Is emergent laparoscopic cholecystectomy for acute cholecystitis safe in a low volume resource poor setting?

Emergency single-incision laparoscopic cholecystectomy for acute cholecystitis: A multi-center study

Single-incision laparoscopy is accepted as a safe alternative to multiple port laparoscopy for elective cholecystectomy; however, there are limited data on its use in patients with acute cholecystitis. The present multi-center study evaluated the outcomes of emergency single-incision surgeries for acute cholecystitis in hospitals in Belgium, Jamaica, and Trinidad and Tobago over a 5-year period. Standardized definitions of uncomplicated and complicated acute cholecystitis were used and the data were compared using SPSS software. The results revealed that over the 5-year period, 108 patients with a mean age of 48±15 years and a mean body mass index of 27±4.2 kg/m² underwent emergency single-incision cholecystectomies. The surgeries were successful in 92.1% of cases without supplemental trocars being used. The overall morbidity rates (9.3%) were also comparable to the historic controls with multiple port cholecystectomy. As was expected, the complicated cholecystitis group required a significantly longer operating time (86.11±30.16 vs. 66.79±16.8; P<0.00194), as well as supplemental trocars (7.9%) vs. 0; P=0.0413). On the whole, the present study demonstrates that emergency single-incision cholecystectomy is a technically feasible and safe procedure for patients with acute cholecystitis. These findings advocate a low threshold to place additional ports to assist with dissection and exposure.

Single Incision Cholecystectomies for Acute Cholecystitis: A Single Surgeon Series from the Caribbean

Introduction. Single incision laparoscopic surgery (SILS) is accepted as a safe alternative to conventional multiport laparoscopic (MPL) cholecystectomy for benign gallbladder disease. Since many surgeons carefully select patients without inflammation, there are limited data on SILS for acute cholecystitis. We report a single surgeon experience with SILS cholecystectomy for patients with acute cholecystitis. Materials and Methods. After securing ethical approval, we performed an audit of all SILS cholecystectomies for acute cholecystitis by a single surgeon from January 1, 2009, to December 31, 2019. The following data were extracted: patient demographics, intraoperative details, surgical techniques, specialized equipment utilized, conversions (additional port placement), morbidity, and mortality. Data were analyzed using SPSS 12.0. Results. SILS cholecystectomy was performed in 25 females at a mean age of 35 ± 4.1 (SD) years and a mean BMI of 31.9 ± 3.8 (SD) using a direct fascial puncture technique without access platforms. The operations were completed in 83 ± 29.4 minutes (mean ± SD) with an estimated blood loss of 76.9 ± 105 (mean + SD). Three (12%) patients required additional 5 mm port placement (conversions), but no open operations were performed. The patients were hospitalized for 1.96 ± 0.9 days (mean ± SD). There were 2 complications: postoperative superficial SSI (grade I) and a diaphragmatic laceration (grade III). No bile duct injuries were reported. There were 9 patients with complicated acute cholecystitis, and this sub-group had longer mean operating times (109.2 ± 27.3 minutes) and mean postoperative hospital stay (1.3 ± 0.87 days). Conclusion. The SILS technique is a feasible and safe approach to perform cholecystectomy for acute cholecystitis. We advocate a low threshold to place additional ports to assist with difficult dissections for patient safety.

Time to abandon the old dictum of delayed laparoscopic cholecystectomy after acute cholecystitis has settled in Caribbean practice

Although laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis, many Caribbean surgeons are reluctant to operate during the acute attack. We collected data for all consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis from January 1 to 31 December 2018. Delayed cholecystectomy was done >6 weeks after acute cholecystitis settled. We compared data between early and delayed groups. Delayed laparoscopic cholecystectomy was performed in 54 patients, and 42 had early laparoscopic cholecystectomy. Delayed surgery resulted in significantly more complications requiring readmission (39% vs 0), longer operations (2.27 vs 0.94 h) and lengthier post-operative hospitalisation (1.84 vs 1.1 days). Caribbean hospitals should abandon the practice of delayed surgery after cholecystitis has settled. Early laparoscopic cholecystectomy would be financially advantageous for our institutions, and it would save patients recurrent attacks of gallstone disease.

Laparoscopic Completion Cholecystectomy: An Audit from the Americas Hepato-Pancreato-Biliary Association (AHPBA) Caribbean Chapter

Objective

Removal of a gallbladder remnant occasionally becomes necessary when retained stones become symptomatic. Although the laparoscopic approach has been described, it is not yet considered the standard of care. We sought to determine the outcomes after completion cholecystectomies in the resource-poor setting within the Caribbean. 

Methods

We carried out an audit of the databases from all hepatobiliary surgeons in the Anglophone Caribbean. We identified all patients who had completion cholecystectomy over the five-year period from July 1, 2012 to June 30, 2018. Retrospective chart review was performed to extract the following data: patient demographics, diagnoses, presenting complaints, operative details, morbidity, mortality, and clinical outcomes. Descriptive statistics were generated using Statistical Packaging for Social Sciences (SPSS), version 12.0 (SPSS Inc., Chicago IL)

Results

There were 12 patients who were subjected to laparoscopic completion cholecystectomy for acute cholecystitis (7), severe biliary pancreatitis (3), and chronic cholecystitis (2) secondary to stones in a gallbladder remnant. There were 10 women and two men at a mean age of 47.4 years (range 32-60; standard deviation (SD) +/-7.81; median 48; mode 52) and a mean body mass index (BMI) of 30.8 Kg/M² (SD +/-3.81; range 26-38; median 29.5). The mean interval between the index operation and the completion operation was 14.8 months (SD +/- 12.3; range 1-48; median 13; mode 18). Five (42%) patients had their original cholecystectomy using the open approach. Five (42%) index operations were done on an emergent basis and the gallbladder remnant was deliberately left behind in three (25%) index operations. The completion cholecystectomies were all completed laparoscopically in 130.5 minutes (SD +/- 30.5; range 90-180, median 125; mode 125) without any conversions or mortality. There were two minor bile leaks that resolved without intervention through an indwelling drain. 

Discussion

Completions cholecystectomy can be completed via the laparoscopic approach with good outcomes and acceptable morbidity and mortality rates. The patients derive the same advantages as elective cholecystectomies. Therefore, the laparoscopic approach, when performed by hepatobiliary surgeons with advanced laparoscopic expertise in specialized centers, should be the new standard of care. 

Impact of a medical university on laparoscopic surgery in a service-oriented public hospital in the Caribbean

INTRODUCTION

The Caribbean lags behind global trends for volume and complexity of laparoscopic operations. In an attempt to promote laparoscopy at a single facility, a partnership was formed between the University of the West Indies (UWI) and the Port of Spain General Hospital in Trinidad and Tobago. This study seeks to document the effect of this partnership on laparoscopic practice.

MATERIALS AND METHODS

In this partnership, the UWI took the bold step of volunteering to staff a surgical team if the Ministry of Health provided the necessary legislative changes. On August 1, 2013, a UWI team was introduced with a mandate to optimize teaching and promote laparoscopic surgery. The UWI team had a similar staff complement to the existing service-oriented teams. There was no immediate investment in equipment, hospital beds, ICU beds, or operating room space. Therefore, the new team was introduced with limited change in existing conditions, resources, and equipment.

RESULTS

There were 252 laparoscopic operations performed over the study period. After introduction of the UWI team, there was an increase in the mean number of unselected laparoscopic operations (3.17 vs 10.83 cases per month; P<0.001; 95% confidence interval [95% CI] -8.5 to -6.84; standard error of the difference [SED] 0.408), the mean number of basic laparoscopic operations (3.17 vs 6.94 cases per month; P<0.0001; 95% CI -4.096 to -3.444; SED 0.165), the mean number of advanced laparoscopic operations (0 vs 3.89; P<0.0001), the number of teams undertaking unselected laparoscopic operations (2 vs 5), and the number of teams independently performing advanced laparoscopic operations (0 vs 4).

CONCLUSION

At this facility, we have demonstrated a significant increase in laparoscopic case volume and complexity when partnerships were formed between the UWI and this service-oriented hospital. Continued cross-fertilization and distribution of skill sets across the surgical community can reasonably be expected. We also identified maneuvers that can be used as a template to build laparoscopic services in other service-oriented hospitals in developing nations.

Pancreatic pseudocyst: combined single incision laparoscopic cystogastrostomy and cholecystectomy in a resource poor setting

Laparoscopic cystogastrostomy is a well-accepted minimally invasive modality to treat pancreatic pseudocysts. There has been one prior report of cystogastrostomy via single incision laparoscopic surgery (SILS) in which specialized instrumentation and access platforms were used.

We report the challenges encountered in a low resource setting with the SILS approach to drainage using only standard laparoscopic instruments. To the best of our knowledge this is the second report of SILS cystogastrostomy and the first to be performed in a resource poor setting without specialized instruments or platforms.