 %) of 353 patients. Three deaths were described in the reviewed series (1 of pulmonary sepsis and 2 of myocardial infarctions). A rough comparison showed that fewer bile leaks, less need for ERCP, and less recurrent symptoms of gallstones seemed to occur when the cystic duct and gallbladder remnant were closed. Literature concerning LPC is scarce. Four different LPC techniques can be distinguished. When a difficult gallbladder is encountered during LC, LPC seems to be a safe and feasible alternative to conversion. Closing of the cystic duct, gallbladder remnant, or both seems to be preferable.

Transumbilical Single-Incision Laparoscopic Cholecystectomy with Conventional Instruments and Ports: The Way Forward?

The quest for scarless surgery continues, but the goal remains elusive. The logical top contender was natural orifice surgery, but unfortunately even today it remains in infancy. Minilaparoscopy also did not generate much interest. In this scenario, transumbilical single-incision laparoscopy surgery holds promise, especially as far as cosmetics is concerned, and may be the ultimate answer. All the 240 patients were operated by the same surgeon through a transversely placed umbilical incision in the upper half of the umbilicus. Three conventional ports, 10, 5, and 5 mm, were introduced through the same skin incision but separate transfacial punctures. The instruments included 10- and 5-mm 30° rigid telescopes and rigid instruments as in standard laparoscopic cholecystectomy (SLC). Patients with acute cholecystitis and calculous pancreatitis were included, but those with choledocholithiasis were excluded. Results were compared with those with SLC. Patients were predominately female, with an average age of 37.6 years. Ten patients had difficult gallbladders, 24 had acute cholecystitis, and 10 had calculous pancreatitis. The mean operating time was 25.8 minutes, compared with 18.4 minutes in SLC. Intracorporeal knotting was required in 2 patients. Conversion to SLC was required in 5 patients. Morrisons pouch drain was left in 1 patient. Injectable analgesic was required in 138 (57.5%) patients and infection was seen in 2 (0.8%) patients. Transumbilical single-skin-incision laparoscopic cholecystectomy performed solely with conventional instruments is feasible, easy to learn, and probably the future of laparoscopic cholecystectomy.

Body-First Laparoscopic Cholecystectomy: A Three-Trocar Technique for Difficult Gallbladders

In this paper, we report on a modified technique of laparoscopic cholecystectomy (LC), using three-trocars in cases of difficult anatomy at the Calot's triangle without the insertion of more additional trocars, in order to validate its feasibility, efficacy, and safety. We retrospectively analyzed 67 consecutive cases of body-first LCs performed for gallbladder disease from January to December 2007. The surgical technique was compared with respect to operative times, conversion to open cholecystectomy, postoperative complications, and length of postoperative stay. The body-first LC was successful in 64 patients (95.6%). The median operating time was 32 minutes (range, 27-90) for chronic cholecystitis, 53 minutes (range, 41-145) for acute cholecystitis, and 62 minutes (range, 35-170) for interval cholecystectomy. The difference in duration of the surgical procedure between the chronic cholecystitis group and the other two groups was significant (P < 0.05). We did not find any significant difference in the average operating time between the acute cholecystitis group and the interval cholecystectomy. The average postoperative hospital stay was 1 day (range, 1-3). No common bile duct injuries and no complications occurred in the series reported in this paper. The body-first three-trocar LC is a safe option when dealing with patients with difficult anatomy at the Calot's triangle. It yields a low conversion rate and avoids the insertion of any additional trocars. Further studies are required on the long-term efficiency and reliability of this technique in order to fully evaluate its value.

GRIPPING THE DIFFICULT GALL BLADDER DURING LAPAROSCOPIC CHOLECYSTECTOMY

Grasping a tense, inflamed gall bladder during laparoscopic cholecystectomy for acute cholecystitis is often a problem. Although many surgeons have developed techniques to deal with this, the published work lacks information about how to manage this problem. To collate experience about how to deal with this we interviewed 20 experienced Australian surgeons and compiled a repertoire of tactics that might help deal with this clinical situation. Most surgeons indicated that they deflated the gall bladder using a needle and suction as a preliminary step. Most respondents also described the use of a specific type of forceps for the task. Various manoeuvres, such as displacement of the gall bladder with forceps, dislodging an impacted stone to make it easier to grasp, the use of a retraction suture through the gall bladder were described. The various tactics are summarized in the paper. A range of strategies applied by experienced surgeons for the task of gripping a difficult gall bladder has been documented in this paper. The variety of approaches suggests that surgeons should be prepared to flexibly apply different approaches to this task.

Hemobilia Due to Hepatic Artery Pseudoaneurysm˙ An Unusual Complication after Cholecystectomy and T-Tube Placement

Hemobilia is one of the causes of obscure gastrointestinal hemorrhage. Arterio-biliary fistula secondary to hepatic artery pseudoaneurysm is an uncommon cause of hemobilia. Hepatic artery pseudoaneurysm has been reported as a rare complication of laparoscopic cholecystectomy. We here report a case of hemobilia due to arterio-biliary fistula in a patient one month after cholecystecomy and percutaneous T-tube placement. A 54 year old woman underwent laparoscopic cholecystectomy for symptomatic cholelithiasis. During the procedure, there was a concern of injury to the common hepatic duct due to difficult gall bladder dissection. Laparoscopic cholecystectomy was converted to an open cholecystectomy which did show common hepatic duct laceration which was repaired and a T-tube was placed. Patient did well for a month after the surgery, when she developed right upper quadrant abdominal pain, jaundice and noted to have migrated out T-tube. Subsequently, T-tube was removed due to malfunction. A computed tomography scan of the abdomen showed dilation of the intra and extra hepatic biliary ducts. Patient underwent endoscopic retrograde cholangiography (ERC) and found to have gross hemobilia. ERC images showed dilated common bile duct with multiple cast-like filling defects, consistent with blood clots. A biliary stent was placed to maintain biliary drainage. Patient continued to require blood transfusions due to ongoing hemobilia. A selective hepatic arteriogram showed hepatic artery pseudo-aneurysm causing arterio-biliary fistula leading to hemobilia. A covered stent was placed in the right hepatic artery occluding the fistula, which resulted in complete resolution of bleeding.

Laparoscopic cholecystectomy - is there a need to convert?

Introduction:The difficult gallbladder is the most common ‘difficult’ laparoscopic surgery being performed by general surgeons all over the world and the potential one that places the patient at significant risk. We present our experience of 6147 cases since January 1993 in a single center with respect to conversion to open cholecystectomy.Methods:Patients who underwent laparoscopic cholecystectomy (LC) from January 1993 to December 2004 were analyzed. The cases were analyzed in relation to conversion rate to open surgery, factors affecting the conversion, and completion rate of LC. Patients having absolute contraindications to LC like cardiovascular and pulmonary disease were not included in the study.Results:Out of 6147 cases, 1518 patients (21.5%) were identified as difficult cases. Laparoscopic cholecystectomy was successfully completed in 6125 patients with a completion rate of 99.6%. Laparoscopic procedure had to be converted to the open procedure in 22 patients with a conversion rate of 0.36% of the total LCs performed and 1.66% of the difficult cases. Conversion had to be done due to several reasons.Conclusion:It can be reliably concluded that LC is the preferred method even in the difficult cases. Our study emphasizes that although the rate of conversion to open surgery and complication rate are low in experienced hands the surgeon should keep a low threshold for conversion to open surgery and it should be taken as a step in the interest of the patient rather than be looked upon as an insult to the surgeon.

Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis.

The open subtotal cholecystectomy technique has simplified removal of the difficult gallbladder. Increasing laparoscopic experience has made laparoscopic subtotal cholecystectomy (LSC) a feasible option in patients with complicated acute or chronic cholecystitis. LSC was performed in 29 patients with severe inflammation or fibrosis of the gallbladder associated with gallstone disease over a 23-month period. These 29 patients (mean age 53 years; 22 women) constituted 8.5 per cent of the total number of laparoscopic cholecystectomies performed (n = 340) and 15.6 per cent of 186 patients with acute cholecystitis. Eighteen patients in the latter group underwent conversion to open cholecystectomy. The indications for LSC were acute cholecystitis/empyema (n = 23) and severe fibrosis (n = 6). The cystic duct was either clipped before division (n = 15), sutured (n = 2) or ligated using an Endoloop (n = 10). In two patients the gallbladder bed was drained without isolating the cystic duct. The posterior wall of the gallbladder was left intact to avoid excessive bleeding or damage to bile ducts in the gallbladder bed. A suction drain was inserted in 14 cases. Median operating time was 73 (range 45-130) min. One patient died after operation from a myocardial infarction. Six patients had local complications (two haematomas, three bile leaks, one minor wound sepsis) and nine developed respiratory infections. Median hospital stay was 5 (range 2-28) days. LSC is a safe, relatively simple and definitive procedure allowing removal of a difficult gallbladder and reducing the need for open conversion or cholecystostomy in the majority of patients.

The Difficult Gallbladder: Technical Tips for Laparoscopic Cholecystectomy

Conversion of laparoscopic cholecystectomy to laparotomy may increase postoperative complications and convalescence and should therefore be avoided when possible. The authors present three technical tips that may prevent unnecessary conversion to open procedure (suspension sutures in the gallbladder, use of the Endo Paddle Retract (United States Surgical Corp., Norwalk, CT, USA) to depress abdominal viscera, and subtotal cholecystectomy). These methods may be used in situations in which there is no operative risk for complications, such as bile duct injury, but technical aspects of the operation normally would have resulted in conversion to laparotomy.

The difficult cholecystectomy: problems related to concomitant diseases.

The difficult gallbladder is the most common "difficult" laparoscopic surgery performed by general surgeons. It is also "potentially" the one that places the patient at significant risk. This article reports on our first 1,900 laparoscopic cholecystectomies. With this report, it is the desire of the authors to share our experiences and lessons learned from more than 300 difficult gallbladder cases. We surgeons must strive for no bile duct injuries. If certain principles are followed, the surgeon will be able to improve his or her completion rate and decrease (if not eliminate) bile duct injuries. First and foremost is to know when to convert to open. Performance of fluorocholangiography to define anatomy is also very helpful in avoidance of bile duct injury. The laparoscopic surgeon should start with simple cases before "graduating" to more complex cases. Lastly, the ability to suture and knot tie is key in performing advanced procedures. This skill will allow completion of cases that otherwise would have to be converted to traditional surgery.

Laparoscopic Cholecystectomy: Difficult Cases &amp;amp; Creative Solutions

Avram Cooperman applies the savvy of an experienced biliary surgeon to the endoscopic technique of cholecystectomy. He first reviews the basics of the technique, and then shows how to extract difficult gall-bladders as well as how to get out of trouble in some cases. He emphasizes the use of an endoscope through the sideports and traditional strategy in open cholecystectomy, such as retrograde dissection. He highlights some illustrative cases with comments from authorities such as Nathaniel Soper, Robert Fitzgibbons, Douglas Olsen, and David Nagorney. A drawback of the book is the fuzzy photographs probably created from videotapes, some obvious limitations in instrumentation, and a cystic artery that looks awfully like the right hepatic artery in several of the drawings. The worst drawback, however, is that the book is too short! It is enjoyable reading, particularly with the illustrative cases, but the book ends too soon. This criticism is meant as

Incision extension is the optimal method of difficult gallbladder extraction at laparoscopic cholecystectomy.

An unsolved problem of laparoscopic cholecystectomy is the optimal method of removing the gallbladder with thick walls and a large stone burden. Proposed solutions include fascial dilatation, stone crushing, and ultrasonic, high-speed rotary, or laser lithotripsy. Our observation was that extension of the fascial incision to remove the impacted gallbladder was time efficient and did not increase postoperative pain. We reviewed the narcotic requirements of 107 consecutive patients undergoing laparoscopic cholecystectomy. Fifty-two patients required extension of the umbilical incision, and 55 patients did not have their fascial incision enlarged. Parenteral meperidine use was 39.5 +/- 63.6 mg in the patients requiring fascial incision extension and 66.3 +/- 79.2 mg in those not requiring fascial incision extension (mean +/- standard deviation). Oral narcotic requirements were 1.1 +/- 1.5 doses vs 1.3 +/- 1.7 doses in patients with and without incision extension, respectively. The wide range of narcotic use in both groups makes these apparent differences not statistically significant. We conclude that protracted attempts at stone crushing or expensive stone fragmentation devices are unnecessary for the extraction of a difficult gallbladder during laparoscopic cholecystectomy.

Safe performance of difficult laparoscopic cholecystectomies

Laparoscopic cholecystectomy has been advocated for the treatment of uncomplicated symptomatic gallstone disease, but has not been widely advocated for the management of more complicated gallbladder disease such as acute cholecystitis, previous surgery, or common duct stones. During the last 9 months, 360 patients underwent laparoscopic removal of their gallbladder. A total of 138 had a complicated presentation, making surgery more difficult. This article discusses the management of these patients with acute cholecystitis, previous surgery, or common duct disease. Using the described techniques, there were no complications or mortality. Laparoscopic management of difficult gallbladder problems is safe and effective.

CHOLECYSTECTOMY: A METHOD FOR THE DIFFICULT GALL-BLADDER

CHOLECYSTECTOMY: A METHOD FOR THE DIFFICULT GALL-BLADDER

The value of laminography in the difficult gallbladder problem.

Laminography is a useful adjunct in the roentgenologic study of the difficult gallbladder problem. The examination is, of course, more time consuming than routine roentgenography. On the other hand, if employed early enough in the examination, it may save hours of watchful waiting to see what happens to a suspicious shadow when the gallbladder contracts. Finally, it must be said that if laminography offers a definite diagnosis where other roentgenographic procedures fails, it should be employed more often.