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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 469-473

Difficulties during laparoscopic cholecystectomy


Department of General Surgery, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt

Date of Submission09-Jul-2013
Date of Acceptance07-Sep-2013
Date of Web Publication26-Sep-2014

Correspondence Address:
Maher Mohammed Sharabash
MBBCh, Kallin-Kafr El Sheik
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141729

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  Abstract 

Objective
The aim of the study was to record different difficulties during laparoscopic cholecystectomy and how to manage with special respect to the preoperative detection of these difficulties.
Background
'Difficult' is a relative term but generally difficult cholecystectomies include difficult peritoneal access due to morbid obesity or previous abdominal surgery, intra-abdominal adhesions, acute cholecystitis, liver cirrhosis, gall bladder mucocele, contracted gall bladder, frozen Calot's triangle, floppy left lobe of the liver, and aberrant anatomy.
Patients and methods
Fifty patients of difficult laparoscopic cholecystectomies were recorded over a period of about 18 months; most of them were preoperatively expected to be difficult and most of these difficulties were overcome by means of laparoscopic techniques.
Results
Laparoscopic cholecystectomy was successfully accomplished in 47 patients (94%) with a mean operative time of 52.6 ± 18.66 min. Three patients were converted to open cholecystectomy (6%), in two patients due to dense adhesions with the gall bladder and in one patient due to iatrogenic injury to the cystic duct during skeletonization of frozen Calot's triangle. Our most common intraoperative pathology was dense intraperitoneal adhesions between the gall bladder and the surrounding structures (28%). The second most common intraoperative pathology was cirrhotic liver (16%). The preoperative parameters that significantly predicted difficult laparoscopic cholecystectomy were previous acute attacks of cholecystitis and long duration of the disease, local signs of acute cholecystitis, obesity, contracted gall bladder, gall bladder with large stones, and increased gall bladder wall thickness greater than 5 mm (based on ultrasound).
Conclusion
Low conversion rate was attributed to adequate vision, minimal use of electrocautery at the triangle of Calot, displaying the structures at the triangle of Calot before clipping, adequate traction in proper direction, use of gauze dissection and hydrodissection in difficult patients and reconfirming the anatomy from time to time.

Keywords: Cholecystectomy, difficult, laparoscopic, prediction


How to cite this article:
Ahmed ML, Lolah MA, Mohammed MA, Sharabash MM. Difficulties during laparoscopic cholecystectomy. Menoufia Med J 2014;27:469-73

How to cite this URL:
Ahmed ML, Lolah MA, Mohammed MA, Sharabash MM. Difficulties during laparoscopic cholecystectomy. Menoufia Med J [serial online] 2014 [cited 2019 Nov 19];27:469-73. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/469/141729


  Introduction Top


The increasing experience in laparoscopic cholecystectomy has led to more difficult cases being performed. Those cases of difficult cholecystectomy have criteria that would have been classified as contraindications of the laparoscopic procedure [1].

High incidence of cholelithiasis combined with the lack of health care facilities and the lack of awareness on the part of the patient contributes to the very common presentation of the patient in the advanced stage of the disease [2]. Laparoscopic cholecystectomy may be rendered difficult by various problems encountered during surgery, such as difficulties in accessing the peritoneal cavity, creating a pneumoperitoneum, dissecting the gall bladder, or extracting the excised gall bladder [3].

Safe dissection is the key to complete laparoscopic cholecystectomy successfully. The level of difficulty may vary with the experience and skill of the operating surgeon. An inexperienced surgeon ascending the learning curve may find conditions such as intra-abdominal adhesions, acutely inflammed friable gall bladder, gangrenous gall bladder, and fibrotic Calot's triangle to be of insurmountable difficulty. In such situation, there should not be any hesitation to call for the expert help if available or to convert the surgery, which should not be considered as a failure [2].

Within a short span of merely two decades since its introduction, laparoscopic cholecystectomy has become widely accepted as the procedure of choice for symptomatic gall bladder disease. With their growing experience in this surgery, the surgeons have started taking up more complex patients and high-risk patients, some of which were considered relative contraindications a couple of years back [4].

The difficulty encompasses a gamut of factors that arise from the patient, the surgical scene, and the surgeon himself. The various safety measures in performing a safe laparoscopic cholecystectomy should not be undermined and left to the oblivion. The surgeon needs to give a due importance and weightage to all those techniques that will safeguard him for a smooth travel. The surgeon needs to be familiar with the angled scopes. Intraoperative cholangiography (IOC) or laparoscopic ultrasound, if available, needs to be performed to identify the biliary anatomy and common duct stones [5].

At the early learning curve of the laparoscopic approach, acute cholecystitis was considered a contraindication. However, with increasing laparoscopic experience, this has been changed. Now, laparoscopic cholecystectomy can be safely performed for acute cholecystitis but with increased rate of conversion to the open technique unless the operation is performed as early as possible following the onset of the acute symptoms - that is, within 48-72 h. This is because delaying surgery allows inflammation to become more intense, thus increasing the technical difficulty of laparoscopic cholecystectomy. This was obvious in previous experience of laparoscopic cholecystectomy performed for acute cholecystitis in the first 72 h due to easier dissection of the inflamed and edematous tissue [6]. Complications of laparoscopic cholecystectomy include bile duct injuries, bile leak, bleeding, vascular and visceral injuries, pneumoperitoneum-related complications (subcutaneous emphysema, pneumothorax, hypercarbia, air embolism, and ileus), infection, retained gall stones (in the common bile duct or intraperitoneal spillage), port site hernia, postcholecystectomy syndrome, and complications related to anesthesia [7],[8],[9],[10],[11].


  Patients and methods Top


This study was conducted on 50 patients in Menoufiya University Hospitals (General Surgery Department) and Gamal Abdel Naser Health Insurance Hospital in Alexandria over a period of about 18 months from the start of November 2011 to the end of April 2013, excluding pregnant women, patients with gall bladder cancer, and concomitant choledocholithiasis. All patients underwent full history taking, thorough clinical examination with emphasis on signs of acute cholecystitis, and routine laboratory investigations in addition to serum bilirubin (total and direct), alkaline phosphatase, and g-glutamyl transferase. Details of the abdominal ultrasound were listed including liver condition, gall bladder shape (distended or contracted), gall bladder wall thickness, stones (number and size), presence of pericholecystic collection, and common bile duct diameter, lumen, and contents. We assessed the procedure regarding total procedure duration, difficulties during accessing the peritoneal cavity, adhesions at the triangle of Calot, aberrant anatomy, gall bladder size and wall, iatrogenic injuries, dissection of the gall bladder from its bed, extraction of the gall bladder, and conversion to open cholecystectomy [Figure 1].
Figure 1:

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The study included 21 obese patients with BMI greater than 30 kg/m 2 . We assessed the degree of obesity using the Metropolitan Insurance Company formula; first degree (20-24% over ideal weight) included five patients, second degree (25-30% over ideal weight) included four patients, third degree (31-99% over ideal weight) included 10 patients, and fourth degree (morbid obesity) included two patients. We used the supraumbilical rather than the infraumbilical route for pneumoperitoneum and did not resort to the extra long ports in obese patients.

We assessed technical difficulty of the operation by Cuschieri's scale. Grade I includes easy cholecystectomies (zero patients). Grade II refers to cholecystectomies of medium difficulty: light pericholecystitis, cystic pedicle masked by adherences or fatty tissue (five patients), or mucocele (four patients). Grade III (difficult cholecystectomies) includes gangrenous cholecystitis, shrunken fibrotic gall bladder, intense pericholecystitis, subhepatic abscesses, Hartmann's pouch adherent to the common bile duct, cases in which the cystic pedicle is hard or impossible to dissect, or liver cirrhosis with portal hypertension (38 patients). Grade IV (conversions) included three patients.

We have not encountered life-threatening complications, but iatrogenic injury to the cystic duct during skeletonization of frozen Calot's triangle was found in one patient, and it was converted to open surgery. In two patients, there was iatrogenic injury to the cystic artery with subsequent bleeding, which was controlled by compression and diathermy coagulation after frequent use of suction irrigation. In the fourth patient, there was iatrogenic injury to the adherent omental vessels during adhesiolysis and was controlled by diathermy coagulation.

Difficult cases were managed by resorting to adequate vision, minimal use of electrocautery at the triangle of Calot, displaying the structures at the triangle of Calot before clipping, adequate traction in proper direction, use of gauze dissection and hydrodissection, and reconfirming the anatomy from time to time.

IOC was performed in two patients. After dissection of the cystic artery and duct, a titanium clip was applied to the cystic duct close to the gall bladder infundibulum. Then a 5-Fr ureteral catheter, which was passed into the abdominal cavity by a grasping forceps (or enters the intra-abdominal cavity next to the subxiphoid trocar), was pushed into the cystic duct through a small transverse incision on the anterior surface of the cystic duct made by scissors, until its distal hole passes into the lumen. Following administration of the contrast dye by a syringe into the catheter, a supine IOC was obtained with a portable unit to visualize the biliary tree.


  Results Top


Preoperative ultrasound showed that 24 patients (48%) had fatty infiltration, whereas eight patients (16%) showed cirrhosis, and the other 18 patients had normal liver. Gall bladder was contracted in four patients (8%) and distended in seven patients (14%). Gall bladder wall thickening was found in 19 patients (38%), 13 of them less than 5 mm and six patients more than 5 mm.

The 50 difficult cases were as follows: five cases of acute cholecystitis (10%) including a case of empyema gall bladder [Figure 2] and were approached within 72 h of the attack, four cases of gall bladder mucocele (8%), two cases of aberrant anatomy (4%) in the form of caterpillar turn [Figure 3], five cases with dense adhesions at Calot's triangle (10%), two cases with sagging left lobe liver (4%), eight cases with liver cirrhosis (16%), two cases with contracted fibrotic gall bladder (4%), three cases with intraoperative bleeding (6%), two cases were subjected to IOC (4%), in the first case due to suspected aberrant ductal anatomy and in the other case due to mild darkening of urine the day before the scheduled date of surgery, 14 cases with intra-abdominal adhesions (28%), and three cases were converted to open cholecystectomy (6%). Laparoscopic cholecystectomy was successfully accomplished in 47 patients (94%) with a mean operative time of 52.6 ± 18.66 min. Three cases were converted to open cholecystectomy (6%), in two cases due to dense adhesions with the gall bladder and in one case due to iatrogenic injury to the cystic duct during skeletonization of frozen Calot's triangle. Our most common intraoperative pathology was dense intraperitoneal adhesions between the gall bladder and the surrounding structures (28%). The second most common intraoperative pathology was cirrhotic liver (16%). The preoperative parameters that significantly predicted difficult laparoscopic cholecystectomy were previous acute attacks of cholecystitis and long duration of the disease, local signs of acute cholecystitis, obesity, contracted gall bladder, gall bladder with large stones, and increased gall bladder wall thickness greater than 5 mm (based on ultrasound) [Figure 4].
Figure 2:

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Figure 3:

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Figure 4:

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  Discussion Top


In our study, laparoscopic cholecystectomy was performed for five patients of acute cholecystitis and four patients of gall bladder mucocele. The procedure was safely performed within 72 h of the onset of the acute attack with no patients converted to the open procedure. Liu et al. [12] conducted two randomized controlled trials of early versus delayed laparoscopic cholecystectomy in the management of acute cholecystitis. Both have shown that early laparoscopic cholecystectomy is safe and associated with lower rates of conversion and reduced total hospital stay compared with delayed surgery. The policy of Singh and Ohri [2] was to intervene in the cases presenting within 72 h of onset of symptoms and their conversion rate in the setting of acute cholecystitis (0.57%) is much lower than that reported in many series. They contradict the conclusion of Knight et al. [13] that timing of urgent laparoscopic cholecystectomy does not influence the conversion rate. Knight et al. [13] had reported a conversion rate of 12%, which is much higher than that reported in the literature. We had a conversion rate of 6% (three patients) of the 50 difficult laparoscopic cholecystectomies [13]. Our most common intraoperative pathology for which the conversion had to be performed was dense intraperitoneal adhesions between the gall bladder and the surrounding structures, two of 14 (14.29%). The second most common intraoperative pathology leading to conversion was frozen triangle of Calot, which resulted in iatrogenic injury to the cystic duct. One of five patients (20%) with adhesions at Calot's triangle was converted to open surgery. Singh and Ohri [2] analyzed 1446 difficult cases of laparoscopic cholecystectomy performed in Dayanand Medical Hospital. They had a conversion rate of 1.86% of the 1446 difficult cholecystectomies and 0.42% of the total laparoscopic cholecystectomies performed at their center, which is lower than the incidence reported in literature, which varies from 2% to as high as 22%. Their most common intraoperative pathology for which the conversion had to be performed was Mirizzi syndrome, two of six (33.33%). Mirizzi syndrome is a rare complication of long-standing gall stone disease, which has been reported to have a high conversion rate and high incidence of bile duct injury. Singh and Ohri [2] declared that the second most common intraoperative pathology leading to conversion was frozen triangle of Calot, which made dissection very difficult and anatomy unclear, causing a high level of difficulty. They had to convert 18.18% of the patients having dense adhesions to open surgery, which is lower than that reported in the literature. In a prospective study on 1676 patients, Fried et al. [14] found that age, sex, acute cholecystitis, obesity, and thickened gall bladder wall were significant predictors for difficult laparoscopic cholecystectomy [14] [Table 1],[Table 2],[Table 3] and [Table 4].
Table 1: Difficult access to the peritoneal cavity

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Table 2: Dense adhesions at Calot's triangle

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Table 3: Dissection of the gall bladder from its bed

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Table 4: Difficult extraction

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  Conclusion Top


Patients with gall stone disease should be advised for early elective laparoscopic cholecystectomy to avoid gall stone complications and difficult laparoscopic cholecystectomy. Acute cholecystitis can be safely managed laparoscopically within 72 h of the attack. Patients of liver cirrhosis were a relative contraindication, but now they can be safely tackled laparoscopically provided that the liver condition is compensated (Child A and B). Clinical and sonographic data may help predict a difficult laparoscopic cholecystectomy, which is very useful to the patient and surgeon.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.Lazar F, Duta C, Bordos D. Difficult laparoscopic cholecystectomy. Chirurgia (Bucur) 2001; 96 :269-276.  Back to cited text no. 1
    
2. Singh K, Ohri A. Difficult laparoscopic cholecystectomy: a large series from north India. Ind J Surg 2006; 68 :205-208.  Back to cited text no. 2
    
3. Nachnani J, Sup A. Preoperative prediction of difficult laparoscopic cholecystectomy. Indian J Gastroentrol 2005; 24 :16-18.  Back to cited text no. 3
    
4. S Khanna. How to predict difficult laparoscopic cholecystectomy and when to convert: a large series from north India. Ind J Surg 2007; 81-88.  Back to cited text no. 4
    
5. Palanivelu C, Rajan PS, Jani K, Shetty AR, Sendhilkumar K, Senthilnathan P. Laparoscopic cholecystectomy in cirrhotic patients: the role of subtotal cholecystectomy and its variants. J Am Coll Surg 2006; 203 :145-151.  Back to cited text no. 5
    
6. Ammori BJ, Davides D, Vezakis A, Larvin M, McMahon MJ. Laparoscopic cholecystectomy. Are patients with biliary pancreatitis at increased operative risk? Surg Endosc 2003; 17 :777-780.  Back to cited text no. 6
    
7. B Krishna Rau. Management of postoperative complications after laparoscopic cholecystectomy: a large series from north India. Ind J Surg 2007; 95-99.  Back to cited text no. 7
    
8. Bismuth H, Majno PE. Biliary strictures: classification based on the principles of surgical treatment. World J Surg 2001; 25 :1241-1244.  Back to cited text no. 8
    
9. Saha KS. Ligating the cystic duct in laparoscopic cholecystectomy. Am J Surg 2000; 179 :494-496.  Back to cited text no. 9
    
10.Kauvar DS, et al. Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy. J Surg Res 2005; 132 :159-163.  Back to cited text no. 10
    
11.Rohatgi A, Widdison AL. An audit of cystic duct closure in laparoscopic cholecystectomies. Surg Endosc 2006; 20 :875-877.  Back to cited text no. 11
    
12.Liu CL, Fan ST, Lai EC, Lo CM Chu KM. Factors affecting conversion from laparoscopic cholecystectomy to open surgery. Arch Surg 1996; 135 :98-101.  Back to cited text no. 12
    
13.Knight JS, Mercer SJ, Somers SS, Walters AM, Sadek SA, Toh SK. Timing of urgent laparoscopic cholecystectomy does not influence conversion rate. Br J Surg 2004; 91 :601-604.  Back to cited text no. 13
    
14.Fried GM, Barkun JS, Sigman HH, et al. Factors determining conversion to laparotomy in patients undergoing laparoscopic cholecystectomy. Am J Surg 1994; 167 :35-41.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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Abstract
Introduction
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