Laparoscopic cholecystectomy in acute cholecystitis: an analysis of the risk factors.

BACKGROUND AND AIM: Laparoscopic cholecystectomy (LC) is increasingly being used as the initial surgical approach in patients with acute cholecystitis (AC). We describe our experience with LC in the treatment of AC. MATERIALS AND METHODS: In this study 2 412 patients underwent LC, in 315 cases for AC. The diagnosis was based on clinical, laboratory and intra-operative findings. Rates of conversion, complications, length of hospital stay, operating times, and factors associated with conversion or morbidity were analysed. RESULTS: Conversion to open cholecystectomy was necessary in 60 patients (19.04%) with AC. Factors associated with conversion were age >65 years, male gender, presence of empyema, previous abdominal surgery, and fever (temperature >37.5oC). There were no deaths, and the complication rate was 6.4%. The only risk factor for morbidity was a bilirubin level of >20.52 µmol/l. The operating time and hospital stay were significantly longer in AC than in elective cases. CONCLUSIONS: LC for AC is technically demanding but safe and effective. With patience, experience, careful dissection and identification of vital structures, the laparoscopic approach is safe in the majority of cases.

Port-site metastasis of extrahepatic bile duct carcinoma after laparoscopic cholecystectomy without evidence of a primary tumour.

A 75-year-old man suffering from symptomatic cholelithiasis underwent laparoscopic cholecystectomy using the four-port technique. No malignancy was observed in the resected gall-bladder and the patient exhibited a good postoperative course. Eleven months postoperatively he presented with two subcutaneous tumours: one at the port-site on the right anterior axillary line (at the position of the vacuum drain) and the other at the subumbilical port-site. The patient underwent an incisional biopsy, which revealed metastatic adenocarcinomas of the primary extrahepatic duct, with no evidence of a primary tumour or other distant metastasis. The patient underwent wide excision of the subcutaneous tumours. Six months later he again presented with subcutaneous tumours at the same positions. Magnetic resonance imaging of the abdomen revealed only the subcutaneous tumours. The patient again underwent wide excision of the subcutaneous tumours, followed by radiotherapy. At a 21-month follow-up the patient was symptom-free. Magnetic resonance imaging of the abdomen and magnetic resonance cholangiopancreatography results were normal, and there was no evidence of other metastasis. Four months later the patient died from metastatic disease of the abdomen.

Comparison of angiogenic activity after urethral reconstruction using free grafts and pedicle flap: an experimental study.

PURPOSE: An experimental study was undertaken in order to estimate the angiogenic activity in different free grafts and pedicle flap in urethral reconstruction in an animal model. METHODS: Twenty-eight white New Zealand rabbits were randomly divided into five groups (O, A, B, C and D). A ventral urethral defect was created in all groups. In the group O, (n = 4), a simple closure of the defect was performed. Free penile skin graft (group A, n = 6), buccal mucosal graft (group B, n = 6), bladder mucosal graft (group C, n = 6), and pedicle penile skin graft (group D, n = 6) were used to bridge the urethral defect as an onlay patch. The animals were euthanized on the 21st postoperative day. The angiogenic activity was assessed with immunohistochemistry, using the anti-CD31 MoAb and the alkaline phosphatase antialkaline phosphatase procedure. The native vascularity of penile skin as well as buccal and bladder mucosa was assessed in rabbits from group O (n = 3). Statistical analysis was performed using one-way ANOVA. RESULTS: The angiogenesis seen with a magnification of x 200 in groups O, A, B, C, and D was 34.1 +/- 4.1 (mean +/- SD), 61.7 +/- 6.4, 94.3 +/- 6.4, 91.5 +/- 7.2, and 30.8 +/- 5.2 vessels per optical field, respectively. There were statistically significant differences (p < 0.001) between group O and groups A, B, C and between group A and groups B, C, D, but not (p > 0.5) between groups B and C and groups O and D. The native vascularity of penile skin, buccal mucosa and bladder mucosa was 23.3 +/- 3.0, 24.6 +/- 3.7 and 17.0 +/- 2.6 vessels per optical field, respectively. CONCLUSION: Buccal and bladder mucosal grafts exhibit a higher angiogenic activity than free and pedicle penile skin flap when transplanted in urethral defects. As the buccal mucosal graft showed the higher angiogenic activity and its harvesting is easier than bladder mucosa, we propose that in urethral reconstruction surgery the use of this graft might offer more reliable results.

Delayed perforation of the large bowel due to thermal injury during laparoscopic cholecystectomy.

We report a case of delayed perforation of the large bowel because of thermal injury during a laparoscopic cholecystectomy. A 78-year-old male with symptomatic cholelithiasis underwent a difficult laparoscopic cholecystectomy because of multiple adhesions resulting from two previous cholecystitis episodes. The patient recovered well after surgery and was discharged on post-operative day 2. On postoperative day 10, the patient returned to the hospital with peritonitis. An exploratory laparotomy revealed perforation of the wall of the hepatic flexure of the large bowel, which was centred in a necrotic area 1 cm in diameter. The perforation was sutured and a temporary ileostomy performed, which was closed at a later date. The patient was doing well at a 10-month follow-up review. A delayed rupture of any part of the bowel after laparoscopic surgery can be potentially fatal if not treated during an emergency exploratory laparotomy, even if the clinical signs are not severe.

Laparoscopic cholecystectomy in a patient with previous open cholecystostomy.

We report the case of a successful elective interval laparoscopic cholecystectomy in a patient with a previous tube cholecystostomy that had been performed surgically 8 weeks earlier for an attack of acute calculous cholecystitis. At surgery, the major omentum was adherent to the right lateral abdominal wall, completely covering the liver edge, the gallbladder, and the inserted tube. The gallbladder and the tube within it were dissected free from the abdominal wall and the greater omentum, the cholecystostomy tube was removed, and the operation was completed successfully without any further difficulties.

Laparoscopic cholecystectomy in a patient with situs inversus totalis and previous abdominal surgery.

Situs inversus totalis is a rare congenital defect that can present difficulties during laparoscopic surgery due to the mirror-image anatomy. We report a patient with symptomatic cholelithiasis and previous abdominal surgery in whom a chest X-ray revealed a right-sided heart, whereas abdominal ultrasound revealed that his gallbladder was located in the left hypochondrium. At surgery, the surgeon and the camera assistant were standing on the right-hand side of the patient, and the first assistant was standing on the left. The camera was introduced through an umbilical incision, and laparoscopy confirmed the situs inversus. The other 10-mm trocar was placed in the midline left of the falciform ligament and two 5-mm trocars were placed in the left subcostal midclavicular line and anterior axillary line, respectively. After dissection of multiple adhesions caused by previous abdominal surgery, a standard laparoscopic cholecystectomy was performed successfully. This report suggests that situs inversus is not a contraindication for laparoscopic surgery. However, the procedure is more difficult and potentially hazardous due to the mirror-image anatomy (particularly the transposition of biliary ducts) causing difficulties in orientation, so that extreme care is required to avoid iatrogenic injuries. Despite these factors, laparoscopic cholecystectomy can be performed safely in patients with situs inversus totalis.

Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery.

BACKGROUND: Previous abdominal surgery has been reported as a relative contraindication to laparoscopic cholecystectomy. This study specifically examined the effect of previous intraabdominal surgery on the feasibility and safety of laparoscopic cholecystectomy. METHODS: Data from 1,638 consecutive patients who underwent laparoscopic cholecystectomy were reviewed and analyzed for open conversion rates, operative times, intra- and postoperative complications, and hospital stay. RESULTS: Of the 1,638 study patients 473 (28.9%) had undergone previous abdominal surgery: 58 upper and 415 lower abdominal operations. The 262 patients who had undergone only a previous appendectomy were excluded from further analysis. Adhesions were found in 70.7%, 58.8% and 2.1% of patients respectively, who had previous upper, lower or no previous abdominal surgery with adhesiolysis required, respectively, in 78%, 30% and 0% of these cases. There were no complications directly attributable to adhesiolysis. Patients with previous upper abdominal surgery had a longer operating time (66.4 +/- 34.2 min), a higher open conversion rate (19%), a higher incidence of postoperative wound infection (5.2%), and a longer postoperative stay (3.4 +/- 2.1 days) than those who had undergone previous lower abdominal surgery (50.8 +/- 24 min, 3.3%, 0.7%, and 2.6 +/- 1.4 days, respectively) and those without prior abdominal surgery (47.4 +/- 25.6 min, 5.4%, 1.2%, and 2.8 +/- 1.9 days, respectively). CONCLUSIONS: Previous abdominal operations, even in the upper abdomen, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with an increased need for adhesiolysis, a higher open conversion rate, a prolonged operating time, an increased incidence of postoperative wound infection, and a longer postoperative stay.

Intraperitoneal air in the diagnosis of blunt diaphragmatic rupture.

We present here a case of blunt traumatic right hemidiaphragmatic rupture with hepatic hernia that was diagnosed preoperatively on the basis of clinical, chest radiogram, and computed tomography scan suspicions. We proposed that the presence of free intraperitoneal air without guarding or peritoneal signs should be considered to be a clinical indication of hemidiaphragmatic rupture with pneumothorax.

Intraperitoneal abscess after an undetected spilled stone.

Gallbladder perforation with loss of calculi in the abdomen is frequent during laparoscopic cholecystectomy and can cause serious late complications. We report on a 65-year-old woman who underwent laparoscopic cholecystectomy for gallbladder empyema, during which a stone spilled into the peritoneal cavity. The spilled gallstone was not noticed during the initial operation. Three months later, she reported left upper quadrant pain of recent onset without associated symptoms such as fever, nausea, or weight loss. On examination, a palpable 2-cm tender subcutaneous mass was found. Abdominal ultrasound demonstrated an incarcerated hernia, and computed tomography (CT) scan showed an intraperitoneal abscess located in the back of the anterior abdominal wall in the left upper quadrant, which contained a recalcification figure. The patient was brought to surgery, at which time an incision was made over the mass. A chronic abscess in the back of the abdominal wall, also spreading into the subfascial space, was drained, and purulent material was obtained with a large stone, 2.8 cm in diameter, which had become lodged in the rectus abdominis after an undetected stone spillage during laparoscopic cholecystectomy. The patient continued receiving antibiotic treatment for 7 days, recovered well, and was discharged 7 days after drainage of the abscess.