Time Of Laparoscopic Cholecystectomy Research Articles

The Use of Holmium Laser Technology for the Treatment of Refractory Common Bile Duct Stones, With a Short Review of the Relevant Literature

The treatment of common bile duct (CBD) stones can vary in complexity and many methods exist to fragment them before removal. Although holmium laser is frequently used in urological surgery, it is rarely used to achieve this aim. The holmium laser was passed along a fiber introduced via a flexible scope through the cystic duct at the time of laparoscopic cholecystectomy. This energy modality was used to fragment the stones to a size that allowed easy removal. The authors have used this technique once so far and achieved complete clearance of the CBD with no mucosal damage. Holmium laser provides an alternative and realistic treatment option for difficult CBD stones.

Post-Laparoscopic Cholecystectomy Port-Site Metastases from Previously Undiagnosed Upper Gastro-Intestinal Malignancies - Our Experience of Six Cases

Aim: Patients undergoing cholecystectomy for cholelithiasis with symptoms of recent-onset dyspepsia should also be investigated for having co-existing upper gastrointestinal malignancy.Methods: In the last one and a half years we have received six cases of port-site metastases who had undergone laparoscopic cholecystectomy for cholelithiasis with symptoms of recentonset dyspepsia. All six patients developed port-site metastases within 1-3 months after the surgeryResults: After thorough history, clinical examination and investigations, all patients were diagnosed as cases of upper gastrointestinal malignancies, which remained undiagnosed at the time of laparoscopic cholecystectomy, with no evidence of malignancy in the gall bladder specimen.Conclusion: Occurrence of port-site metastases from undiagnosed UGI malignancies suggests that care should be exercised in attributing dyspepsia to gall stone disease only and an UGI endoscopy may be included as an essential preoperative investigation tool, especially in middle-aged and elderly patients Some measures should be adopted in order to decrease the incidence of PSM.

Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP

The purpose of this study is to determine the incidence of residual common bile duct (CBD) stones after preoperative ERCP for choledocholithiasis and to evaluate the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) in this patient population. All patients who underwent preoperative ERCP and interval LC with IOC from 5/96 to 12/05 were reviewed under an Institutional Review Board (IRB)-approved protocol. Data collected included all radiologic imaging, laboratory values, clinical and pathologic diagnoses, and results of preoperative ERCP and LC with IOC. Standard statistical analyses were used with significance set at p < 0.05. A total of 227 patients (male:female 72:155, mean age 51.9 years) underwent preoperative ERCP for suspicion of choledocholithiasis. One hundred and eighteen patients were found to have CBD stones on preoperative ERCP, and of these, 22 had choledocholithiasis diagnosed on IOC during LC. However, two patients had residual stones on completion cholangiogram after ERCP and were considered to have retained stones. Therefore, 20 patients overall were diagnosed with either interval passage of stones into the CBD or a false-negative preoperative ERCP. In the 109 patients without CBD stones on preoperative ERCP, nine patients had CBD stones on IOC during LC, an 8.3% incidence of interval passage of stones or false-negative preoperative ERCP. In both groups, there was no correlation (p > 0.05) between an increased incidence of CBD stones on IOC and a longer time interval between ERCP and LC, performance of sphincterotomy, incidence of cystic duct stones, or pathologic diagnosis of cholelithiasis. The overall incidence of retained or newly passed CBD stones on IOC during LC after a preoperative ERCP is 12.9%. Although the natural history of residual CBD stones after preoperative ERCP is not known, the routine use of IOC should be considered in patients with CBD stones on preoperative ERCP undergoing an interval LC.

Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis of randomized clinical trials

Background The appropriate timing for laparoscopic cholecystectomy in the treatment of acute cholecystitis remains controversial. More recent evaluation indicates early laparoscopic surgery may be a safe option in acute cholecystitis, although conversion rates may be higher. No conclusive evidence establishing best practice in terms of clinical benefit exists. Methods All randomized clinical studies published between 1987 and 2006 comparing early versus delayed laparoscopic cholecystectomy for acute cholecystitis were analyzed, irrespective of language, blinding, or publication status. Exclusions were quasi-randomized trials, inadequate follow-up description, or allocation concealment. Endpoints included conversion rates, postoperative complications, total hospital stay, and operation time. Random and fixed-effect models were used to aggregate the study endpoints and assess heterogeneity. Results Four studies containing 375 patients were included. No significant study heterogeneity or publication bias was found. There was no significant difference in conversion rates (odds ratio = .915 [95% confidence interval (CI), .567–1.477], P = .718) and postoperative complications (odds ratio = 1.073 [95% CI, .599–1.477], P = .813) between both groups. Operation time was significantly reduced (weighted mean difference [WMD] = .412 [95% CI, .149–.675], P = .002) with delayed cholecystectomy. The total hospital stay was significantly reduced (WMD = .905 [95% CI, .630–1.179], P = .0005) with early cholecystectomy. The postoperative stay was significantly reduced in the delayed group (WMD = .393 [95% CI, .128–.659], P = .004). Conclusions These meta-analysis data suggest that early laparoscopic cholecystectomy allows significantly shorter total hospital stay at the cost of a significantly longer operation time with no significant differences in conversion rates or complications.

Timing of laparoscopic cholecystectomy for acute lithiasic cholecystitis and influencing factors for conversion to open procedure

目的 探讨腹腔镜手术治疗急性结石性胆囊炎的最佳时机以及影响中转开腹的因素.方法 对468例行腹腔镜胆囊切除术的急性结石性胆囊炎病人的临床资料进行回顾性分析.将468例病人分为A(症状发作48 h内手术)、B(48～72 h内手术)、C(72 h后手术)、D(保守治疗后再择期手术)4组.结果 A、B、C、D 4组的术后并发症发生率分别为3.48%(5/146)、3.69%(5/137)、5.88%(6/102)和3.17%(2/63),各组间术后并发症发生率并无显著性差异(P均＞0.05);C组的手术时间较其他3组明显延长(P＜0.05),且手术中转率也显著高于其他各组(P＜0.05);A组的手术时间较其他组短,开腹中转率也较其他组低(P＜0.05);单因素分析结果显示体温、右上腹肌紧张、胆囊肿大、白细胞计数、胆囊壁厚度、胆囊颈部结石嵌顿、手术时机7个因素与中转开腹率显著相关(P＜0.05).多因素回归分析显示白细胞计数和手术时机是影响腹腔镜中转开腹率的独立危险因素.结论急性结石性胆囊炎症状发作后48 h内是腹腔镜手术的最佳时机,白细胞计数和手术时机是影响腹腔镜中转开腹率的独立危险因素。

Is there an optimal time for laparoscopic cholecystectomy in acute cholecystitis?

Laparoscopic cholecystectomy (LC) is safe in acute cholecystitis, but the exact timing remains ill-defined. This study evaluated the effect of timing of LC in patients with acute cholecystitis. Prospective data from the hospital registry were reviewed. All patients admitted with acute cholecystitis from June 1994 to January 2004 were included in the cohort. Laparoscopic cholecystectomy was attempted in 1,967 patients during the study period; 80% were women, mean patient age was 44 years (range, 20-73 years). Of the 1,967 LC procedures, 1,675 were successful, and 292 were converted to an open procedure (14%). Mean operating time for LC was 1 h 44 min (SD +/- 50 min), versus 3 h 5 min (SD +/- 79 min) when converted to an open procedure. Average postoperative length of stay was 1.89 days (+/- 2.47 days) for the laparoscopic group and 4.3 days (+/- 2.2 days) for the conversion group. No clinically relevant differences regarding conversion rates, operative times, or postoperative length of stay were found between patients who were operated on within 48 h compared to those patients who were operated on post-admission days 3-7. The timing of laparoscopic cholecystectomy in patients with acute cholecystitis has no clinically relevant effect on conversion rates, operative times, or length of stay.

Evaluation of suspected bile duct injuries

The proper diagnosis and appropriate treatment are paramount in ensuring a satisfactory outcome after a bile duct injury associated with laparoscopic cholecystectomy. Immediate recognition of a bile duct injury during laparoscopic cholecystectomy can allow proper treatment at that time, averting difficult complications that could occur in the postoperative period should the injury be missed. Unfortunately, most bile duct injuries are not recognized at the time of laparoscopic cholecystectomy. An appropriate level of suspicion followed by prompt and complete evaluation should result in accurate delineation of the biliary anatomy, which is essential for directing appropriate surgical reconstruction.

Case 96: Hepatic Epithelioid Hemangioendothelioma

History A 34-year-old woman was admitted to the hospital with a 1-year duration of intermittent discomfort in the right upper quadrant of the abdomen. An ultrasonographic (US) examination of the gallbladder was performed to evaluate suspected cholelithiasis; this examination revealed gallstones. An abnormal liver was visualized at the time of laparoscopic cholecystectomy. This woman had been in good health and had not undergone previous surgical procedures. She had had three normal-term pregnancies and took no regular medications. She had no known exposure to hepatotoxins and had not undergone previous transfusions. There was no history of regular tobacco or alcohol use and no family history of liver disease or familial neoplasia. She had elevated levels of serum aspartate aminotransferase (ie, 56 U/L; normal level, 12-31 U/L) and alkaline phosphotase (ie, 708 U/L; normal level, 37-98 U/L). Tumor marker levels-including α-fetoprotein, carcinoembryonic antigen, and cancer antigen 19-9 levels-were normal. This patient was referred for further examination. US imaging, including Doppler examination of hepatic vessels, and computed tomography (CT) with late hepatic arterial phase and portal phase imaging were performed to allow further evaluation.

The Optimal Timing of Laparoscopic Cholecystectomy in Mild Gallstone Pancreatitis

The Optimal Timing of Laparoscopic Cholecystectomy in Mild Gallstone Pancreatitis

Introduction of laparoscopic cholecystectomy in a large teaching hospital: independent audit of the first 3 years.

Commencing with the introduction of laparoscopic cholecystectomy, a detailed independent prospective audit of all cholecystectomies attributable to 12 general consultant surgeons has been carried out over a period of 3 years. Of 650 operations 502 were intended laparoscopic cholecystectomies. In the first year 58 per cent were intended laparoscopic cholecystectomies; this rose to 80 per cent in the second year and to 90 per cent in the third. The conversion rate was 21 per cent in the first year, 21 per cent in the second and 15 per cent in the third. The mean operating time for laparoscopic cholecystectomy was 133 min for year 1, 123 min for year 2 and 115 min for year 3, compared with 92, 101 and 95 min respectively for open cholecystectomy. The overall complication rate was 10 per cent for laparoscopic and 21 per cent for open cholecystectomy. This included six bile duct injuries (1.2 per cent) in the patients undergoing the laparoscopic procedure and one (0.7 per cent) in those having open cholecystectomy. This unselected audit of a group of general surgeons introducing laparoscopic cholecystectomy into their practice has revealed complication and conversion rates that are higher than those reported in most of the published literature, but may be representative of practice throughout the UK.

Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis.

The development of laparoscopic cholecystectomy has created a dilemma in the management of choledocholithiasis. A number of options exist, including endoscopic sphincterotomy (ES) before laparoscopic cholecystectomy in patients with suspected common bile duct (CBD) calculi, laparoscopic bile duct exploration, open CBD exploration and postoperative ES. None of these options has emerged as ideal or universally acceptable. An alternative technique, peroperative ES, has been developed. A prospective assessment of the use of peroperative ES in 13 patients in whom choledocholithiasis was demonstrated with operative cholangiography is presented. Eleven patients had successful ES and clearance of stones. The CBD could not be cannulated in one patient, and an adequate ES for stone extraction could not be performed in the remaining patient. Both procedures were converted to open CBD exploration. Complications were mild postoperative pancreatitis (two patients) and pulmonary atelectasis (one). The median total operating time was 165 min and the median postoperative hospital stay was 3 days. Peroperative ES at the time of laparoscopic cholecystectomy provides a safe technique for clearance of the CBD.

Long‐term Survival of Patients with Gallbladder Cancer Detected during or after Laparoscopic Cholecystectomy

Little evidence is available regarding long-term survival of patients with gallbladder cancer that is discovered at the time of laparoscopic cholecystectomy (LC). Therefore the present study was performed to evaluate long-term outcomes of this disease. Of 1546 patients who underwent LC for benign gallbladder disease between January 1992 and January 2002, 8 patients (0.5%) had cancers that were found during or after LC. The median follow-up period was 55 months (range: 36-142 months). The gallbladder was resected without perforation in all cases. During surgery there was a suspicion of malignancy in 6 of 8 cases. Frozen section analysis showed that 2 had TNM stage Tis tumors, 2 had T1a tumors, and 2 had T2 tumors. Two patients with T2 tumors were immediately converted to extended cholecystectomy. The final pathology revealed another 2 tumors, and demonstrated that 3 patients had Tis tumors, 3 had T1a tumors, and 2 had T2N0M0 tumors. None of the patients underwent additional surgery. All patients survived with no evidence of recurrence during the median follow-up of 55 months. In conclusion, before and during LC, we have not overlooked T2 or more advanced tumor, which requires additional procedures for curative resection. This might result in good survival. We consider that an intensive preoperative work-up and meticulous inspection of the opened gallbladder should be mandatory to detect gallbladder cancer in patients who undergo LC. At present, this is not routinely practiced.

Dropped Gallstone as a Nidus of Intra-abdominal Abscess Complicated by Empyema

We describe a patient who developed an intra-abdominal abscess and empyema from a dropped gallstone at the time of laparoscopic cholecystectomy 1.5 years ago. As minimally invasive surgeries become conventional, clinicians should be aware of this increasingly common complication.

Intraoperative cholangiography time in laparoscopic cholecystectomy

The debate for and against the routine use of intraoperative cholangiography (IOC) continues. One of the main arguments against the routine use of the technique during laparoscopic cholecystectomy (LC) is the length of time it takes, which in turn increases the cost. In this study, we recorded the time spent by the radiographer providing IOC service in the context of optimizing the utilization of the radiographer and IOC time. A total of 91 consecutive LCS, including 19 laparoscopic bile duct explorations, from April 2003 to January 2004 were included in the study. We recorded the time the radiographer took from receiving a call to arriving in the theater, the time he or she spent performing the IOC, and the total time spent in theater. We also recorded the total operative time. The mean time from call to arrival was 9 min (SD = 3, n = 91). The mean total time spent by the radiographer in the theater involved in performing the IOC during LC was 15 min (SD = 8, n = 72), and that during laparoscopic exploration was 46 min (SD = 20, n = 19). The mean operative time was 67 min (SD = 24) and 135 min (SD = 59), respectively. Radiographer services as well as IOC time could be optimized to facilitate the routine use of this important technique in LC. Optimizing the logistics and time factor in IOC is an integral component of single-stage management of patients with suspected bile duct stones.

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Over the three-year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio-pancreatography. Transcystic stenting was the 'intention-to-treat' basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1-15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio-pancreatography, was 98%. A second endoscopic retrograde cholangio-pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. A treatment option open to all surgeons for non-jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.

Postgraduate Year Does Not Influence Operating Time in Laparoscopic Cholecystectomy

Background. Surgical resident education may contribute to increased operating time, thus increasing costs at teaching institutions. It is possible that junior residents, in particular, with less experience could contribute to longer operating times for laparoscopic cholecystectomy. We hypothesized that all general surgery residents, regardless of level of training and with proper supervision, could complete a laparoscopic cholecystectomy in a safe and timely fashion.Materials and methods. A retrospective study was performed using data collected from laparoscopic cholecystectomies completed under the supervision of one attending surgeon over a 2-year period. Operating times were recorded, the operating surgeon was identified, and cases were assigned an acuity level based on pathologic findings. Operative times were compared after dividing surgeons into three groups (junior residents, senior residents, and staff).Results. Seventy-one cases were entered into the study. There were no differences when comparing mean operating times among the three groups (P = 0.2, analysis of variance). The pathologic acuity in each group was similar (P = 0.8, Fisher's exact test). There was a difference when evaluating the operating times for the pathologic level of acuity (P = 0.002, Kruskal–Wallis test).Conclusions. Resident level does not affect the operating time in performing laparoscopic cholecystectomy. The pathologic acuity of the gallbladders was distributed similarly for all three groups. There was a difference in mean operating time based on pathologic acuity. Laparoscopic cholecystectomy can be performed in a safe and efficient manner at a teaching institution.

A balanced approach to choledocholithiasis.

We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy. We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients. A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14). Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.

Infection after laparoscopic cholecystectomy: effect of infected bile and infected gallbladder wall.

To assess the incidence of infected bile and gallbladder wall infection at the time of laparoscopic cholecystectomy, and find out if they influenced the rate of postoperative infective complications. Prospective study. District hospital, Kuwait. All 279 patients who had their gallbladders removed laparoscopically for gallbladder disease between September 1995 and August 1998. Samples of bile and gallbladder wall were taken from all patients and cultured separately for aerobic and anaerobic bacteria. Patients with complicated gallbladder disease (n = 80) were given preoperative therapeutic antibiotics for five days (cephalosporin plus metronidazole), and other high-risk patients (n = 138) were given prophylactic ceftriaxone either 1 g x 3 starting at induction of anaesthesia (n = 42), or a single dose at induction (n = 96). Incidence of infected cultures, and infective morbidity. 26 specimens of bile (9%) and 56 specimens of gallbladder wall (20%) were infected. Two patients in whom neither specimen had shown any growth developed minor infections at the umbilical port. No patient in whom either specimen was infected developed an infective complication. The overall rate of infective complications was negligible, and did not correlate with the presence of bacteria in the bile or gallbladder wall. This is probably a reflection of our aggressive antibiotic regimen in the management of high-risk patients.

7251 Natural history of asymptomatic bile duct stones at time of cholecystectomy.

There is relatively little data on the natural history of asymptomatic bile duct stones. As there is currently uncertainty on the management of asymptomatic bile duct stones at time of laparoscopic cholecystectomy, we followed up a group of patients over a 5-year period. METHODS: We followed up 59 patients who underwent laparoscopic cholecystectomy (study group). None of these patients had a pre-operative suspicion of bile duct stones and therefore no intra-operative cholangiogram or ERCP was performed pre or post surgery. Follow up was in the form of a telephone questionnaire to their respective primary care physicians. The control group had no pre-operative suspicion of bile duct stones but had routine intraoperative cholangiogram performed. RESULTS: 59 patients were followed up for an average of 57 months (4.8 years)(range 30-78 months) after laparoscopic cholecystectomy. Mean age was 52yrs (range 31-84yrs). 4 patients had seen their primary care physicians with symptoms of gastroesophageal reflux disease. 2 patients were diagnosed with duodenitis following EGD. 1 patient had been referred for barium enema for lower abdominal pain and diagnosed with diverticulitis. 1 patient had ongoing nausea. 1 patient had continuing right upper quadrant pain, which was diagnosed as neuropathic pain, and referred to the pain clinic. None of the patients had pancreatitis, jaundice, deranged liver function tests, ERCP or other biliary investigations. In the control group, intra-operative cholangiogram was performed in 73 patients without suspected bile duct stones. 4 of 73 (6%) patients had intraductal stones detected, which were removed either endoscopically or, by surgery. CONCLUSIONS: The prevalence of asymptomatic bile duct stones during time of cholecystectomy in our population was 6% i.e. we would expect 3 patients in our study group to have asymptomatic bile duct stones.We found that the study group had no complications related to bile duct stones during the 5-year follow up period. This would support the view that incidental bile duct stones found in patients undergoing laparoscopic cholecystectomy do not need removed.

Cystic duct tube placement in patients with choledocholithiasisdiscovered at the time of laparoscopiccholecystectomy

Cystic duct tube placement in patients with choledocholithiasisdiscovered at the time of laparoscopiccholecystectomy