Laparoscopic cholecystectomy in a single, non-teaching hospital: an analysis of 1557 patients

Preoperative and Intraoperative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy: A Systematic Review of 30 Studies

This systematic review aims to review articles that evaluate the risk of conversion from laparoscopic to open cholecystectomy and to analyze the identified preoperative and intraoperative risk factors. The bibliographic databases CINAHL, Cochrane, Embase, Medline, and PubMed were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only English-language retrospective studies and systematic reviews with more than 200 patients were included. The time of publication was limited from 2012 to 2022. Our systematic review identified 30 studies with a total of 108,472 patients. Of those, 92,765 cholecystectomies were commenced laparoscopically and 5,477 were converted to open cholecystectomy (5.90%). The rate of conversion ranges from 2.50% to 50%. Older males with acute cholecystitis, previous abdominal surgery, symptom duration of more than 72 hours, previous history of acute cholecystitis, C-reactive protein (CRP) value of more than 76 mg/L, diabetes, and obesity are significant preoperative risk factors for conversion from laparoscopic to open cholecystectomy. Significant intraoperative risk factors for conversion include gallbladder inflammation, adhesions, anatomic difficulty, Nassar scale of Grades 3 to 4, Conversion from Laparoscopic to Open Cholecystectomy (CLOC) score of more than 6 and 10-point gallbladder operative scoring system (G10) score more than 3.

Glisson's capsule cauterisation is associated with increased postoperative pain after laparoscopic cholecystectomy: a prospective case-control study

INTRODUCTION Postoperative pain after laparoscopic cholecystectomy has three components: parietal, visceral and referred pain felt at the shoulder. Visceral peritoneal injury on the liver (Glisson's capsule) during cauterisation sometimes occurs as an unavoidable complication of the operation. Its effect on postoperative pain has not been quantified. In this study, we aimed to evaluate the association between Glisson's capsule injury and postoperative pain following laparoscopic cholecystectomy. METHODS The study was a prospective case-control of planned standard laparoscopic cholecystectomy with standardized anaesthesia protocol in patients with benign gallbladder disease. Visual analogue scale (VAS) abdominal pain scores were noted at 2 and 24 hours after the operation. One surgical team performed the operations. Operative videos were recorded and examined later by another team to detect presence of Glisson's capsule cauterisation. Eighty-one patients were enrolled into the study. After examination of the operative videos, 46 patients with visceral peritoneal injury were included in the study group, and the remaining 35 formed the control group. RESULTS VAS pain score at postoperative 2 and 24 hours was significantly higher in the study group than control (P = 0.027 and 0.017, respectively). CONCLUSIONS Glisson's capsule cauterisation in laparoscopic cholecystectomy is associated with increased postoperative pain. Additional efforts are recommended to prevent unintentional cauterisation.

Can Laparoscopic Cholecystectomy Prevent Recurrent Idiopathic Acute Pancreatitis?: A Prospective Randomized Multicenter Trial

OBJECTIVE

The aim of the present trial was to ascertain whether laparoscopic cholecystectomy (LCC) can prevent recurrent attacks of idiopathic acute pancreatitis (IAP).

SUMMARY

Up to 50% to 75% of IAP may be due to microlithiasis, which is undetectable by conventional imaging methods.

METHODS

This randomized, prospective trial included 85 patients (39 in the LCC and 46 in the control group) in 8 hospitals in Finland. We included adult patients (over 18 years) with their first attack of IAP. The diagnosis of IAP was based on the exclusion of common etiological reasons for acute pancreatitis (AP), whereafter the patients were randomized into conservative watchful waiting (controls) or LCC group. The primary end point was the number of patients with recurrent AP during the follow-up. All recurrent attacks of AP after an initial IAP episode were registered.

RESULTS

During a median follow-up of 36 (5-58) months, the recurrence of IAP was significantly higher in the control group than in LCC group (14/46 vs. 4/39, P = 0.016), as was also the number of recurrences (23/46 vs. 8/39, P = 0.003). In the subgroup of patients with at least 24 months' follow-up, the recurrence was still higher among controls (14/37 vs. 4/35, P = 0.008). In patients with normal liver function, recurrence was also significantly higher in the control than in the LCC group (13/46 vs. 4/39, P = 0.026). During surgery, 23/39 (59%) of the gallbladders were found to contain biliary stones or sludge.

CONCLUSIONS

LCC can effectively prevent the recurrence of IAP when all other possible etiologies of pancreatitis are carefully excluded. A total of 5 patients needed to be treated (NNT-value) to prevent 1 IAP.

Use of floseal hemostatic matrix for control of hemostasis during laparoscopic cholecystectomy for acute cholecystitis: a multicenter historical control group comparison (the GLA study gelatin matrix for acute cholecystitis)

BACKGROUND

In patients with acute cholecystitis undergoing laparoscopic cholecystectomy, bleeding is a common complication that can reduce procedural visibility and worsen outcome. Insufficient hemostasis can also lead to postoperative bleeding that can, in rare cases, be fatal. Topical hemostatic agents are used to ensure adequate hemostasis during laparoscopic cholecystectomy.

SUBJECTS AND METHODS

This prospective, open-label, nonrandomized, historical control group study investigated the use of Floseal(®) (Baxter International, Inc., Deerfield, IL) hemostatic matrix as an adjunct to surgical techniques to achieve hemostasis of the resected areas in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. The primary end point was the rate of complete hemostasis 10 minutes after laparoscopic application of Floseal to the gallbladder bed. Secondary end points included complete hemostasis rates at 2, 4, and 6 minutes, surgery time, laparoscopic procedure to open laparotomy conversion rate, postoperative bleeding rate, and mortality and safety outcomes over the entire follow-up period.

RESULTS

From April to November 2011, 101 consecutive patients were enrolled (51 men; mean age, 61.5±6.2 years). The historical control group of 100 age- and gender-matched patients with acute cholecystitis had undergone laparoscopic cholecystectomy without hemostatic agent. In the Floseal group, bleeding ceased within 10 minutes after laparoscopic application of the hemostatic agent to the gallbladder bed in all patients. The conversion rate was significantly lower in the Floseal group than in the control group (4 versus 12 patients, P<.05).

CONCLUSIONS

Floseal in acute cholecystitis is safe, is effective in controlling bleeding, and results in a lower conversion rate compared with cholecystectomy without hemostatic agents.

Effect of institutional volume on laparoscopic cholecystectomy outcomes: Systematic review and meta-analysis

AIM: To determine whether institutional laparoscopy cholecystectomy (LC) volume affects rates of mortality, conversion to open surgery, bile leakage and bile duct injury (BDI).

METHODS: Eligible studies were prospective or retrospective cohort studies that provided data on outcomes from consecutive LC procedures in single institutions. Relevant outcomes were mortality, conversion to open surgery, bile leakage and BDI. We performed a Medline search and extracted data. A regression analysis using generalized estimating equations were used to determine the influence of annual institutional LC caseload on outcomes. A sensitivity analysis was performed including only those studies that were published after 1995.

RESULTS: Seventy-three cohorts (127404 LC procedures) were included. Average complication rates were 0.06% for mortality, 3.23% for conversion, 0.44% for bile leakage and 0.28% for bile duct injury. Annual institutional caseload did not influence rates of mortality (P = 0.142), bile leakage (P = 0.111) or bile duct injury (P = 0.198) although increasing caseload was associated with reduced incidence of conversion (P = 0.019). Results from the sensitivity analyses were similar.

CONCLUSION: Institutional volume is a determinant of LC complications. It is unclear whether volume is directly linked to complication rates or whether it is an index for protocolised care.