Intraabdominal contamination after gallbladder perforation during laparoscopic cholecystectomy and its complications

Laparoscopic vs open radical resection in management of gallbladder carcinoma: A systematic review and meta-analysis

BACKGROUND

Radical resection offers the only hope for the long-term survival of patients with gallbladder carcinoma (GBC) above the T1b stage. However, whether it should be performed under laparoscopy for GBC is still controversial.

AIM

To compare laparoscopic radical resection (LRR) with traditional open radical resection (ORR) in managing GBC.

METHODS

A comprehensive search of online databases, including Medline (PubMed), Cochrane Library, and Web of Science, was conducted to identify comparative studies involving LRR and ORR in GBCs till March 2023. A meta-analysis was subsequently performed.

RESULTS

A total of 18 retrospective studies were identified. In the long-term prognosis, the LRR group was comparable with the ORR group in terms of overall survival and tumor-free survival (TFS). LRR showed superiority in terms of TFS in the T2/tumor-node-metastasis (TNM) Ⅱ stage subgroup vs the ORR group (P = 0.04). In the short-term prognosis, the LRR group had superiority over the ORR group in the postoperative length of stay (POLS) (P < 0.001). The sensitivity analysis showed that all pooled results were robust.

CONCLUSION

The meta-analysis results show that LRR is not inferior to ORR in all measured outcomes and is even superior in the TFS of patients with stage T2/TNM Ⅱ disease and POLS. Surgeons with sufficient laparoscopic experience can perform LRR as an alternative surgical strategy to ORR.

Effectiveness of no drainage after elective day-case laparoscopic cholecystectomy, even with intraoperative gallbladder perforation: a randomized controlled trial

BACKGROUND

Laparoscopic cholecystectomy (LC) has been carried out as day-case surgery. Current guidelines do not mention the role of drainage after LC. In particular, data stay blank with no prospective study on drainage management when gallbladder perforation (GP) accidentally occurs intraoperatively.

METHODS

A randomized controlled trial was conducted to compare clinical outcomes of drainage and no drainage after elective day-case LC. Intraoperative GP was recorded. The primary and secondary outcomes were major and minor complications, respectively.

RESULTS

Two hundred patients were randomized. No major complications occurred in either group. In secondary outcomes, nausea/vomiting, pain, hospital stay, and cost were similar in the drainage group and no drainage group; postoperative fever, WBC, and CRP levels were significantly lower in the no drainage group. GP occurred in 32 patients. Male patients with higher BMI and CRP and abdominal pain within 1 month were more likely to occur GP. Subgroup analysis of GP, primary outcomes, and most secondary outcomes had no difference. Postoperative WBC and CRP were higher in the drainage group. Postoperative fever occurred in 63 patients. Univariate analysis of fever showed that blood loss, drainage, postoperative WBC, CRP, and hospital stay were significant. Multivariable logistic regression analysis demonstrated that drainage was an independent risk factor for fever after LC (OR 3.418, 95% CI 1.392-8.390; p = 0.007).

CONCLUSIONS

No drainage after elective day-case LC is safe and associated with fewer complications, even in intraoperative GP. The trial proves that drainage is an independent risk factor for postoperative fever. The use of a drain after LC may lead to an unsuccessful day-case procedure by causing fever, elevated CRP, and extended hospital stay (NCT03909360).

Iatrogenic gallbladder perforation during laparoscopic cholecystectomy and outcomes: a systematic review and meta-analysis

AIMS

We aimed to compare the outcomes of iatrogenic gallbladder perforation (IGP) versus no gallbladder perforation in patients undergoing laparoscopic cholecystectomy.

METHODS

A systematic review and meta-analysis was conducted in compliance with PRISMA statement standards. We searched the MEDLINE, EMBASE, CINAHL Scopus, and CENTRAL to identify eligible studies. The last search was run on 17 October 2021. The outcome of interest included surgical site infection (SSI), postoperative collection, operative time, and length of hospital stay. Random effects modelling was applied to calculate pooled outcome data. The certainty of evidence was assessed using GRADE system.

RESULTS

Analysis of 5366 patients from 11 observational studies suggested that IGP during laparoscopic cholecystectomy does not increase the risk of SSI (OR: 1.48, 95% CI 0.57-3.86, P = 0.42) and postoperative collection (RD: 0.00, 95% CI - 0.00-0.01, P = 0.41) but may result in longer operative time (MD 10.28 min, 95% CI 7.40-13.16, P < 0.00001) and length of hospital stay (MD 0.51 days, 95% CI 0.15-0.87, P = 0.005). The results remained consistent through sensitivity analyses. The quality of available evidence was judged to be moderate, and the GRADE certainty of the evidence was judged to be high.

CONCLUSIONS

The best available evidence suggests that IGP during laparoscopic cholecystectomy may not increase the risk of SSI and postoperative collection but may result in longer operative time and length of hospital stay. Whether prompt retrieval of spilled stones, adequate peritoneal irrigation, and intraoperative use of prophylactic antibiotic contribute to the above findings remains unknown.

Recurrence of Citrobacter koseri-associated Intra-abdominal Infection 2 Years after Spilled Gallstones during Laparoscopic Cholecystectomy

Spilled gallstones during laparoscopic cholecystectomy (LC) are common. Lost gallstones can lead to complications such as intra-abdominal abscesses, which can occur days, months, or even years after the procedure. Citrobacter koseri belongs to the family of Enterobacteriaceae. It is a low-virulence pathogen; however, it is linked to infections of the urinary tract and abdomen. We report the case of a 70-year-old diabetic male who presented with C. koseri- associated subhepatic abscess. Two years prior, he had emphysematous cholecystitis and liver abscess caused by C. koseri. During his LC, gallstones were spilled in the abdominal cavity and every effort was made to retrieve them. However, 2 years later, an aspiration of the subhepatic abscess revealed cholesterol fragments. We hypothesize that dislodged cholesterol gallstones and bile, contaminated with C. koseri, were the culprits for the appearance of the subhepatic abscess with the same organism 2 years after the LC.

Case report: an unwanted leftover after laparoscopic cholecystectomy

BACKGROUND

A 72-year-old female patient with a history of laparoscopic cholecystectomy presented at the gastroenterology consultation with intermittent complaints of abdominal pain since two months in the right hemi abdomen.

METHODS

Imaging discovered a subhepatic abscess. Explorative surgery showed multiple gallstones as the cause of the abscess. A brief literature study was conducted and after a thorough selection based on title and abstract, we ended up with 14 articles. These were compared in the discussion with the literature concerning incidence, range of complications, risk factors and prevention and management.

RESULTS

Spilled gallstones are an unusual complication of a frequently performed procedure.

CONCLUSIONS

This case report elaborates on the incidence, different complications, prevention and management of spilled gallstones by means of a brief literature study. In case spillage happens removal of as many gallstones as possible is indicated the spillage should also be communicated to the patient to ease the diagnosis of a possible complication.

Gallbladder perforation during elective laparoscopic cholecystectomy: Incidence, risk factors, and outcomes

OBJECTIVE:

This study aimed to reveal the risk factors and outcomes of gallbladder perforation (GP) during laparoscopic cholecystectomy.

METHODS:

Videotapes of all patients who underwent an elective cholecystectomy at our department were retrospectively analyzed, and the patients were divided into two groups based on the presence of GP. The possible risk factors and early outcomes were analyzed.

RESULTS:

In total, 664 patients [524 (78.9%) females, 49.7±13.4 years of age] were observed, and GP occurred in 240 (36.1%) patients, mostly while dissecting the gallbladder from its bed (n=197, 82.1%). GP was not recorded in the operation notes in 177 (73.8%) cases. Among the studied parameters, there was no significant risk factor for GP, except preoperatively elevated alanine transaminase level (p=0.005), but the sensitivity and specificity of this measure in predicting GP were 14.2% and 7.4%, respectively. The two groups had similar outcomes, but the operation time (35.4±17.5 vs 41.4±18.7 min, p=0.000) and incidence of drain use (25% vs 45.8%, p=0.000) increased in the GP group.

CONCLUSION:

The present study reveals that GP occurs in 36.1% of patients who undergo laparoscopic elective cholecystectomy, but it may not be recorded in most cases. We did not find any reliable risk factor that increases the possibility of GP. GP causes an increase in the operation time and incidence of drain use; however, the other outcomes were found to be similar in patients with GP and those without.

Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study

BACKGROUND AND STUDY AIMS

The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment.

METHODS

Twenty pigs were randomized to trCCE (n = 10) or lapCCE (n = 10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14 days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination.

RESULTS

Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p = 0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p = 1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0 ± 2.7 vs. 14.6 ± 2.3; p = 0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114 ± 32 vs. 111 ± 27 min; p = 0.921) did not differ, but wound closure took longer for trCCE (31.5 ± 19 vs. 13 ± 5 min; p = 0.002).

CONCLUSIONS

After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted.

Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article

BACKGROUND

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

METHODS

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

RESULTS

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

CONCLUSIONS

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.

Influence of clamping stress and duration on the trauma of liver tissue during surgery operation

BACKGROUND

Tissue grasping damage often occurs in minimally invasive surgery, which would increase the postoperative recovery time and the risk of surgical complications. The purpose of this study was to evaluate the relationship between liver tissue trauma and compression stress magnitude and duration during tissue clamping operation.

METHODS

The clamping experiments of liver tissues in vivo were conducted by using a universal soft tissue mechanical testing machine under different clamping stress magnitudes and durations. The rabbit liver was used to simulate human liver. A minimally invasive surgery grasper was used in these tests to simulate the real tissue-surgical operation condition. A pathological grading system was created to quantitatively assess the trauma within the liver tissue. The hyperbolic regression models were utilized to predict the trauma degree of liver tissue.

FINDINGS

Obvious hyperemia, hemorrhage, hepatic capsule rupture and inflammatory cell infiltration appeared in the clamping sites of the liver. Assessment results indicated that the trauma degree increased nonlinearly with the increasing clamping stress and duration time. There exist safe thresholds, in which the severe trauma of the studied tissue can be avoided during grasping operation.

INTERPRETATION

The results could provide the safety margins and the trauma prediction models for surgeons during grasping and palpation tasks in minimally invasive surgery.

Attitudes and Practices of Surgeons towards Spilled Gallstones during Laparoscopic Cholecystectomy: An Observational Study

The sequelae of spilled gallstones after Laparoscopic cholecystectomy (LC) and the occurring complications may go unnoticed for a long time and can be a diagnostic challenge. The aim of this survey was to study the knowledge, attitude, and practices of surgeons regarding spilled gallstones during LC. An observational, cross-sectional survey, using a questionnaire based on 11 self-answered close-ended questions, was conducted among general surgeons. Of the 138 respondents only 29.7% had observed a complication related to gallstone spillage during LC. There was varied opinion of surgeons regarding management of spilled gallstones, documenting the same in operative notes and consent. It was observed that there is lack of knowledge regarding the complications related to gallstone spillage during LC. There is need to educate surgeons regarding safe practices during LC to avoid gallstone spillage, early diagnosis, and management of complications. There is need to standardize practice to retrieve lost gallstones to reduce complication and legal consequences.

Methods for reducing peak pressure in laparoscopic grasping

During tissue retraction with a laparoscopic grasper, tissue-damaging pressures can occur. Past research suggests that peak pressures can be considerably reduced by rounding the edges or covering the tip of the end effector with a silicon sleeve. To identify grasping methods that limit tissue damage, the effects of (a) Young’s modulus of the end effector, (b) curvature of the end effector, and (c) angle with which the tissue is pulled relative to the plane of the end effector, on the pressure generated on the tissue were investigated. Artificial skin was placed between two non-serrated jaws, a pressure-sensitive film was interposed between the skin and upper jaw, and the end effector was loaded with 13 N. End effectors with Young’s moduli of 0.09, 0.67, 1.49 MPa, and 69 GPa, and with non-rounded and 5 mm rounded edges were tested under pulling angles of 25°, 50°, and 75°. For non-rounded end effectors, the maximum pressure and the area across which pressure exceeded the safety threshold for tissue damage increased with Young’s modulus and pulling angle. For rounded end effectors, maximum pressure did not increase monotonically with Young’s modulus. Instead, the end effector with the second lowest Young’s modulus yielded significantly lower maximum pressure than the end effector with the lowest Young’s modulus. For rounded end effectors, pressures were below the safety threshold for all Young’s moduli. This indicates that to prevent tissue damage, soft graspers may not be needed; rounding the edges of metal graspers could suffice for preventing tissue damage.

Gallstone-related abdominal abscess 8 years after laparoscopic cholecystectomy

An unusual collection of fluid in the perihepatic space needs to be investigated for abscess in patients with a remote history of cholecystectomy.

Background:

A common intraoperative complication during laparoscopic cholecystectomy is gallbladder perforation with spillage of gallstones. The undesirable consequence of spilled gallstones is the formation of abscesses months or years after an operation.

Case Description:

Our clinical report describes an intraabdominal abscess formation in an 82-year-old man that developed 8 years after a laparoscopic cholecystectomy. A computed tomography scan of the abdomen showed an elongated fluid collection in the right abdominal compartment musculature at the level of the internal oblique muscle. Abdominal ultrasonography confirmed a large fluid collection, with 2 echogenic masses in the dependent portion. Incision and drainage of the abscess were performed, and 2 gallstones were found.

Conclusion:

Any unusual collection of fluid in the perihepatic space and abdominal wall in the area of the surgical incision in a patient with a remote history of cholecystectomy should be evaluated for abscess related to retained gallstone. Early abscess formation is usually diagnosed and treated by the surgeon. However, the late manifestation might be a clinical problem seen in the primary care physician's office. Therefore, the primary care physician should incorporate diagnosis of gallstone-related abscess in patients with abdominal abscess formation of unknown etiology.

Does sex affect the outcome of laparoscopic cholecystectomy? A retrospective analysis of single center experience

INTRODUCTION

The aim of our study was to determine the effect of sex on the outcome of laparoscopic cholecystectomy in terms of operative time, conversion to open cholecystectomy, postoperative complications and mean hospital stay.

METHODS

In this retrospective observational study, we analyzed the medical records of 2061 patients who underwent laparoscopic cholecystectomy in the surgical department of Khyber Teaching Hospital (Peshawar, Pakistan) between March 2008 and January 2010. χ(2) test and t-test were respectively used to analyze categorical and numerical variables. P ≤ 0.05 was considered significant.

RESULTS

The study included 1772 female and 289 male patients. The mean age for male patients was 44.07 ± 11.91 years compared to 41.29 ± 12.18 years for female patients (P = 0.706). Laparoscopic cholecystectomy was successfully completed in 1996 patients. The conversion rate was higher in men (P < 0.001), and the mean operating time was longer in men (P < 0.001). Bile duct injuries occurred more frequently in men (P < 0.001). Gallbladder perforation and gallstone spillage also occurred more commonly in men (P = 0.001); similarly severe inflammation was reported more in male patients (P = 0001). There were no statistically significant differences in mean hospital stay, wound infection and port-site herniation between men and women. Multivariate regression analysis showed that the male sex is an independent risk factor for conversion to open cholecystectomy (odds ratio = 2.65, 95% confidence interval: 1.03-6.94, P = 0.041) and biliary injuries (odds ratio = 0.95, 95% confidence interval: 0.91-0.99, P-value = 0.036).

CONCLUSIONS

Laparoscopic cholecystectomy is often challenging in men on account of more adhesions and inflammation. This leads to higher conversion rates and more postoperative complications. Optimized planning and a more experienced operating surgeon may help overcome these problems.

A meta-analysis of outcomes after routine aspiration of the gallbladder during cholecystectomy

We conducted a meta-analysis of published literature comparing outcomes after aspirating (ASP) the gallbladder versus nonaspiration (NASP). Electronic databases were searched from January 1985 to November 2009. A meta-analysis was performed to obtain a summative outcome. Two randomized, controlled trials involving 360 patients were analyzed. A total of 180 patients were in the ASP group, and 180 were in the NASP group. There was no significant increase in operative time in the ASP group compared with the NASP group [random-effects model: standardized mean difference, -0.72; 95% confidence interval (CI), -2.16, 0.71; z = 0.99; df = 1; P = 0.32], but there was significant heterogeneity among trials (Q = 42.4; P < 0.001; I2 = 98%). Patients undergoing ASP were less likely to have a gallbladder perforation [random-effects model: risk ratio (RR), 0.42; 95% CI, 0.19, 0.96; z = 2.05; df = 1; P < 0.05], but no difference was found regarding the loss of gallstones (random-effects model: RR, 1.33; 95% CI, 0.30, 5.85; z = 0.38; df = 1; P = 0.70). No difference was seen for liver bed bleeding (P = 0.43) or overall 30-day infection rates (P = 0.66). After aspiration, gallbladder perforation rates may be lower. This does not appear to translate into decreased loss of gallstones or infection rates. There was no significant difference between techniques in blood loss from the liver bed. Further randomized, controlled trials and follow-up studies are required to confirm these results and to establish long-term sequelae.

Use of retrieval bags in incidental gallbladder cancer cases

INTRODUCTION

Accidental intraoperative gallbladder perforation is a problem in laparoscopic surgery, especially in cases with incidental gallbladder carcinoma (IGBC). The question is whether intraoperative gallbladder perforation has a prognostic disadvantage or a retrieval bag provides protection against tumor dissemination.

METHODS

A standardized questionnaire was sent to all German surgical clinics based on the central register of "incidental gallbladder carcinoma" of the German Society of Surgery founded in 1997.

RESULTS

In 592 IGBC-registered cases, there were 330 laparoscopies, 154 open surgeries, and intraoperative conversion was performed in 106 cases. Of laparoscopic surgeries (n = 330), the recurrence rate was 30%. The recurrence rate for cases with (174/330) and without (156/330) the use of retrieval bag was 32.2% and 27%, respectively. In laparoscopies with intraoperative gallbladder perforation (73/330 cases), the recurrence rate was 38.4%. Of these cases the recurrence rate with (51/73) and without (22/73) the use of retrieval bags was 39.2% and 36.4%, respectively. In 257 cases without intraoperative perforation, tumor recurrence rate was 27.2%, and it was 29.3% or 25.4% with (123/257) and without (134/257) the use of retrieval bags.

CONCLUSIONS

According to the registry data, the intraoperative gallbladder perforation results in significant (P = 0.047) prognostic disadvantage and in these cases retrieval bags were used more often (P = 0.001). However, in IGBC cases if intraoperative gallbladder perforation has already happened, the use of retrieval bags had no protective effects.

The impact of gallbladder aspiration during elective laparoscopic cholecystectomy: a prospective randomized study

BACKGROUND

The aim of this prospective randomized study was to investigate the effect of gallbladder aspiration during elective laparoscopic cholecystectomy on the operative and postoperative course of patients.

METHODS

Between August 2005 and February 2007, 160 consecutive patients with symptomatic cholelithiasis were randomized into 2 clinically comparable groups. Gallbladders were aspirated before dissection in group A (aspiration, n = 80), and they were not aspirated in group C (control, n = 80). Patients' characteristics and general operative outcomes were compared and analyzed.

RESULTS

The mean dissection time (P = .45), amount of gas used (P = .49), and liver bed bleeding (P = .30) were not significantly different between group A and group C. Similarly, there were no differences between the groups regarding gallbladder perforation (P = .12), spillage of gallstones into the abdominal cavity (P = 1.00), or wound infection (P = 1.00).

CONCLUSIONS

The findings suggest that routine gallbladder aspiration is unnecessary in elective laparoscopic cholecystectomy.

An alternative gallbladder extraction technique in laparoscopic cholecystectomy

In this era of minimally invasive surgery, the challenge remains in finding techniques to reduce access trauma in terms of fewer and smaller size trocar ports. Our new described technique will allow a smaller subxiphoid port to be used to achieve extraction of the gallbladder without the need to change to a 5 mm laparoscope. We believe this method is easy to learn, safe and with no observable complications from our experience.

Peritoneal gallstones following laparoscopic cholecystectomy

BACKGROUND

Gallstone spillage during laparoscopic cholecystectomy (LC) is a common intraoperative event. Although gallstones left in the peritoneal cavity were initially considered harmless, a significant number of complications have been reported. Our aim was to quantify the likelihood, and to document the range, of subsequent complications.

METHODS

A Medline search from 1987 to January 2003 was performed. Articles with more than 500 LCs that quantified the frequency of complications due to peritoneal gallstones were reviewed, as were representative case studies of different stated complications.

RESULTS

Six studies, covering 18,280 LCs, were found. The incidence of gallbladder perforation was 18.3%, that of gallstone spillage was 7.3%, and that of unretrieved peritoneal gallstones was estimated to be 2.4%. There were 27 patients with complications. The likelihood of a complication when gallstone spillage occurred was 2.3%, which increased to 7.0% when unretrieved peritoneal gallstones were documented.

CONCLUSION

Spilt gallstones have a small but quantifiably real risk of causing a wide range of significant postoperative problems.

Spilled gall stones during laparoscopic cholecystectomy: a review of the literature

Laparoscopic cholecystectomy is associated with spillage of gall stones in 5%-40% of procedures, but complications occur very rarely. There are, however, isolated case reports describing a range of complications occurring both at a distance from and near to the subhepatic area. This review looks into the various modes of presentation, ways to minimise spillage, treating the complications, and the legal implications.

L’effraction de la vésicule lors des cholécystectomies laparoscopiques n'influence pas la morbidité. Étude prospective

BACKGROUND

Perforation of the gallbladder and spillage of gallstones frequently occur in laparoscopic cholecystectomy. As stones may be lost and as spilled bile is known to be contaminated, influence on morbidity may be expected.

AIMS

To evaluate the immediate and late consequences on morbidity of peroperative gallbladder perforation during laparoscopic cholecystectomy (LC) in an universitary hospital center.

PATIENTS AND METHODS

One hundred and twenty one LC were prospectively evaluated with a mean follow-up of 30 months. Elective operations on 30 men and 91 women with a mean age of 56.4 years (18-85) were carried out for symptomatic cholecystolithiasis in 97 cases (80%), and in 24 cases for complicated cholecystolithiasis. The "french technique" was used for all LC, with systematic intra-operative cholangiography and ultra Sonography. Thirty-seven (30.5%) LC were performed by surgical trainees, 84 LC by confirmed surgeons. The consequences of ultra-operative gallbladder perforation were evaluated in the immediate postoperative period, especially for septic complications, and thereafter, patients were followed up 1, 6, 12 and 24 months postoperatively.

RESULTS

Ultra-operative gallbladder perforation occurred in 24 cases (20%), in 83.3% during gallbladder dissection. Gallstone spillage occurred six times, and all spilled stones were removed. Gallbladder perforation was more frequent (but non significant) in acute cholecystitis (25 vs 19%, ns). A clear correlation to the skill and experience of the surgeon is shown (32.4 vs 14.2%, P =0.01). Gallbladder perforation is accompanied by an elevated (nonsignificant) postoperative morbidity (16.6 vs 7.2%, P =0.62) which is, in fact related to older patient and more acute cholecystitis in this group. No reoperations were necessary. One and two years follow-up revealed no long-term complications specially due to lost gallstones.

CONCLUSION

Peroperative gallbladder perforation during LC carries no morbidity, provided a total and complete recuperation of gallstones spilled and local treatment of bile contamination with local irrigation and antibiotics. This complication is correlated to the surgeon's skill and experience.

Effectiveness of grasping and duration of clamping using laparoscopic graspers

BACKGROUND

Manipulating tissue with laparoscopic forceps is more difficult than using the hands. This study investigates the effectiveness of grasping and the duration of tissue-clamping using laparoscopic forceps.

METHODS

Video recordings of 10 laparoscopic colectomies and 15 cholecystectomies were analyzed using time-action analysis.

RESULTS

The results indicated that 62% of the grasping actions were successful: the tissue was clamped sufficiently to perform an action. Of all the clamping actions on the colon, 10% were repeated actions. On the gallbladder 7% were repeated actions. The bowel slipped out of the grasper in 7% of the clamping actions, whereas the gallbladder slipped in 17%. In 89%, the colon was clamped less than 1 min. The maximum clamping time for colon clamps was 7 min for the colon, and 55 min for the gallbladder.

CONCLUSION

The low percentage of successful grasping actions indicates that the design of laparoscopic graspers is not optimal.

A compliant tip reduces the peak pressure of laparoscopic graspers

BACKGROUND

Previous studies have demonstrated that high pressures are generated at the tips of laparoscopic graspers, which can cause tissue injury. This study examines the effect of a compliant edge on tip pressure.

METHODS

One of a pair of identical laparoscopic graspers was modified by refashioning the tip out of silicone. A thin film pressure transducer (I-scan 6900 sensor) was deployed between the jaws of the grasper and a simulated tissue (leather strap). Load and handle pressures were kept constant. Peak tip pressure readings were taken as the load orientation was increased from the perpendicular to 135 degrees (n = 10). The data was analysed using anova and a post-hoc Duncan's multiple range test.

RESULTS

Peak tip pressures generated by the compliant tipped grasper were significantly less than those developed by the unmodified grasper, particularly at high-load orientations.

CONCLUSION

High pressures generated at the tip of laparoscopic graspers can be reduced by altering the mechanical properties (compliance) of the tip.

Grasper trauma during laparoscopic cholecystectomy

BACKGROUND

The present study characterized the histopathological nature of laparoscopic grasper trauma during laparoscopic cholecystectomy in a prospective, blinded trial in order to establish a model for laparoscopic grasper trauma. The null hypothesis that graspers cause no histologically distinct tissue injury was tested.

METHODS

The gall bladders of 19 patients undergoing laparoscopic cholecystectomy were examined. The area of gall bladder that had been grasped by Debakey laparoscopic forceps was excised (sample), along with an area of gall bladder that had not been grasped (control). Paired specimens were examined by a pathologist (blinded) to identify which was 'sample' and which was 'control' and to assess for histological markers of crushed tissue injury. The data were analysed by chi-squared or Fisher's exact tests.

RESULTS

The pathologist was able to identify the sample (gripped) specimen in 13 of the 19 cases. In the remaining six cases the pathologist was unable to determine the specimen that had been gripped due to either absence of damage (four cases), or severe inflammation precluding assessment (two cases). The ability of the pathologist to distinguish the sample from the control specimen was significant (chi-squared test, P = 0.003). Of the histological markers of crushed tissue injury, focal thinning of the gall bladder wall and epithelial loss were present in significantly more sample (gripped) specimens than control specimens (chi-squared test, P = 0.0002 and P < 0.0001, respectively).

CONCLUSIONS

Laparoscopic graspers cause tissue trauma that can be assessed histologically. The current study presents a relevant, reproducible, ethically acceptable human model for assessing the interaction between laparoscopic graspers and soft tissues.

Postlaparoscopic cholecystectomy pelvic gallstones associated with chronic pain

A 23-year-old gravida 1, para 1 woman experienced chronic pelvic pain and cul-de-sac nodularity starting 1 year after laparoscopic cholecystectomy. Repeat laparoscopy revealed numerous clusters of gallstones that were removed, resulting in resolution of her symptoms. Gallstones should be included in the differential diagnosis of the symptomatic patient with a history of cholecystectomy, and surgical records should be carefully reviewed for spillage of stones. It is feasible to remove gallstones laparoscopically.

Transdiaphragmatic abscess: late thoracic complication of laparoscopic cholecystectomy

Spillage of gallstones into the peritoneal cavity is a frequent problem during laparoscopic cholecystectomy (as much as 30%) and is frequently dismissed as a benign occurrence. However, several complications associated with spillage of gallstones have been reported recently. Most of these complications presented late after the original procedure, many with clinical pictures not related to biliary etiology, confounding and delaying adequate management. For patients presenting with intraabdominal or thoracic abscesses of unknown etiology, if there is a history of laparoscopic cholecystectomy, regardless of the time interval, certain evaluations should be considered. A sonogram and a CT scan are advisable to detect retained extraluminal gallstones, as most patients will require, not only drainage of fluid collections, but also removal of the stones. A case is described of a patient who presented with a right empyema and transdiaphragmatic abscess 18 months after a laparoscopic cholecystectomy. Treatment included decortication, enbloc resection of the abscess, repair of the diaphragm, and drainage.

Iatrogenic Gallbladder Perforation during Laparoscopic Cholecystectomy: Etiology and Sequelae

Iatrogenic perforation of the gallbladder (PGB) during laparoscopic cholecystectomy (LC) leads to spillage of bile and gallstones into the peritoneal cavity, which can result in serious postoperative infection. The objective of this study is to prospectively evaluate with long-term follow-up the risk factors, mechanisms, and complications associated with PGB in patients undergoing LC. Data from 1412 patients undergoing LC were collected prospectively between 1989 and 1995. Patients with and without iatrogenic gallbladder perforation were compared. Long-term follow-up was obtained using mailed questionnaires and telephone interviews, when needed. Of the 1412 patients, 512 (36%) sustained a PGB. Male sex, weight, gallbladder inflammation, thickening of the gallbladder, presence of adhesions, and a difficult hilar dissection were all associated with an increased incidence of PGB. The most common mechanisms of PGB were laceration due to grasper traction (55%) and electrocautery dissection (40%). Both the operating time and length of hospital stay were significantly longer in the PGB group. No difference was observed in the rate of wound infections between PGB and non-PGB patients (1.6% versus 1.8%). Only one patient (with an inflamed and perforated gallbladder) developed an early postoperative intra-abdominal abscess. Long-term follow-up averaging 48 months was achieved with a response rate of 44 per cent. No late intra-abdominal abscesses or complications attributable to retained gallstones were discovered.

Laparoscopic cholecystectomy and unsuspected gallbladder carcinoma

Gallbladder cancer is a relatively uncommon malignancy in the United States. Its presentation is similar to that of lithic disease of the gallbladder. Laparoscopic cholecystectomy has become the method of choice for removing the gallbladder in most benign conditions. Occasionally, unsuspected gallbladder carcinoma is encountered in association with laparoscopic cholecystectomy. Overall, gallbladder cancer portends a poor prognosis. However, in select cases, a favorable outcome can be expected and the less favorable predicted expected outcome can be improved. Management of patients with gallbladder cancer in different situations is discussed: gallbladder cancer noted postoperatively on final pathology, gallbladder cancer noted after removal of the gallbladder and opening of the specimen at the time of surgery, difficulty encountered at the time of dissection and resultant suspicion of gallbladder cancer, and diagnosis of extensive disease at initial placement of the laparoscope. The technique of extended cholecystectomy is outlined.