The porcelain gallbladder-laparoscopic approach

A long time porcelain gallbladder was considered a relative contraindication to laparoscopic cholecystectomy, because of a high incidence of gallbladder cancer. From 12,000 patients underwent cholecystectomy in First Surgical Clinic of Iasi, 5 (0.04%) patients had porcelain gallbladder. All patients underwent ultrasound examen. Patients with porcelain gallbladder were classified as Type I to II according to preoperative ultrasound findings: three cases with porcelain gallbladder type I and two cases with porcelain gallbladder type II (in one case we found associated gallbladder carcinoma). We describe a three cases with porcelain gallbladder type I (complete calcification of gallbladder wall) treated by laparoscopic approach. Laparoscopic cholecystectomy was difficult because of adhesions and problems with grasping the thick gallbladder wall, but the postoperative course was uneventful. The histopathologic result of the specimen established the diagnosis of porcelain gallbladder type I and no cancer in the calcified wall of the gallbladder. We conclude based on cases presented and the literature review, although there is a high conversion rate, that patients with a type I porcelain gallbladder should be considered for laparoscopic cholecystectomy using a preoperative selection based on the ultrasound findings.     

Laparoscopic cholecystectomy for porcelain gallbladder

The porcelain gallbladder is uncommon type of chronically inflamed gallbladder wall considered to be associated with a high frequency of adenocarcinoma and subsequently not suitable for a laparoscopic approach. In 12,000 patients chosen for a laparoscopic cholecystectomy 4 porcelain gallbladders were diagnosed. In 2 cases the laparoscopic approach was successful. One conversion was due to an unconfirmed suspicion of gallbladder cancer and the other one to a fistula between the gallbladder and the common bile duct. Patients with a preoperative diagnosis of porcelain gallbladder must not be excluded from the laparoscopic approach yet a low threshold for conversion must be maintained in those with a cancer suspicion.     

Are new treatment methods of gallbladder stones the death-knell for gallstone surgery?

Recent advances in elective treatments for gallbladder (GB) gallstones (GS) provide so many options that we may be entering a new therapeutic era. Many of the 20 million Americans with GS are asymptomatic and do not need any treatment unless they are diabetic or cirrhotic, have a porcelain gallbladder, or can have an incidental cholecystectomy while undergoing an elective abdominal operation for other reasons. Therapy is required for significantly symptomatic gallstones and for complications of GS. With the development of so many options for nonoperative treatments, some predicted these would eclipse surgical cholecystectomy as the gold standards. However, such therapies are palliative and leave a "guilty" gallbladder in situ in the presence of lithogenic bile, circumstances inviting the recurrence of GS. The few selected patients for whom a general anesthetic represents an inordinate risk should be considered for biliary lithotripsy or percutaneous cholecystolithotomy, both of which can be done without anesthesia. When anesthesia does not present a risk, laparoscopic cholecystectomy, which incurs minimal disruption of a patient's normal function, has returned cholecystectomy to its position as the therapeutic gold standard for cholelithiasis. Complicated biliary anatomy or disease may dictate the need for traditional open cholecystectomy. However, most patients and referring physicians are demanding laparoscopic cholecystectomy even as this technique is evolving. Its risk for common bile duct injury is uncertain.     

Laparoscopic cholecystectomy for early gallbladder carcinoma: long-term outcome in comparison with conventional open cholecystectomy

Background The role of laparoscopic surgery for malignant gallbladder tumors remains uncertain. This study compared the surgical results of laparoscopic versus conventional open cholecystectomy for patients with early-stage gallbladder carcinoma and examined the role of laparoscopic surgery for early gallbladder carcinomas. Methods Data for the treatment of gallbladder carcinomas were gathered from Chang Gung Memorial Hospital (Linkou, Taiwan). A retrospective analysis of 40 patients with either stage 0 or stage 1 gallbladder carcinoma was performed. The patients were categorized into two groups on the basis of cholecystectomy procedures. The long-term outcomes for the two groups were compared. Results During the follow-up period, which ranged from 6.5 to 197.6 months, four patients in the conventional open cholecystectomy group encountered tumor recurrence, and one patient in the laparoscopic cholecystectomy group experienced distant tumor recurrence (p = 0.216). No local port-site tumor recurrence was identified in patients who underwent laparoscopic cholecystectomy. The overall 5-year survival rate in this series was 87.1%. A comparison of survival rates between the two groups demonstrated no significant difference (p = 0.340). Conclusion The laparoscopic cholecystectomy procedure did not adversely influence the prognosis of patients with early-stage gallbladder carcinomas. Furthermore, meticulous removal of gallbladders during laparoscopic surgery, in which early gallbladder carcinoma can be managed successfully using laparoscopic cholecystectomy, achieved a satisfactory surgical result and a low port-site tumor recurrence rate.     

Radical Second Resection Provides Survival Benefit for Patients with T2 Gallbladder Carcinoma First Discovered after Laparoscopic Cholecystectomy

Port site recurrence or peritoneal seeding is a fatal complication following laparoscopic cholecystectomy for gallbladder carcinoma. The aims of this retrospective analysis were to determine the association of gallbladder perforation during laparoscopic cholecystectomy with port site/peritoneal recurrence and to determine the role of radical second resection in the management of gallbladder carcinoma first diagnosed after laparoscopic cholecystectomy. A total of 28 patients undergoing laparoscopic cholecystectomy for gallbladder carcinoma were analyzed, of whom 10 had a radical second resection. Five patients had recurrences; port site/peritoneum recurrence in 3 and distant metastasis in 2. The incidence of port site/peritoneal recurrence was higher in patients with gallbladder perforation (3/7, 43%) than in those without (0/21, 0%) (p = 0.011). The outcome after laparoscopic cholecystectomy was worse in 7 patients with gallbladder perforation (cumulative 5-year survival of 43%) than in those without (cumulative 5-year survival of 100%) (p <0.001). Among 13 patients with a pT2 tumor, the outcome after radical second resection (cumulative 5-year survival of 100%) was better than that after laparoscopic cholecystectomy alone (cumulative 5-year survival of 50%) (p = 0.039), although there was no survival benefit of radical second resection in the 15 patients with a pT1 tumor (p = 0.65). In conclusion, gallbladder perforation during laparoscopic cholecystectomy is associated with port site/peritoneal recurrence and worse patient survival. Radical second resection may be beneficial for patients with pT2 gallbladder carcinoma first discovered after laparoscopic cholecystectomy.     

Open versus laparoscopic cholecystectomy for gallbladder carcinoma

Laparoscopic surgery has replaced conventional open cholecystectomy for benign gallbladder disease. A major concern is how to handle gallbladder cancer in the laparoscopic era, since there are numerous case reports of port site metastases from gallbladder cancer after laparoscopic cholecystectomy. There are also many experimental studies favoring the opinion that the laparoscopic technique implies a higher risk of spreading malignant disease. This opinion has gained wide acceptance despite little previous clinical effort to determine the risk of tumor dissemination and the lack of comparisons between open and laparoscopic surgery. This report is a short summary of our own studies and present knowledge with special respect to the clinical aspects of the development and incidence of abdominal wall metastases. Among 270 patients with verified gallbladder carcinoma in whom 210 had open surgery and 60 a laparoscopic cholecystectomy, 12 patients (6.5%) in the open cholecystectomy group and 9 (15%) in the laparoscopic group developed incisional metastases. Although the sparse clinical documentation does not unavoidably mean that laparoscopic cholecystectomy has an increased risk of disseminating tumor cells, we recommend open surgery in cases of known or suspected gallbladder carcinoma. Received: January 9, 2001 / Accepted: August 1, 2001     

Port site recurrences after laparoscopic cholecystectomy

Port site metastasis is a well-documented event after laparoscopic procedures in cancer patients. We summarize current epidemiological knowledge about the risk of this complication after laparoscopic/conventional cholecystectomy in patients with unexpected gallbladder cancer as well as other intraabdominal malignancies. We found 174 cases of port site metastasis after laparoscopic cholecystectomy and 12 recurrences in the surgical scar after converted or open cholecystectomy. A review of all case reports and its comparison with four international surveys show a 14% incidence of port site metastases 7 months after laparoscopic cholecystectomy for cancer. Similar numbers are available for open cholecystectomy. Our data suggest that abdominal wall metastases of gallbladder cancer are not a specific complication of laparoscopy. The long-term prognosis of patients with unknown gallbladder cancer however seems to be worsened by laparoscopy. The registry of the German Society of Surgery, which prospectively compares follow-up and prognosis of all cases of cholecystectomy, laparoscopic as well as open, in patients with incidental gallbladder cancer will definitively clarify whether laparoscopy affects the prognosis of patients with unsuspected gallbladder cancer. Received: February 13, 2001 / Accepted: August 1, 2001     

Ultrasonographic assessment of the risk of injury to branches of the middle hepatic vein during laparoscopic cholecystectomy

BACKGROUND: Although hemorrhage from the gallbladder bed during laparoscopic cholecystectomy is one of main reasons for conversion to open cholecystectomy, the cause of this life-threatening complication is unclear. PATIENTS AND METHODS: Color Doppler ultrasound was used to examine the cause of venous hemorrhage from the gallbladder bed during laparoscopic cholecystectomy in 4 patients postoperatively and to examine the anatomic relationship between the gallbladder bed and branches of the middle hepatic vein in 50 healthy volunteers. RESULTS: Injury to a large branch of the middle hepatic vein adjacent to the gallbladder bed was diagnosed in all 4 patients. One patient required conversion to open cholecystectomy while the bleeding in 2 patients was immediately controlled by direct pressure with the gallbladder. The branch of the middle hepatic vein was completely adherent to the gallbladder bed in 5 of the 50 volunteers, and in 1 the diameter of the branch was as large as 3.5 mm. In 3 volunteers branches 3.0 to 3.8 mm in diameter traversed as close as 1.0 mm from the gallbladder bed. CONCLUSIONS: Patients with large branches of the middle hepatic vein close to the gallbladder bed are at risk of hemorrhage during laparoscopic cholecystectomy and should be identified preoperatively with ultrasound.     

Reoperation for a symptomatic double gallbladder

A case of a complicated postoperative course after laparoscopic cholecystectomy in which, ultimately, gallbladder duplication was suspected and confirmed at laparotomy is described. The diagnostic tools, differential diagnosis, and therapy are discussed. After open cholecystectomy patients' complaints dissolved. Awareness of the possibility of a double gallbladder in case of persisting symptoms after laparoscopic cholecystectomy can lead to diagnosis of this condition at an earlier stage.     

Porcelain gallbladder: a clinical case and a review of the literature

Porcelain bladder is defined as calcification of the gallbladder wall. It is a rare condition and is seen in 0.06% to 0.8% of cholecystectomies. It origin is still unknown.We report two cases of patients with a porcelain gallbladder. One case is a 60 year-old male patient who was seen due to having biliary symptoms. The diagnosis was made by ultrasound and computed tomography, and he was surgically intervened by performing a partial cholecystectomy. The histopathology reported a gallbladder wall with sclerohyalinosis and dystrophic calcification foci. The other case is a 98 year-old female patient, whose form of presentation was incidental given that she suffered from symptoms of an intestinal obstruction. A cholecystectomy was performed with a good post-surgical outcome.A series published in between 1950 and 1960 show that the porcelain bladder can be frequently observed in patients with cancer of the gallbladder, although this relationship is currently being rejected. The reason why these cases are being presented is because of their low incidence and the controversy over what treatment to use, due to its association with gallbladder cancer.     

Laparoscopic Treatment of Stone Recurrence in a Gallbladder Remnant: Report of an Additional Case and Literature Review

Cholecystectomy is an effective treatment of gallstones. Nevertheless, recurrence of biliary symptoms following cholecystectomy, either laparotomic or laparoscopic, is quite common. Causes are either biliary or extrabiliary. Symptoms of biliary origin chiefly depend on bile duct residual stones or strictures. Rarely, they depend on stone recurrence in a gallbladder remnant. Diagnosis of gallstone recurrence in gallbladder remnant is difficult, mainly arising from ultrasonography, computed tomography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. Incomplete gallbladder removal may be either voluntary or inadvertent: in the first case, it is performed to remove gallstones without dissecting a difficult Calot’s triangle or an excessively bleeding posterior wall of gallbladder caused by liver cirrhosis. Available data do not support the hypothesis that laparoscopic cholecystectomy entails an increased incidence of this condition, in spite of some opposite opinions. Treatment of lithiasis in gallbladder remnants is chiefly surgical. Although technically demanding, completion cholecystectomy can be safely performed in a laparoscopic way. We report a case of stone relapse in a gallbladder remnant, discovered 16 years following laparoscopic cholecystectomy and successfully treated by laparoscopic completion cholecystectomy. We furthermore review literature data in order to ascertain whether recent large diffusion of laparoscopic surgery causes an increase of such cases.     

Hepatic metastasis after laparoscopic cholecystectomy for polypoid gallbladder cancer followed by radical surgery

While laparoscopic cholecystectomy is being increasingly performed on patients with gallbladder disease, this approach in cases of polypoid lesions in the gallbladder may not always be justified. We report here a case of early development of intrahepatic metastasis after laparoscopic cholecystectomy for polypoid gallbladder cancer; wedge resection of the gallbladder bed and dissection of regional lymph nodes had to be done. When a malignancy of the gallbladder is suspected during preoperative examinations, open cholecystectomy should be done.     

腹腔镜胆囊切除术中肝中静脉分支损伤的危险性因素分析

目的探讨腹腔镜胆囊切除术中胆囊床出血的原因.方法对从2000年9月到2001年3月接受腹腔镜胆囊切除手术的617例中1例患者中,随机选取其中91例进行前瞻性分析,并对617例发生胆囊床出血的病例进行回顾性分析.结果多普勒超声检查均发现有1根肝中静脉的重要分支从胆囊床后面通过,该血管离胆囊床的最近距离点(C点)到胆囊的平均距离为(5.0±4.6)mm,其中15.4%(14例)肝中静脉是直接和胆囊床相贴,11.0%(10例)和胆囊床的距离在1mm以内,C点的内径为(3.2±1.1)mm;约有34.7%(31例)C点位于胆囊纵轴左侧,位于右侧的有39例(42.9%),正好落在胆囊纵轴上的有21例(23.1%).C点肝静脉的流速为(9.9±3.3)cm/s.结论肝中静脉最靠近胆囊点,较多会出现在胆囊纵轴的右侧.建议在术前,尤其是在腹腔镜胆囊切除术前进行常规的多普勒超声检查,以明确肝中静脉和胆囊床的关系,高度重视肝中静脉和胆囊床直接相贴的病例.     

Significance of preoperative ultrasound measurement of gallbladder wall thickness

Evaluation of patients with signs and symptoms of biliary tract disease usually includes ultrasound assessment of the gallbladder. Does measurement of the thickness of the gallbladder wall yield any significant information to the clinical surgeon? The records of all my patients undergoing cholecystectomy since 1990 were reviewed. The entire series consists of 401 consecutive patients, in whom 388 procedures were completed laparoscopically, with 14 patients requiring conversion to an open cholecystectomy. Each patient's preoperative evaluation included a gallbladder ultrasound, which included measurement of the diameter of the gallbladder wall. The entire series of cholecystectomies was evaluated according to the ultrasound measured diameter of the gallbladder wall. A thin gallbladder wall was less than 3 mm in diameter. A thick gallbladder wall was 3 mm or greater in diameter. Of the 401 consecutive patients who underwent cholecystectomy for symptomatic gallbladder disease, 86 (21.5%) were removed laparoscopically for acalculous disease. Eleven per cent of patients with acalculous cholecystitis had acute cholecystitis and 89 per cent had chronic cholecystitis. Every patient with either a thin or thick gallbladder wall with acalculous cholecystitis had a successful laparoscopic cholecystectomy. Three-hundred fifteen patients had a laparoscopic cholecystectomy for calculous cholecystitis. In patients with calculous cholecystitis, 28.3 per cent had acute cholecystitis and 71.7 per cent had chronic cholecystitis. The gallbladder wall was found to be greater than 3 mm in 38 per cent of patients with acute calculous cholecystitis and greater than 3 mm in 41 per cent of patients with chronic calculous cholecystitis. One-hundred, forty-two patients, out of a series total of 401, had a gallbladder wall thickness greater than 3 mm by preoperative sonography and 14 of these patients (10%) required conversion to an open cholecystectomy. A preoperative gallbladder ultrasound evaluation for symptomatic cholecystitis, which documents a thick gallbladder wall (> or =3 mm) with calculi, is a clinical warning for the laparoscopic surgeon of the potential for a difficult laparoscopic cholecystectomy procedure which may require conversion to an open cholecystectomy procedure.     

Lessons on laparoscopic cholecystectomy (summary of the experience

The experience of laparoscopic cholecystectomy conduction in 6524 patients with nontumoral diseases of gallbladder (chronic calculous cholecystitis, an acute calculous cholecystitis, chronic noncalculous cholecystitis, the gallbladder polyposis) was summarized. While comparing the initial seizing experience in laparoscopic cholecystectomy in the clinic the tendency was noted, trusting the skills improvement in management of laparoscopic technique, permitting to reduce the contraindications quantity for laparoscopic cholecystectomy. Several principles were elaborated, which is necessary to follow doing laparoscopic cholecystectomy for improvement of results of treatment in patients and for complications reduction.     

腹腔镜胆囊大部切除术不闭锁缝合胆囊残端的可行性研究

目的:探讨残留部分胆囊壶腹或困难胆囊行腹腔镜胆囊大部切除术不闭锁缝合胆囊残端的可行性。方法:总结2006年1月至2008年3月16例Calot三角解剖困难患者行腹腔镜胆囊大部切除术中残留部分胆囊壶腹或胆囊管的临床资料,术中胆囊残端不闭锁缝合,分析术后胆漏发生率、持续时间、量及住院时间、胆囊管残留综合征(cholecystic duct remain syn-drome,CDRS)发生率、胆道损伤等。结果:术后发生胆漏5例(31.25%);胆漏持续时间2~5d,平均(3.4±1.1)d;24h最大胆漏量10~150ml,平均(58±57.6)ml;住院时间7~12d,平均(8.7±1.4)d,未发生CDRS及胆道损伤。16例患者均治愈出院。随访1~18个月未发现与手术有关的近远期并发症。结论:Calot三角解剖困难时残留部分胆囊壶腹或胆囊管的腹腔镜胆囊大部切除术,术中不闭锁缝合胆囊残端可以避免发生CDRS及误伤肝外胆管等,出现胆漏经过短期持续腹腔引流后可自愈。腹腔镜胆囊大部切除术不闭锁缝合胆囊残端是安全、可行、有效的手术方法。     

腹腔镜胆囊切除困难与对策

急性与慢性胆囊炎导致腹腔镜胆囊切除的困难因素有多种,应采取个体化的处理策略才能顺利完成手术。灵活运用胆囊体造洞抓持技术、纵切法超细纤维胆管镜探查辨识胆囊管与胆总管、胆囊翻转技术、胆囊大部切除技术、胆囊逆行或顺逆结合切除技术、胆囊穿刺与劈开技术、胆囊黏膜下剥离技术、压迫止血法以及置管引流等,有助于实现"无开腹胆囊切除术"。     

Wound recurrence from gallbladder cancer after open cholecystectomy

BACKGROUND: Reports of port site recurrences from gallbladder cancer after laparoscopic cholecystectomy have raised considerable concern as to whether the laparoscopic technique implies an increased risk of metastatic disease. In a previous study of gallbladder cancer and laparoscopic cholecystectomy, we reported a frequency of 16% port site metastases. The purpose of the present study was to determine the frequency of wound metastases from gallbladder cancer after open cholecystectomy. METHODS: The registers from the Swedish Oncological Centers and the National Board of Health and Welfare were checked for reported cases of gallbladder cancer and surgical classification codes for open cholecystectomy from 1991 to 1994. The study included all 8 university and 24 county hospitals in Sweden. The files from all patients with gallbladder cancer who had an open cholecystectomy were retrospectively reviewed. RESULTS: The study included 270 patients who had a cholecystectomy, of which 215 were classified as open and 55 as laparoscopic. Of the 215 patients, 11 patients were excluded because of an incorrect or deficient histopathologic or surgical classification. In 186 patients (91%), sufficient data were obtained for follow-up. Twelve patients (6.5%) had wound metastases from their gallbladder cancer. All patients with wound metastases died with a median survival of 10 months (range, 3 to 65 months). CONCLUSIONS: Wound metastases from gallbladder cancer after open cholecystectomy may be more common than previously assumed.     

Laparoscopic cholecystectomy does not demonstrably decrease survival of patients with serendipitously treated gallbladder cancer

BACKGROUND: The purpose of this study was to evaluate the possibility that laparoscopic cholecystectomy has worsened the prognosis of patients with resected gallbladder cancer; particularly for patients whose cancer was accidentally resected. STUDY DESIGN: We conducted a retrospective review of Connecticut Tumor Registry data and data extracted from individual patient records at 15 of 30 hospitals in Connecticut reporting data to the Registry, at two separate time points, 1985-1988 (immediate prelaparoscopic era) and 1992-95 (laparoscopic cholecystectomy well established). There were 194 and 208 patients in each 3-year period, respectively. Additional information was extracted from hospital records in 82 and 91 patients, respectively. Twenty-five percent of patients in both data sets presented with "local" or Tis, T1, T2 disease. RESULTS: Three-year survival for localized disease was 29% in the prelaparoscopic period and 34% once laparoscopic cholecystectomy was established. But analysis of individual patient records indicated that 36% of patients from the laparoscopic period did not actually undergo a laparoscopic procedure. Fifty-nine patients had their gallbladder cancer discovered in the specimen postoperatively (serendipitously treated). A higher proportion of cancers were discovered postoperatively in the laparoscopic era (44% versus 24%). Three-year survival for these patients was 25%. If the data from the two eras are grouped according to whether or not the cancer-bearing gallbladder was manipulated laparoscopically, 24 of 59 patients (41%) turned out to be at risk for the possibility of increased laparoscopic dissemination of tumor. Survival of these patients (11-month median survival) was not statistically different from survival of patients whose serendipitously discovered gallbladder cancer was never manipulated laparoscopically (16-month median survival); p = 0.54 by log rank test. CONCLUSIONS: The widespread adoption of laparoscopic cholecystectomy did not worsen the survival of patients with gallbladder cancer, and patients with serendipitously treated gallbladder cancers did not have a worse survival after laparoscopic manipulation than after a standard open cholecystectomy. The laparoscopic aspects of operative manipulation of a gallbladder with cancer in it do not appear to be a proximate cause of the poor prognosis in this disease.     

Videolaparoscopy and carcinoma of the gallbladder

There have been several reports claiming that there is a risk that laparoscopic cholecystectomy might worsen the prognosis of unexpected gallbladder cancer. The objective of this study was to evaluate which factors influence the prognosis of such cancers. A clinicopathological study was conducted in 25 patients with unexpected gallbladder cancer. The results of 10 patients undergoing laparoscopic cholecystectomy were compared with those of 15 patients undergoing open cholecystectomy. Correlations were evaluated between cumulative survival rates and seven prognostic factors, namely, age, sex, histopathological grade, pathological stage, occurrence of bile spillage, type of cholecystectomy (laparoscopic or open) and additional surgical treatments. Seven patients after laparoscopic cholecystectomy (70%) and 9 patients after open cholecystectomy (64%) had cancer recurrence: the difference was not statistically significant. There was a statistically significant correlation between survival rate and tumour stage (P < 0.01) and occurrence of bile spillage (P < 0.05). There was no difference in survival depending on whether cholecystectomy was carried out using laparoscopic or traditional techniques. Laparoscopic cholecystectomy does not adversely affect the prognosis of unexpected gallbladder cancer. Once the histological findings have been examined, the surgeon will decide whether it is necessary to extend surgery, regardless of whether laparoscopic or open cholecystectomy is carried out.